Schlaganfallprävention – ein Update

Zusammenfassung

Die strukturierte Sekundärprävention ist eine wesentliche Voraussetzung für eine erfolgreiche Schlaganfallvermeidung in der Zukunft. Die einzelnen Bereiche müssen konsequent behandelt werden. Wesentlicher Risikofaktor ist der Bluthochdruck. Hier wurde gezeigt, dass eine Blutdruckbehandlung nach einem Schlaganfall eine langfristige Reduktion der Letalität von 10 % (über 5 Jahre) bewirkt. Außerdem konnte durch eine Metaanalyse an fast 1 Mio. Patienten gezeigt werden, dass sowohl in der primär- wie auch sekundärpräventiven Situation die konsequente Blutdruckeinstellung das Schlaganfallrisiko um rund 40 % senkt. Je stärker die Blutdrucksenkung, je stärker der präventive Effekt. Die vermeintliche relevante Interaktion von Protonenpumpenhemmern und Clopidogrel, bei der der antiaggregatorische Effekt von Clopidogrel abgeschwächt werden sollte, scheint zwar pharmakologisch relevant, aber klinisch keine Rolle zu spielen. Beide Substanzgruppen können derzeit ohne Einschränkung kombiniert werden. Patienten mit Vorhofflimmern und zerebrovaskulärem Ereignis sollten wenn irgend möglich oral antikoaguliert werden. Bei Kontraindikation hat die Kombination von ASS und Clopidogrel einen leichten Vorteil (deutliche Risikoreduktion bei erhöhtem Blutungsrisiko) gegenüber ASS alleine und kann in Betracht gezogen werden. Dabigatran als oraler direkter Thrombinantagonist hat gegenüber Vit.-K-Antagonisten den Vorteil der sofortigen Wirksamkeit und fehlenden Notwendigkeit der Gerinnungskontrollen. Nach der RELY-Studie scheint es bei gleicher Wirksamkeit in der niedrigeren Dosis sicherer und bei gleicher Sicherheit in der höheren Dosis wirksamer als Vit.-K-Antagonisten zu sein. Die Marktzulassung sollte in 2010 erfolgen. Statine wirken bis zu 10 Jahre nach einem zerebrovaskulären Ereignis sekundärpräventiv. Die Operation einer Karotisstenose scheint der Stentversorgung nach den Ergebnissen der Internationalen Carotid Stenosis Stenting Study überlegen zu sein. Das Risiko eines Rezidivschlaganfalls bei dem Vorliegen eines PFO ist mit einer OR von 1,1 sehr niedrig und sollte nicht Anlass zu invasiveren Maßnahmen geben.

Abstract

Organised secondary prevention is a prerequisite for successful stroke therapy. One of the most relevant factors is elevated blood pressure. It has been shown that long-term blood pressure treatment leads to a significant reduction in mortality of almost 10 % over a 5-year period. Additionally, a large meta-analysis in almost 1 million patients confirmed that blood pressure reduction leads to a constant reduction in secondary cerebrovascular events by 40 %, both in primary and secondary prevention. The preventive effect was stronger as the blood pressure reduction increased. Interactions between proton-pump inhibitors and the antiplatelet agent clopidogrel did not receive scientific confirmation. There is no reason to avoid this combination. Patients suffering from atrial fibrillation and stroke should, whenever possible, be treated by oral anticoagulation. In cases in which this treatment is abandoned, the combination of aspirin and clopidogrel offers some marginal benefits over aspirin alone (higher stroke risk reduction, but increase in brain haemorrhages). Dabigatran is a new direct oral thrombin antagonist. It has the advantage compared to the oral vitamin K antagonists that it acts immediately after intake and does not need further regular coagulation test controls. The huge RELY study revealed that dabigatran is safer with the same efficacy in the lower dose, but more effective with the same safety in the higher dose, compared to oral vitamin K antagonists. It will be licensed in 2010. Statins seem to be beneficial for as long as 10 years after a cerebrovascular accident. Carotid stenosis treatment seems to be better done by operation as revealed by the International Carotid Stenosis Stenting study. A patent foramen ovale is a slight risk factor with an OR of 1.1. Therefore, any aggressive treatment options in patients with stroke and pfo seem to be unjustified.

Schlüsselwörter

Schlaganfall - Sekundärprävention - Blutdruck

Keywords

stroke - secondary prevention - blood pressure

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