Anticoagulation during and after acute coronary syndrome

Summary

Current antithrombotic therapy in patients with acute coronary syndrome (ACS) comprises antiplatelet and anticoagulant therapy. Dual antiplatelet therapy composed of aspirin plus a third generation P2Y12 inhibitor (prasugrel or ticagrelor) represents the gold standard, while aspirin plus second generation P2Y12 inhibitor (clopidogrel) may be used as an alternative in the presence of contraindications for third generation P2Y12 inhibitors and/or a high risk of bleeding. Unfractionated heparin (UFH) has been the unchallenged mainstay in anticoagulation for ACS for many decades and is still widely used in patients with ACS treated interventionally. Novel alternative parenteral anticoagulant strategies include the low molecular weight heparin enoxaparin and the synthetic pentas-accharide fondaparinux. Both of these agents share advantages over UFH particularly in medically treated patients with ACS not scheduled for PCI. The direct parenteral factor IIa (thrombin) inhibitor bivalirudin, when used as sole anticoagulant in patients with ACS undergoing PCI, is as effective as the regimen of UFH plus GPIIb/IIIa inhibitor in NSTEMI and superior to the latter regimen in patients with STEMI. The novel approach of a long-term low dose factor Xa inhibition with rivaroxaban in the post ACS phase even further reduced cardiovascular mortality in a clinical trial but has yet to be established in daily clinical practice in the setting of third generation P2Y12 inhibitors. This review discusses currently clinically established anticoagulants for the treatment of ACS alongside with novel approaches such as rivaroxaban.

Zusammenfassung

Die derzeitige antithrombotische Therapie bei Patienten mit akutem Koronarsyndrom umfasst Antiplättchen- und antikoagulative The-rapie. Die duale Plättchenhemmung bestehend aus Aspirin sowie einem P2Y12-Inhibitor der dritten Generation (Prasugrel oder Ticagrelor) stellt den Goldstandard dar, während Aspirin zusammen mit einem P2Y12-Inhibitor der zweiten Generation (Clopidogrel) beim Vorhandensein von Kontraindikationen für P2Y12-Inhibitoren der dritten Generation oder aber bei hohem Blutungsrisiko als Alternative eingesetzt wird. In der klassischen anti koagulativen Therapie gilt unfraktioniertes Heparin nach wie vor als Therapiestandard besonders bei Patienten, die interventionell behandelt werden. Neue alternative parenterale Antikoagulationsstrategien umfassen den Einsatz von niedermolekularen Heparinen, z. B. Enoxaparin, und dem synthetischen Pentasaccharid Fondaparinux. Beide Substanzen teilen Vorteile im Vergleich zum unfraktionierten Heparin, besonders bei Patienten mit akutem Koronarsyndrom, die konservativ behandelt werden. Der direkte parenterale Faktor-IIa(Thrombin)-Inhibitor Bivalirudin ist genauso effektiv wie die Kom-bination aus unfraktioniertem Heparin plus Glykoprotein-IIb/IIIa-Inhibitor bei Patienten mit NSTEMI und sogar überlegen zu dem genannten Regime bei STEMI-Patienten, sofern Bivalirudin als einziges Antikoagulanz während der PCI genutzt wird. Der neue Ansatz einer Langezeitbehandlung mit einer niedrigen Dosis des oralen Faktor-Xa-Inhibitors Riva roxaban in der Post-ACS-Phase konnte in der Atlas-II-Studie die kardiovaskuläre Mortalität weiter reduzieren. Allerdings muss sich dieses Konzept in der Klinik in Verbindung mit P2Y12-Inhibitoren der dritten Generation bewähren. Diese Übersichtsarbeit diskutiert ausführlich die etablierten Antikoagulanzien für die Behandlung des akuten Koronarsyndroms sowie neue Ansätze, z. B. Rivaroxaban.

Keywords

ACS - activated clotting time - anticoagulation - heparin - enoxaparin - fondaparinux - bivali -rudin - pegnivacogin - rivaroxaban

Schlüsselwörter

Akutes Koronarsyndrom - Antikoagulation - Heparin - Enoxaparin - Fondaparinux - Bivali -rudin - Pegnivacogin - Rivaroxaban

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