Duale antiaggregatorische Therapie nach Implantation von Koronarstents

Zusammenfassung

Die duale antiaggregatorische Therapie mit Aspirin und Clopidogrel nach koronarer Stentimplantation ist heute trotz fehlender offizieller Zulassung Standard der perinterventionellen Behandlung. Die Clopidogrel-Therapie wird vor PCI mit einer „loading dose” begonnen. Diese beträgt 300 mg mindestens 6 Stunden vor PCI, ansonsten 600 mg. Die notwendige Dauer der dualen antiaggregatorischen Therapie nach koronarer Stentimplantation ist von der Art des Stents und dem bestehenden Krankheitsbild abhängig und beträgt mindestens: 3 - 4 Wochen bei Bare-metal Stent, 6 Monate bei Drug-eluting Stent, 12 Monate nach koronarer Brachytherapie und 9 Monate nach Akutem Koronarsyndrom. Diese Zeitintervalle sollten auch bei bevorstehenden chirurgischen Eingriffen eingehalten werden. Vorzeitige, nicht aufschiebbare Operationen müssen nach individueller Einschätzung des Blutungsrisikos unter der antiaggregatorischen Therapie durchgeführt werden. Ein vorzeitiges Beenden der antiaggregatorischen Therapie geht mit einem gesteigertem Risiko kardiovaskulärer Ereignisse, insbesondere von Stenthrombose und Myokardinfarkten, einher. Von einer prolongierten dualen antiaggregatorischen Therapie profitieren insbesondere kardiovaskuläre Hochrisikopatienten. Patienten mit einer Indikation zur dauerhaften Antikoagulation bedürfen nach koronarer Stentimplantation für den Zeitraum der größten Gefährdung durch eine Stentthrombose einer kombinierten Gabe von Aspirin, Clopidogrel und Antikoagulantien mit einem INR-Zielwert im unteren therapeutischen Bereich. Das erhöhte Risiko für relevante Blutungen muss einkalkuliert und in Relation zum potenziellen Nutzen abgewogen werden.

Summary

Dual antiplatelet-aggregation treatment with aspirin and clopidogrel after coronary stent implantation is nowadays standard peri-interventional practice, although its use is not yet licensed for this indication in many European countries. Clopidogrel administration is initiated before PCI with a loading dose of 300 mg when given at least 6 hours before PCI, otherwise 600 mg. The required duration of combined (aspirin + clopidogrel) antiplatelet-aggregation treatment after coronary stent implantation depends on the type of stent and the pre-existing disease. After bare-metal stent implantation dual antiplatelet medication is needed for at least 3-4 weeks, after drug-eluting stent implantation 6 months, after coronary brachytherapy 12 months, and 9 months after an acute coronary syndrome. These time intervals should also be respected before any elective surgical intervention. Early operations, because postponement is impossible, should be performed under antiplatelet-aggregation treatment after assessment of bleeding risk in the individual case. Premature termination of this treatment carries an increased risk of serious cardiovascular events, especially stent thrombosis and myocardial infarction. Prolonged antiplatelet-aggregation treatment is of benefit especially in patients with a high risk of serious cardiovascular events. Patients with an indication for long-term anticoagulation may require, during the period of highest risk of stent thrombosis after stent implantation, administration of combined aspirin, clopidogrel and anticoagulants with an INR target value in the lower therapeutic range. The increased risk of bleeding must be weighed up against the potential benefit.

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