Differenzierte antithrombozytäre Therapie bei akutem Koronarsyndrom

Zusammenfassung

Die duale antithrombozytäre Therapie ist ein Eckpfeiler der Nachbehandlung interventionell versorgter Patienten mit einem akuten Koronarsyndrom (ST-Hebungsinfarkt, Nicht-ST-Hebungsinfarkt, instabile Angina Pectoris). In den vergangenen Jahren hat sich besonders die zusätzlich zur niedrig-dosierten Acetylsalicylsäuregabe durchgeführte P2Y₁₂-Hemmung intensiver Debatten erfreut. Dies liegt vor allem an den in den letzten Jahren veröffentlichten Daten der großen Phase III-Studien „TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN“ (TRITON) mit Prasugrel sowie „Study of Platelet Inhibition and Patient Outcomes“ (PLATO) mit Ticagrelor jeweils im Vergleich zu Clopidogrel bei Patienten mit akutem Koronarsysndrom. Im vorliegenden Artikel fassen wir nochmals kurz die wichtigen Daten und Subanalysen aus den beiden Studienprogrammen zusammen und zeigen eine klinische Entscheidungsfindung in der Handhabung der drei Substanzen beim akuten Koronarsyndrom auf. Besonderes Augenmerk liegt dabei auf sogenannten Hochrisikokollektiven wie Patienten mit ST-Hebungsinfarkt und bei Diabetes, aber auch auf der Vermeidung von relevanten Blutungen, wie sie unter einer verstärkten Thrombozytenhemmung unabdinglich häufiger auftreten.

Abstract

Dual antiplatelet therapy is the cornerstone of maintenance medication following invasive treatment of patients with acute coronary syndromes (ST elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina). Over the last decade, P2Y₁₂ inhibition in addition to low-dose acetylsalicylic acid has been intensively debated. The debate was enriched by the results of the large phase III clinical trials for prasugrel (TRITON) and ticagrelor (PLATO) compared to clopidogrel in patients with acute coronary syndromes. This article summarizes the critical details und subanalyses of both study programmes and highlights on clinical decision making when using the three P2Y₁₂ blockers in acute coronary syndromes. A special focus is on higher risk patients such as those with ST elevation myocardial infarction and those with coexisting diabetes, but also on minimizing relevant bleedings, which are common during more intense platelet inhibition.

Schlüsselwörter

akutes Koronarsyndrom - P2Y12-Blocker - Thrombozyteninhibition - Koronarintervention

Keywords

acute coronary syndrome - P2Y12 blockers - platelet inhibition - coronary intervention

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