Zeit ist Myokard - Frühbehandlung des akuten Koronarsyndroms von besonderer Bedeutung

Bei der Akuttherapie des akuten Koronarsyndroms ist die Frühphase von besonderer Bedeutung - einerseits müssen lebensbedrohliche tachykarde Rhythmusstörungen vermieden werden, andererseits kann eine schnellstmögliche kausale Therapie dazu beitragen, das Ausmaß der Folgeschäden gering zu halten. So ist beim ST-Elevationsinfarkt besonders wichtig, das akut verschlossene Gefäß mithilfe der Lyse oder der perkutanen Koronarintervention schnellstmöglich wieder zu eröffnen. Gelingt die Reperfusion frühzeitig, lassen sich relevante Myokardanteile retten. Im Vordergrund der Bemühungen beim Nicht-ST-Hebungsinfarkt dagegen stehen andere Ziele. Hier muss vor allem das Fortschreiten des thrombotischen Geschehens aufgehalten und ein kompletter Verschluss durch gezielte antikoagulatorische Maßnahmen (Hemmung von Thrombozytenaggregation und -aktivierung sowie Koagulation) verhindert werden. Die einzelnen Studienergebnisse zur Therapie des akuten Koronarsyndroms sind allerdings so umfangreich, dass sie für den Einzelnen fast nicht mehr überschaubar sind. Abhilfe schaffen sollen aktuelle Leitlinien - wie die des European Resuscitation Council (ERC), die versuchen, die wesentlichen Erkenntnisse zusammenzufassen und zu komprimieren.

For the immediate treatment of acute coronary syndromes, the early phase is of special significance - not only must life-threatening tachycardic rhythm disorders be avoided, but also rapid causal treatment can help minimize the severity of negative sequelae. Thus, in the case of an ST-elevation myocardial infarction it is of particular importance to open acutely blocked vessels by lysis or percutaneous coronary intervention as quickly as possible. If early reperfusion is successful, relevant portions of the myocardium can be saved. In the management of non-ST-elevation infarction, however, different priorities apply. Here, the main objective is to halt the progression of the thrombotic process, and prevent complete occlusion by specific anticoagulation measures (inhibition of platelet aggregation and activation, anticoagulants). The reported results of studies of the treatment of acute coronary syndrome are, however, so voluminous as to be confusing for the average individual. Here, help is available in the form of current guidelines, such as those of the European Resuscitation Council (ECR), which summarise and compress the major results.

acute coronary syndrome - STEMI - NSTEMI - instable angina pectoris - acute intervention - reperfusion - anticoagulation - guidelines

Literatur

• 1 Antman EM, Anbe DT, Armstrong PW. et al. . ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction - executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).  J Am Coll Cardiol. 2004;  44 671-719
• 2 Arntz HR, Bossaert L, Filipatos GS. European resuscitation council guidelines for resuscitation 2005. Section 5. Initial management of acute coronary syndromes.  Resuscitation. 2005;  67 S87-S96
• 3 ASSENT-3 Study Group . Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: the ASSENT-3 randomised trial in acute myocardial infarction.  Lancet. 2001;  358 605-13
• 4 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;  367 569-678
• 5 Bertrand ME, Simoons ML, Fox KAA. et al. . Management of acute coronary syndromes: acute coronary syndromes without persistent ST segment elevation. Recommendations of the Task Force of the European Society of Cardiology, Recommendations of the Task Force of the European Society of Cardiology.  Eur Heart J. 2002;  23 1809-1840
• 6 Boersma E, Harrington RA, Moliterno DJ. et al. . Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials.  Lancet. 2002;  359 189-198
• 7 Boersma E, Maas ACP, Deckers JW. et al. . Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour.  Lancet. 1996;  348 771-775
• 8 Bonnefoy E, Lapostolle F, Leizorovicz A. et al. . Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study. Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) study group.  Lancet. 2002;  360 825-829
• 9 Cannon CP, Weintraub WS, Demopoulos LA. et al. . Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.  N Engl J Med. 2001;  344 1879-1887
• 10 Chen ZM, Jiang LX, Chen YP. et al. . Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.  Lancet. 2005;  366 1607-1621
• 11 De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts.  Circulation. 2004;  109 1223-1225
• 12 de Winter RJ, Windhausen F, Cornel JH. et al. . Early invasive versus selectively invasive management for acute coronary syndromes.  N Engl J Med. 2005;  353 1095-1104
• 13 Eikelboom JW, Anand SS, Malmberg K. et al. . Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis.  Lancet. 2000;  355 1936-1942
• 14 Fox KA, Mehta SR, Peters R. et al. . Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial.  Circulation. 2004;  110 1202-1208
• 15 Gersh BJ, Stone GW, White HD, Holmes Jr. DR. Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future?.  JAMA. 2005;  293 979-986
• 16 Gershlick AH, Stephens-Lloyd A, Hughes S. et al. . Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction.  N Engl J Med. 2005;  353 2758-2768
• 17 Hamm C, Arntz HR, Bode C. et al. . Leitlinien: Akutes Koronarsyndrom (ACS) Teil 1: ACS ohne persistierende ST-Hebung.  Z Kardiol. 2004;  93 72-90
• 18 Hamm C, Arntz HR, Bode C. et al. . Leitlinien: Akutes Koronarsyndrom (ACS) Teil 2: ACS mit ST-Hebung.  Z Kardiol. 2004;  93 324-341
• 19 Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.  Lancet. 2003;  361 13-20
• 20 Mahaffey KW, Cohen M, Garg J. et al. . High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial.  JAMA. 2005;  294 2594-2600
• 21 Morrison LJ, Verbeek PR, McDonald AC. et al. . Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis.  JAMA. 2000;  283 2686-2692
• 22 Myocardial infarction redefined - a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.  Eur Heart J. 2000;  21 1502-1513
• 23 Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.  Lancet. 2 349-360
• 24 Sabatine MS, Cannon CP, Gibson CM. et al. . Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation.  N Engl J Med. 2005;  352 1179-11789
• 25 Simoons ML. GUSTO IV-ACS Investigators. Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial.  Lancet. 2001;  357 1915-1924
• 26 Steg PG, Bonnefoy E, Chaubaud S. et al. . Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty.  Circulation. 2003;  108 2851-2856
• 27 Steinhubl SR, Berger PB, Mann 3rd JT. et al. . Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial.  JAMA. 2002;  288 2411-2420
• 28 Topol EJ. GUSTO V Investigators. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial.  Lancet. 2001;  357 1905-1914
• 29 Van de Werf F, Ardissino D, Betriu A. et al. . Management of acute myocardial infarction in patients presenting with ST-segment elevation.  Eur Heart J. 2003;  24 28-66
• 30 Wallentin L, Goldstein P, Armstrong PW. et al. . Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 PLUS randomized trial in acute myocardial infarction.  Circulation. 2003;  108 135-142

1 CLopidogrel as Adjunctive ReperfusIon Therapy

2 Facilitated INtervention with Enhanced reperfusion Speed to Stop Events

Anschrift des Verfassers