Duale antithrombozytäre Therapie und Triple-Therapie vs. dualer Therapie bei Vorhofflimmern nach jeweils koronarem Stenting

Thrombozyten spielen eine entscheidende Rolle bei der Entstehung eines intrakoronaren Thrombus, der infolge Plaqueruptur zur Thrombosierung einer Koronararterie und damit zum Koronarverschluss unter dem klinischen Bild eines ACS führen kann. Eine antithrombozytäre Therapie verhindert ischämische Ereignisse wie Stentthrombose, Myokardinfarkt und kardiovaskulären Tod. Insbesondere Patienten mit einem akuten Koronarsyndrom, die eine stärkere Plättchenaktivität mit anhaltend höherer Thrombinaktivierung aufweisen, profitieren von einer dualen antithrombozytären Therapie (DAPT). Die aktuellen Leitlinien empfehlen die jeweilige Dauer einer DAPT je nach Indikation und Blutungsrisiko. Verschiedene randomisierte klinische Studien wie die DAPT-Studie oder die PEGASUS-Studie untersuchten, inwieweit Patienten mit einem hohen ischämischen Risiko von einer verlängerten DAPT profitieren.

Die WOEST-Studie und die PIONEER AF-PCI-Studie verglichen die duale Therapie (Kombination aus Antikoagulans und Clopidogrel) mit einer Triple-Therapie (Kombination aus ASS, Clopidogrel und einem Antikoagulans) bei Vorhofflimmern und koronarem Stenting. Dabei zeigte sich in der PIONEER AF-PCI-Studie eine deutlich erhöhte Blutungsrate unter der Standard-Triple-Therapie, sodass eine Triple-Therapie aus Dicumarinen mit ASS und Clopidogrel nicht mehr gerechtfertigt erscheint.

Thrombocytes play a decisive role in the development of an intracoronary thrombus, which, due to plaque rupture, can lead to thrombosis of a coronary artery and consequently to coronary occlusion under the clinical presentation of an ACS. An antithrombotic treatment prevents ischemic events, such as stent thrombosis, myocardial infarction and cardiovascular death. In particular, patients with acute coronary syndrome who have higher platelet activity with persistently higher thrombin activation benefit from dual antithrombotic therapy (DAPT). The current guidelines recommend the duration of a DAPT depending on the indication and the risk of bleeding. Various randomized clinical trials, such as the DAPT trial or the PEGASUS trial, have investigated the extent to which patients with a high ischemic risk benefit from a prolonged DAPT.

The WOEST trial and the PIONEER AF-PCI trial compared dual therapy (combination of an anticoagulant and clopidogrel) with triple therapy (combination of aspirin, clopidogrel and an anticoagulant) for atrial fibrillation and coronary stenting. In the PIONEER AF-PCI trial, a significantly higher bleeding rate under standard triple therapy was shown, such that triple therapy composed of dicumarins with ASA and clopidogrel no longer appears to be justified.

Key words

Thrombocytes - antithrombocytic therapy - coronary heart disease - atrial fibrillation - coronary stents - dual antithrombocytic therapy - triple therapy

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