Der alte Patient mit akutem Koronarsyndrom. Konservative oder interventionelle Therapie?

Der alte Patient mit einem akuten Koronarsyndrom (ACS) wird häufig aufgrund des Alters, von Vorerkrankungen und auch erhöhtem Blutungsrisiko nicht evidenzbasiert therapiert. Dies gilt sowohl für die medikamentöse als auch die interventionelle Therapie. Valide Daten zeigen jedoch deutlich, dass gerade auch alte Patienten von einer leitlinienkonformen Therapie – vor allem auch der interventionellen Therapie und der Revaskularisation – profitieren.

Publication History

Article published online:
20 January 2021

• Literatur

• 1 Dai X, Busby-Whitehead J, Alexander KP. Acute coronary syndrome in the older adults. J Geriatr Cardiol 2016; 13: 101-108
• 2 Brieger D, Eagle K, Goodman S. et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the Global Registry of Acute Coronary Events. Chest 2004; 126: 461-469
• 3 Bayer AJ, Chadha JS, Farag RR. et al. Changing Presentation of Myocardial Infarction with increasing old age. J Am Geriatr Soc 1986; 34: 263-266
• 4 Freisinger E, Fuerstenberg T, Malyar NM. et al. German nationwide data on current trends and management of acute myocardial infarction: Discrepancies between trials and real-life. Eur Heart J 2014; 35: 979-988
• 5 Rosengren A, Wallentin L, Simoons M. et al. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J 2006; 27: 789-795
• 6 Ibanez B, James S, Agewall S. et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the management of acute myocardial infarction. Eur Heart J 2018; 39: 119-177
• 7 Moscucci M, Fox KAA, Cannon CP. et al. Predictors of major bleeding in acute coronary syndromes: The Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2003; 24: 1815-1823
• 8 Gallagher S, Knight C. Contrast-induced nephropathy in primary percutaneous coronary intervention. Heart 2011; 97: 1723-1725
• 9 Skolnick AH, Alexander KP, Chen AY. et al. Characteristics, Management, and Outcomes of 5,557 Patients Age ≥ 90 Years With Acute Coronary Syndromes. Results From the CRUSADE Initiative. J Am Coll Cardiol 2007; 49: 1790-1797
• 10 Devlin G, Gore JM, Elliott J. et al. Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events. Eur Heart J 2008; 29: 1275-1282
• 11 Bauer T, Koeth O, Jünger C. et al. Effect of an invasive strategy on in-hospital outcome in elderly patients with non-ST-elevation myocardial infarction. Eur Heart J 2007; 28: 2873-2878
• 12 De Boer MJ, Ottervanger JP, VanʼT Hof AWJ. et al. Reperfusion therapy in elderly patients with acute myocardial infarction: A randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol 2002; 39: 1723-1728
• 13 Bueno H, Betriu A, Heras M. et al. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio en Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2011; 32: 51-60
• 14 Alexander KP, Chen AY, Roe MT. et al. Investigators C. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA 2005; 294: 3108-3116 [Erratum in: JAMA 2006; 295: 628]
• 15 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87-165
• 16 Valgimigli M, Bueno H, Byrne RA. et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J 2018; 39: 213-260
• 17 Mehran R, Baber U, Sharmka S. et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N Engl J Med 2019; 38: 1-10
• 18 Collet JP, Thiele H, Barbato E. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020;
• 19 Mockel M, Searle J, Muller R. et al. Chief complaints in medical emergencies: do they relate to underlying disease and outcome? The Charité Emergency Medicine Study (CHARITEM). J Emerg Med 2013; 20: 103-108
• 20 Bach RG, Cannon CP, Weintraub WS. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. ACC Curr J Rev 2004; 13: 53-54
• 21 Roffi M, Patrono C, Collet JP. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 1101-1106
• 22 Alexander KP, Newby LK, Cannon CP. et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115: 2549-2569
• 23 Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. Eur Heart J 2014; 35: 1726-1731
• 24 Kirchhof P, Benussi S, Kotecha D. et al. ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37: 2893-2962
• 25 Dewilde WJM, Oirbans T, Verheugt FWA. et al. WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115
• 26 Gibson CM, Mehran R, Bode C. et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med 2016; 375: 2423-2434
• 27 Cannon CP, Bhatt DL, Oldgren J. et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med 2017; 377: 1513-1524
• 28 Vranckx P, Valgimigli M, Eckardt L. et al. Articles Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet 2019; 394: 1335-1343
• 29 Lopes R, Heizer G, Aronson R. et al. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med 2019; 380: 1509-1524
• 30 Knuuti J, Wijns W, Chairperson I. et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes The Task Force for the diagnosis and management of chronic. Eur Heart J 2020; 41: 407-477
• 31 Yu J, Mehran R, Grinfeld L. et al. Sex-Based Differences in Bleeding and Long Term Adverse Events After Percutaneous Coronary Intervention for Acute Myocardial Infarction : Three Year Results From the HORIZONS-AMI Trial. Catheter Cardiovasc Interv 2015; 85: 359-368
• 32 Yasuda S, Kaikita K, Akao M. et al. Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease. N Engl J Med 2019; 381: 1103-1113
• 33 Reiter M, Twerenbold R, Reichlin T. et al. Early diagnosis of acute myocardial infarction in the elderly using more sensitive cardiac troponin assays. Eur Heart J 2011; 32: 1379-1389
• 34 Liebetrau C, Gaede L, Wolter JS. et al. Release kinetics of highsensitivity cardiac troponins I and T and troponin T upstream open reading frame peptide (TnTuORF) in clinically induced acute myocardial infarction. Biomarkers 2017; 22: 304-310
• 35 Liebetrau C, Nef HM, Dörr O. et al. Release kinetics of early ischaemic biomarkers in a clinical model of acute myocardial infarction. Heart 2014; 100: 652-657