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DOI: 10.1055/s-0030-1270838
© Georg Thieme Verlag KG Stuttgart · New York
Notfallbehandlung bei akutem Koronarsyndrom nach aktuellen Leitlinien
Publication History
Publication Date:
21 March 2011 (online)
Kernaussagen
Akutes Koronarsyndrom
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Das akute Koronarsyndrom setzt sich aus den Entitäten STEMI, NSTEMI und instabile Angina zusammen.
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Neben der klinischen Symptomatik stellt ein 12-Kanal-EKG das wichtigste und schnellste diagnostische Kriterium für einen akuten STEMI dar. Die sofortige Ableitung und korrekte Interpretation eines 12-Kanal-EKGs durch den medizinischen Erstkontakt ist unumgänglich.
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Beim NSTEMI zeigt das EKG variable oder keine Veränderungen. Die Diagnose wird durch zusätzliche Laborparameter gestellt, die Ausdruck einer myokardialen Nekrose sind, deren Bestimmung im Rettungsdienst aber keine Rolle spielt.
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Die Therapie beim akuten Koronarsyndrom besteht aus einer symptomatischen und einer kausalen Therapie.
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Die symptomatische Therapie beinhaltet die Gabe von Nitroglyzerin und eventuell einem Opiat. Aufgrund möglicher negativer Effekte sollte die Sauerstoffgabe nicht mehr routinemäßig erfolgen.
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Zur kausalen Therapie gehört die Gabe von Antithrombinen und Thrombozytenaggregationshemmern.
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Weiterhin obliegt dem Notarzt bei der Diagnose STEMI die Einleitung einer Triage zur Reperfusionstherapie. Der Notarzt hat folgende Entscheidungen zu treffen:
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primäre PCI oder (prä-)hospitale Lyse?
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bei Entscheidung zur primären PCI: Umgehung von Nicht-PCI-Krankenhäusern?
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Wahl des Reperfusionsverfahrens bei überlebtem plötzlichen Herzstillstand
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Die Zeit spielt für die Reperfusionstherapie bei STEMI eine wichtige Rolle.
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Bei der Entscheidung für eine Lyse, die nur bei nicht optimalen Bedingungen für eine primäre PCI zu erwägen ist, spielen eine Rescue-PCI oder pharmakoinvasives Vorgehen eine wichtige Rolle in Abhängigkeit vom Lyseerfolg.
Literatur
- 1 Schnoor J, Gillmann B, Pavlakovic G et al. [Characteristics of repeated emergency physician use]. Notarzt. 2006; 22 141-146
- 2 Lowel H, Meisinger C, Heier M et al. [Myocardial infarction and coronary mortality in Southern Germany]. Dt Ärztebl. 2006; 103 616-622
- 3 Arntz H R, Bossaert L L, Danchin N et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 5: Initial management of acute coronary syndromes. Resuscitation. 2010; 81 1353-1363
- 4 Anderson J L, Adams C D, Antman E M et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction. Circulation. 2007; 116 e148-e304
- 5 Antman E M, Anbe D T, Armstrong P W et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction – executive summary. Circulation. 2004; 110 588-636
- 6 Bassand J P, Hamm C W, Ardissino D et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007; 28 1598-1660
- 7 Kushner F G, Hand M, Smith Jr. S C et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009; 120 2271-2306
- 8 Van de Werf F, Bax J, Betriu A et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J. 2008; 29 2909-2945
- 9 Wijns W, Kolh P, Danchin N et al. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2010; 31 2501-2555
- 10 Fox K A, Dabbous O H, Goldberg R J et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study. BMJ. 2006; 333 1091-1094
- 11 Wiviott S D, Morrow D A, Frederick P D et al. Application of the Thrombolysis In Myocardial Infarction risk index in non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006; 47 1553-1558
- 12 Wijesinghe M, Perrin K, Ranchord A, Simmonds M, Weatherall M, Beasley R. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart. 2009; 95 198-202
- 13 Freimark D, Matetzky S, Leor J, Boyko V, Barbash I M, Behar S et al. Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis. Am J Cardiol. 2002; 89 381-385
- 14 Wallentin L, Becker R C, Budaj A et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361 1045-1057
- 15 Wiviott S D, Braunwald E, McCabe C H et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007; 357 2001-2015
- 16 Mehta S R, Yusuf S, Peters R J et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001; 358 527-533
- 17 Yusuf S, Zhao F, Mehta S R et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001; 345 494-502
- 18 COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) . Early intravenous then oral metoprolol in 45852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005; 366 1622-1632
- 19 Sabatine M S, Cannon C P, Gibson C M et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005; 352 1179-1189
- 20 Verheugt F W, Montalescot G, Sabatine M S et al. Prehospital fibrinolysis with dual antiplatelet therapy in ST-elevation acute myocardial infarction: a substudy of the randomized double blind CLARITY-TIMI 28 trial. J Thromb Thrombolysis. 2007; 23 173-179
- 21 COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) . Addition of clopidogrel to aspirin in 45852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005; 366 1607-1621
- 22 Mehilli J, Kastrati A, Schulz S et al. Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: A randomized double-blind trial. Circulation. 2009; 119 1933-1940
- 23 van't Hof A W J, ten Berg J, Heestermans T et al. Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (On-TIME 2): a multicentre, double-blind, randomised controlled trial. Lancet. 2008; 372 537-546
- 24 Thiele H, Schindler K, Friedenberger J et al. Intracoronary compared with intravenous bolus abciximab application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circulation. 2008; 118 49-57
- 25 Thiele H, Wöhrle J, Neuhaus P et al. Intracoronary compared with intravenous bolus abciximab application during primary percutaneous coronary intervention: design and rationale of the Abciximab Intracoronary versus intravenously Drug Application in ST-Elevation Myocardial Infarction (AIDA STEMI) trial. Am Heart J. 2010; 159 547-554
- 26 Ellis S G, Tendera M, de Belder M A et al. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008; 358 2205-2217
- 27 Eikelboom J W, Mehta S R, Anand S S et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006; 114 774-782
- 28 Antman E M, McCabe C H, Gurfinkel E P et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. 1999; 100 1593-1601
- 29 Cohen M, Demers C, Gurfinkel E P et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997; 337 447-452
- 30 Mehta S R, Boden W E, Eikelboom J W et al. Antithrombotic therapy with fondaparinux in relation to interventional management strategy in patients with ST- and non-ST-segment elevation acute coronary syndromes: an individual patient-level combined analysis of the Fifth and Sixth Organization to Assess Strategies in Ischemic Syndromes (OASIS5 and 6) randomized trials. Circulation. 2008; 118 2038-2046
- 31 Stone G W, McLaurin B T, Cox D A et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006; 355 1531-1538
- 32 Antman E M, Morrow D A, McCabe C H et al. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med. 2006; 354 1477-1488
- 33 Montalescot G. ATOLL-Study. Vortrag: Late breaking clinical trials. ESC Stockholm 2010
- 34 Yusuf S, Mehta S R, Chrolavicius S et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006; 354 1464-1476
- 35 Stone G W, Witzenbichler B, Guagliumi G et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008; 358 2218-2230
- 36 Boersma E. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J. 2006; 27 779-788
- 37 Morrison L J, Verbeek P R, McDonald A C et al. Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA. 2000; 283 2686-2692
- 38 Boersma E, Maas A C, Deckers J W et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet. 1996; 348 771-775
- 39 Keeley E C, Boura J A, Grines C L. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003; 361 13-20
-
40 Thiele H. Door to balloon times in acute myocardial infarction. http://www.uni-leipzig.de/~card/d2bt/ Accessed 3.4.2010
- 41 Bonnefoy E, Steg P G, Boutitie F et al. Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up. Eur Heart J. 2009; 30 1598-1606
- 42 Steg P G, Bonnefoy E, Chabaud S, Lapostolle F, Dubien P Y, Cristofini P et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty. Circulation. 2003; 108 2851-2856
- 43 Pinto D S, Kirtane A J, Nallamothu B K et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: Implications when selecting a reperfusion strategy. Circulation. 2006; 114 2019-2025
- 44 Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet. 2006; 367 569-578
- 45 Ellis S G, Stone G W, Cox D A et al. Long-term safety and efficacy with paclitaxel-eluting stents: 5-year final results of the TAXUS IV clinical trial (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent). JACC Cardiovasc Interv. 2009; 2 1248-1259
- 46 Herrmann H C, Lu J, Brodie B R et al. Benefit of facilitated percutaneous coronary intervention in high-risk ST-segment elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention hospitals. J Am Coll Cardiol Intv. 2009; 2 917-924
- 47 Gershlick A H, Stephens-Loyd A, Hughes S et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med. 2005; 353 2758-2768
- 48 Danchin N, Coste P, Ferrieres J et al. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction. Data from the French registry on Acute ST-elevation Myocardial Infarction (FAST-MI). Circulation. 2008; 118 268-276
- 49 Kalla K, Christ G, Karnik R et al. Implementation of guidelines improves the standard of care: The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry). Circulation. 2006; 113 2398-2405
- 50 Desch S, Eitel I, Rahimi K et al. Timing of invasive treatment after fibrinolysis in ST elevation myocardial infarction – a meta-analysis of immediate or early routine versus deferred or ischemia-guided randomised controlled trials. Heart. 2010; DOI: 10.1136/hrt.2010.193862 epub ahead of print.
- 51 Sunde K, Pytte M, Jacobsen D et al. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007; 73 29-39
- 52 Garot P, Lefevre T, Eltchaninoff H et al. Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction. Circulation. 2007; 115 1354-1362
- 53 Spaulding C M, Joly L M, Rosenberg A et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med. 1997; 336 1629-1633
- 54 Arntz H R, Wenzel V, Dissmann R et al. Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction. Resuscitation. 2008; 76 180-184
- 55 Bottiger B W, Arntz H R, Chamberlain D A et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008; 359 2651-2662
Prof. Dr. med. Hans-Richard Arntz
Universitätsklinikum Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Phone: 030/84 45 46 79
Fax: 030/84 45 26 40
Email: hans-richard.arntz@charite.de
Prof. Dr. med. Holger Thiele
Universität Leipzig – Herzzentrum
Klinik für Innere Medizin/Kardiologie
Strümpellstraße 39
04289 Leipzig
Phone: 03 41/8 65-14 26/14 28
Fax: 03 41/8 65-14 61
Email: thielh@medizin.uni-leipzig.de