Antithrombotische Therapie der koronaren Herzerkrankung

Abstract

The optimal antithrombotic strategy in patients with coronary artery disease gains increasing complexity along with the development of a variety of novel antiplatelet medications. Variable doses as well as combinations of the various treatment options allow a more and more individualised regimen with regard to the respective patient condition (e. g. stable angina, acute coronary syndrome), the treatment strategy (e. g. conservative, CABG, coronary stenting), the stent type (e. g. bare metal, drug eluting stent) and the individual comorbidities and comedications (e. g. indication for anticoagulation or individual bleeding risk).

Kernaussagen

Stabile koronare Herzerkrankung

Bei konservativer Therapie sollte ASS 75 – 100 mg/d die Standardtherapie darstellen. Clopidogrel 75 mg/d ist das Alternativpräparat. Nach Implantation eines BMS sollte für mindestens 4 Wochen, nach DES für mindestens 6 – 12 Monate mit ASS und Clopidogrel behandelt werden. Besteht bei Implantation eines BMS zusätzlich die Indikation zur permanenten Antikoagulation, wird eine 4-wöchige Dreifachtherapie mit ASS/Clopidogrel/Antikoagulation (meist Phenprocoumon) unter engmaschiger Kontrolle empfohlen.

Akutes Koronarsyndrom

Bei konservativer wie interventioneller Therapie sollte eine duale antithrombozytäre Therapie mit ASS und Clopidogrel für 12 Monate gegeben werden, gefolgt von einer dauerhaften Monotherapie. Prasugrel ist nach Stentimplantation eine vielversprechende Alternative zu Clopidogrel, wenn es sich um jüngere Patienten handelt, deren Blutungsrisiko nicht erhöht ist und die kein zerebrovaskuläres Ereignis (TIA/Schlaganfall) in der Anamnese aufweisen – insbesondere bei Patienten mit hohem Risiko für ischämische Komplikationen wie STEMI oder Diabetes mellitus.

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