Stellenwert der Antikoagulation

Zusammenfassung

Die Bedeutung der Antikoagulation in der Akutphase des ischämischen Schlaganfalls und in der Sekundärprävention hat bereits seit einigen Jahren einen Wandel erfahren. Große Studien konnten keinen positiven Effekt der frühen Antikoagulation nach ischämischem Schlaganfall nachweisen. Bis auf wenige Ausnahmen, wie eindeutige kardiale Emboliequelle, progressive Hirnstammsymptomatik, Sinusvenenthrombosen, Dissektion der hinversorgenden Gefäße und evtl. hochgradige Karotisstenosen vor Operation, hat die Antikoagulation in der Akutphase des ischämischen Schlaganfalls an Bedeutung verloren. In der Sekundärprophylaxe bei kardioembolischen Infarkten stellt sie weiterhin die Therapie der Wahl dar. Darüber hinaus wird die Antikoagulation bei persistierendem Foramen ovale (PFO) und zusätzlichen Vorhofseptumaneurysma diskutiert. Neueste Studien weisen daraufhin, dass die Antikoagulation bei intrakraniellen Stenosen der Thrombozytenaggregationshemmung nicht überlegen ist.

Summary

The role of anticoagulation in acute ischemic stroke and secondary prevention of ischemic stroke has been changed in the last years. Several large studies could not demonstrate a significant benefit of early anticoagulation in patients with acute stroke. Possible remaining indications for acute anticoagulation were an undoubtful cardioembolic cause of the stroke, progressive stroke, intracranial sinus venous thrombosis, dissections of cerebral arteries and high grade carotid stenosis before CEA. For secondary prevention of cardioembolic stroke anticoagulation is the first line treatment. Recently anticoagulation is discussed in patients with persistent foramen ovale and atrial septum aneurysm (ASA). For the treatment of intracranial stenosis oral anticoagulation might be better than aspirin.

Schlüsselwörter

Schlaganfall - Antikoagulation - Vorhofflimmern - persistierendes Foramen ovale - intrakranielle Stenosen

Keywords

Stroke - anticoagulation - atrial fibrillation - persistent foramen ovale - intracranial stenosis

• Literatur

• 1 Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996; 348 (9028): 633-8.
• 2 The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997; 349 (9065): 1569-81.
• 3 Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Jama 1998; 279 (16) 1265-72.
• 4 Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993; 342 (8882): 1255-62.
• 5 Adams Jr HP. Emergent use of anticoagulation for treatment of patients with ischemic stroke. Stroke 2002; 33 (03) 856-61.
• 6 Adams Jr HP, Brott TG, Crowell RM, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA. et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994; 90 (03) 1588-601.
• 7 Akins PT, Pilgram TK, Cross 3rd DT, Moran CJ. Natural history of stenosis from intracranial atherosclerosis by serial angiography. Stroke 1998; 29 (02) 433-8.
• 8 Arenillas JF, Molina CA, Montaner J, Abilleira S, Gonzalez-Sanchez MA, Alvarez-Sabin J. Progression and clinical recurrence of symptomatic middle cerebral artery stenosis: a long-term follow-up transcranial Doppler ultrasound study. Stroke 2001; 32 (12) 2898-904.
• 9 Bath PM, Lindenstrom E, Boysen G, De Deyn P, Friis P, Leys D, Marttila R, Olsson J, O’Neill D, Orgogozo J, Ringelstein B, van der Sande J, Turpie AG. Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial. Lancet 2001; 358 (9283): 702-10.
• 10 Beitzke A, Schuchlenz H, Beitzke M, Gamillscheg A, Stein HI, Zartner P. Interventioneller Verschluss von Foramen ovale und Vorhofseptumdefekten nach paradox embolischen Ereignissen. Z Kardiol 2002; 91 (09) 693-700.
• 11 Berge E, Abdelnoor M, Nakstad PH, Sandset PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 2000; 355 (9211): 1205-10.
• 12 Chimowitz MI, Kokkinos J, Strong J, Brown MB, Levine SR, Silliman S, Pessin MS, Weichel E, Sila CA, Furlan AJ. et al. The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995; 45 (08) 1488-93.
• 13 Counsell C, Sandercock P. Low-molecularweight heparins or heparinoids versus standard unfractionated heparin for acute ischemic stroke (Cochrane review). Stroke 2002; 33 (07) 1925-6.
• 14 Daffertshofer M, Grips E, Dempfle CE, Hennerici M. Heparin in der Akutphase des ischämischen Schlaganfalls: Datenlage und klinische Realität. Nervenarzt 2003; 74 (04) 307-19.
• 15 Hacke W, Kaste M, Olsen TS, Orgogozo JM, Bogousslavsky J. Empfehlungen der Europäischen Schlaganfall-Initiative zur Versorgung und Behandlung des Schlaganfalls. Nervenarzt 2001; 72 (10) 807-19.
• 16 Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105 (22) 2625-31.
• 17 Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001; 345 (24) 1740-6.
• 18 Toth C, Voll C. Validation of a weight-based nomogram for the use of intravenous heparin in transient ischemic attack or stroke. Stroke 2002; 33 (03) 670-4.