Aktuelle kardiologische Pharmakotherapie

Zusammenfassung

Die Einführung neuer Medikamente und eine Vielzahl von aktuellen Studien macht es schwierig, deren Relevanz zu bewerten und in der klinischen Praxis umzusetzen. Im folgenden Text sollen drei wichtige Themen vertieft werden: 1. Die Thrombozytenhemmung ist eines der wichtigsten Therapieprinzipien der modernen Pharmakotherapie geworden. Die Kombinationstherapie aus ASS und Clopidogrel nach Stentimplantation wird für verschiedene klinische Situationen erklärt. Nach welchen Kriterien soll man eine Primärprophylaxe mit ASS einleiten? 2. Aldosteronantagonisten spielen heute kaum noch als Diuretika eine Rolle. Dagegen haben sie einen neuen, gut begründeten Stellenwert in der Herzinsuffizienzbehandlung. Wie dosiert man hier richtig? Welche Indikationen sind gesichert? Welche neuen Substanzen kommen zum Einsatz? 3. In der Therapie der chronischen Herzinsuffizienz sind die ACE-Hemmer fest etabliert. Unsicherheit besteht bezüglich der möglichen Kombination mit Angiotensin-Rezeptorantagonisten: Wie ist das Rationale zu verstehen? Wie sollte man dosieren? Welche Komplikationen sind zu erwarten? Welche Kontrollen sind notwendig?

Abstract

The recent introduction of numerous medications in cardiovascular pharmakotherapie makes it difficult to assess their relevance in daily clinical practice. Three relevant topics will be discussed in this article: 1. Inhibition of platelet aggregation has become a predominant strategy in modern cardiovascular pharmacotherapy. The evidence for combined treatment with ASS and clopidogrel is explained for various clinical settings. What are relevant criteria for platelet inhibition in primary prophylactic treatment? 2. The improving knowledge on pathophysiology of chronic heart failure led to a revival of aldosterone antagonism. Which patients benefit from new agents like eplerenone? What is the scientific background? 3. ACE inhibitors are established agents for heart failure treatment. Why is the combination with angitensin receptor blockers advocated in some cases? What doses are recommended? Are there relevant complications to expect? How can we treat and control patients safely?

Schlüsselwörter

Thrombozytenaggregationshemmer - ACE-Hemmer - Aldosteronantagonismus - Eplerenone

Key words

platelet inhibition - ACE inhibitor - aldosteron antagonism - eplerenone

Literatur

• 1 RISC Group . Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease.  Lancet. 1990;  336 827-830
• 2 Catella-Lawson F RM, Kapoor S C, Cucchiara A J. et al . Cyclooxigenase inhibitors and the antiplatelet effects of aspirin.  N Engl J Med. 2001;  345 1809-1818
• 3 Second Joint Task Force of European and other Societies on Coronary Prevention . Prevention of coronary heart disease in clinical practice.  Eur Heart J. 1998;  19 1435-1503
• 4 Wilson P WFDR, Levy D, Belanger A M. et al . Prediction of coronary heart disease using risk factor categories.  Circulation. 1998;  97 1837-1847
• 5 Patrono C, Bachmann F, Baigent C. et al . Expert consensus document on the use of antiplatelet agents. The task force on the use of antiplatelet agents in patients with atherosclerotic cardiovascular disease of the European society of cardiology.  Eur Heart J. 2004;  25 166-181
• 6 Steering Comittee of the Physician's Health Study Research Group . Final report on the aspirin component of the ongoing Physician's Health Study.  N Engl J Med. 1989;  312 129-135
• 7 Ridker P MCN, Lee I M, Gordon D. et al . A Randomized trial of low-dose Aspirin in the primary prevention of cardiovascular disease in women.  N Engl J Med. 2005;  352 1293-1304
• 8 Steinhubl S R, Berger P B, Mann J T. et al . Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial.  Jama. 2002;  288 2411-2420
• 9 Hochholzer T D, Frundi D, Blanke P. et al . Time dependence of platelet inhibition after a 600 mg loading dose of Clopidogrel in a large, unselected cohort of candidates for percutaneous coronary intervention.  Circulation. 2005;  111 1-5
• 10 Schomig A, Neumann F J, Kastrati A. et al . A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents.  N Engl J Med. 1996;  334 1084-1089
• 11 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
• 12 Hamm C. Leitlinien: Akutes Koronarsyndrom ohne persistierende ST-Hebung.  Z Kardiol. 2004;  93 72-90
• 13 Chan F K, Ching J Y, Hung L C. et al . Clopidogrel versus Aspirin and Esomeprazole to prevent recurrent ulcer bleeding.  N Engl J Med. 2005;  352 238-244
• 14 Staessen J LP, Fagard R. et al . Rise in plasma concentration of aldosterone during longterm angiotensin II suppression.  J Endocrinol. 1981;  91 457-465
• 15 Brown N. Eplerenone - Cardiovascular protection.  Circulation. 2003;  107 2512-2518
• 16 Pitt Z F, Remme W J. The effect of spironolactone on morbidity and mortality in patients with severe heart failure.  N Engl J Med. 1999;  341 709-717
• 17 Pitt B RW, Zannad F. et al . Eplerenone, a selective aldosterone blocker in patients with left ventricular dysfunction after myocardal infarction.  N Engl J Med. 2003;  348 1309-1321
• 18 Lopez-Sendon J SK, McMurray J, Tamargo J. et al . Expert consensus document on angiotensin enzyme inhibitors in cardiovascular disease.  Eur Heart J. 2004;  25 1454-1470
• 19 The PEACE Trial Investigators . Angiotensin converting enzyme inhibitors in stable coronary artery disease.  N Engl J Med. 2004;  351 2058-2068
• 20 McMurray J VÖJ, Swedberg K, Granger C B. et al . Effects of candesartan in patients with chronic heart failure and reduced left-ventruicular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial.  Lancet. 2003;  362 767-771
• 21 Hunt S AAW, Chin M H, Feldman A M. et al . ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult - summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): Developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: Endorsed by the Heart Rhythm Society.  Circulation. 2005;  112 1825-1852