Chronisches Koronarsyndrom – optimale medikamentöse Therapie

Zusammenfassung

Der Begriff „chronisches Koronarsyndrom“ ersetzt mit den aktuellen Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) die Begrifflichkeit der sogenannten „stabilen koronaren Herzerkrankung (KHK)“. Hierdurch werden insbesondere die chronisch-progredienten Eigenschaften der KHK betont. Die medikamentöse Therapie des chronischen Koronarsyndroms zielt auf die Minimierung der Ereignisraten und Symptomprogredienz ab. Zu den wesentlichen Säulen dieser medikamentösen Therapie zählen die Antianginosa (u. a. Betablocker, Kalziumantagonisten, organische Nitrate), die verschiedenen Plättchenaggregationsregime, Lipidsenker sowie Modulatoren des Renin-Angiotensin-Aldosteron-Systems. Eine sogenannte allgemeingültige „optimale Therapie“ ist schwierig zu definieren, daher gilt es, individuell für jeden Patienten die bestmögliche Therapie und Symptomkontrolle anhand dieser Leitlinienempfehlungen zu definieren und nach Bedarf anzupassen.

Abstract

“Chronic coronary syndromes” replaces the term of the so-called “stable coronary artery disease (CAD)” with the current guideline recommendations of the European Society of Cardiology (ESC). This emphasizes the chronic-progressive nature of CAD. The drug therapy for chronic coronary syndromes aims at minimizing event rates and symptom progression/optimal symptom control. The main pillars of these drug therapies include anti-angina therapy (e.g. beta-blockers, calcium antagonists, organic nitrates), the various platelet aggregation regimens, statins, and modulators of the renin-angiotensin-aldosterone system. A so-called, generally valid “optimal therapy” is difficult to define, therefore it is necessary to define the best possible therapy and symptom control for each patient on the basis of these guidelines and to adapt it as required.

Was ist wichtig?

• Der Begriff „chronisches Koronarsyndrom“ ersetzt erstmals den Terminus der „stabilen koronaren Herzerkrankungen“.

• Zu den wesentlichen Komponenten der Sekundärprävention zählen Symptom- und Ischämiereduktion sowie Minimierung der Krankheitsprogression.

• Antianginosa, Plättchenaggregationsregime, Lipidsenkung und Modulatoren des Renin-Angiotensin-Aldosteron-Systems bilden die Grundpfeiler der medikamentösen Therapie.

Schlüsselwörter

Nitrate - chronisches Koronarsyndrom - stabile Angina pectoris - antianginöse Therapie

Key words

nitrates - chronic coronary syndromes - stabile angina - antianginal therapy

Publication History

Article published online:
30 June 2020

• Literatur

• 1 Knuuti J, Wijns W, Saraste A. et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41: 407-477 doi:10.1093/eurheartj/ehz425
• 2 Bangalore S, Maron DJ, OʼBrien SM. et al. Management of Coronary Disease in Patients with Advanced Kidney Disease. N Engl J Med 2020; 382: 1608-1618 doi:10.1056/NEJMoa1915925
• 3 Maron DJ, Hochman JS, Reynolds HR. et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020; 382: 1395-1407 doi:10.1056/NEJMoa1915922
• 4 Spertus JA, Jones PG, Maron DJ. et al. Health Status after Invasive or Conservative Care in Coronary and Advanced Kidney Disease. N Engl J Med 2020; 382: 1619-1628 doi:10.1056/NEJMoa1916374
• 5 Spertus JA, Jones PG, Maron DJ. et al. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. N Engl J Med 2020; 382: 1408-1419 doi:10.1056/NEJMoa1916370
• 6 Belsey J, Savelieva I, Mugelli A. et al. Relative efficacy of antianginal drugs used as add-on therapy in patients with stable angina: A systematic review and meta-analysis. Eur J Prev Cardiol 2015; 22: 837-848 doi:10.1177/2047487314533217
• 7 Klein WW, Jackson G, Tavazzi L. Efficacy of monotherapy compared with combined antianginal drugs in the treatment of chronic stable angina pectoris: a meta-analysis. Coron Artery Dis 2002; 13: 427-436 doi:10.1097/00019501-200212000-00008
• 8 Diaz A, Bourassa MG, Guertin MC. et al. Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease. Eur Heart J 2005; 26: 967-974 doi:10.1093/eurheartj/ehi190
• 9 Fox KM, Mulcahy D, Findlay I. et al. The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group. Eur Heart J 1996; 17: 96-103 doi:10.1093/oxfordjournals.eurheartj.a014699
• 10 Bangalore S, Steg G, Deedwania P. et al. β-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 2012; 308: 1340-1349 doi:10.1001/jama.2012.12559
• 11 Poole-Wilson PA, Lubsen J, Kirwan BA. et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet 2004; 364: 849-857 doi:10.1016/S0140-6736(04)16980-8
• 12 Tardif JC, Ford I, Tendera M. et al. Efficacy of ivabradine, a new selective I(f) inhibitor, compared with atenolol in patients with chronic stable angina. Eur Heart J 2005; 26: 2529-2536 doi:10.1093/eurheartj/ehi586
• 13 Schupke S, Neumann FJ, Menichelli M. et al. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med 2019; 381: 1524-1534 doi:10.1056/NEJMoa1908973
• 14 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87-165 doi:10.1093/eurheartj/ehy394
• 15 Bonaca MP, Bhatt DL, Cohen M. et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015; 372: 1791-1800 doi:10.1056/NEJMoa1500857
• 16 Eikelboom JW, Connolly SJ, Bosch J. et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med 2017; 377: 1319-1330 doi:10.1056/NEJMoa1709118
• 17 Lip GYH, Collet JP, Haude M. et al. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2019; 21: 192-193 doi:10.1093/europace/euy174
• 18 Lopes RD, Hong H, Harskamp RE. et al. Optimal Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: An Updated Network Meta-analysis. JAMA Cardiol 2020; DOI: 10.1001/jamacardio.2019.6175.
• 19 Mach F, Baigent C, Catapano AL. et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41: 111-188 doi:10.1093/eurheartj/ehz455