Die Thrombolyse als therapeutische Option bei akutem ST-Streckenhebungsinfarkt

Zusammenfassung

Die Ära der Reperfusionstherapie bei ST-Streckenhebungsinfarkt (STEMI) begann mit der Einführung der i. v. Thrombolyse. Durch zusätzliche Gabe von Acetylsalicylsäure konnte die Infarktsterblichkeit nahezu halbiert werden. Die Einführung der primären Koronarangioplastie (PPCI) meist in Kombination mit einer Stentimplantation anstelle der Lysetherapie konnte die Rate an offenen Gefäßen steigern sowie die Sterblichkeit, die Zahl der Re-Infarkte und das Auftreten von Schlaganfällen verringern. Studien, die den Vorteil der PPCI gegenüber der Lyse demonstrieren, beziehen sich jedoch häufig auf Patienten mit einer langen Symptomdauer (bis zu 12 Stunden und mehr). Ebenso sind mit Einführung der Thienopyridine Unterschiede in der Post-Infarkt-Behandlung in beiden Gruppen zu verzeichnen. Die routinemäßige Kombination beider Verfahren in Form der Facilitated PCI (prähospitale Lyse und sofortige Intervention) hat sich nicht bewährt, während die pharmakoinvasive Strategie mit prähospitaler Lyse und Intervention im zeitnahen Intervall Vorteile bieten könnte. Subgruppen-Analysen der Vergleichsstudien zeigten einen potentiellen Nutzen der Lyse bei Patienten, die besonders früh nach Symptombeginn (≥ 2 Stunden) behandelt wurden. Ein solches strategisches Konzept bei früh nach Symptombeginn behandelbaren Patienten aus prähospitaler Lyse mit möglicher Rescue-Intervention und gezielter pharmakoinvasiver Strategie im Vergleich zur PPCI zu testen, verfolgt die STREAM-Studie (STrategic Reperfusion Early After Myocardial Infartion), die hoffentlich diese wichtige Frage definitiv beantworten wird.

Abstract

The introduction of intravenous thrombolytic therapy started the new era of reperfusion therapy in ST elevation myocardial infarction. The addition of aspirin almost halved mortality in patients with ST elevation infarction. Primary coronary intervention (PCI) often in combination with stent implantation instead of thrombolytic therapy increases infracted-artery patency and reduces mortality, number of re-infarction and stroke even further. However, studies comparing the benefits of both therapeutic regimens often included patients with long symptom duration (up to 12 hours and more). In addition, there are differences in long term treatment after myocardial infarction in both groups since the addition of thienopyridines to standard treatment after stent implantation. The routine combination of thrombolytic therapy and immediate PCI (facilitated PCI) did not prove beneficial whereas a pharamacoinvasive strategy including thrombolytic therapy and PCI at a later time point could be beneficial. Subgroup analysis in the studies comparing PCI and thrombolytic therapy suggested a beneficial effect for patients receiving thrombolytic therapy early after symptom onset (≥ 2 h). Therefore, a strategic concept of thrombolytic therapy early after symptom onset in patients presenting with ST elevation myocardial infarction combined with either rescue intervention when indicated or planned PCI is currently tested in the so STREAM-study (STrategic Reperfusion Early After Myocardial Infarction). Hopefully this study will clarify the role of thrombolytic therapy in ST Elevation myocardial infarction compared to PCI alone.

Schlüsselwörter

prähospitale Lyse - ST-Hebungsinfarkt - Koronarintervention

Keywords

out-of-hospital fibrinolysis - ST-elevation myocardial infarction - coronary intervention

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