Bridging: Perioperatives Vorgehen bei dauerhafter oraler Antikoagulation oder Plättchenfunktionshemmung

Zusammenfassung

Orale Antikoagulanzien [Vitamin-K-Antagonisten, Dabigatran, Rivaroxaban, Apixaban] und Plättchenfunktionshemmer (PH) [ASS, Clopidogrel, Prasugrel, Ticagrelor] werden alleine oder kombiniert zur Prävention und Behandlung thromboembolischer Erkrankungen eingesetzt. Patienten mit Indikation zu einer dauerhaften Antikoagulation [Vorhofflimmern, mechanischer Herzklappenersatz, venöse Thromboembolie] oder PH-Therapie [zerebro- oder kardiovaskuläre Ereignisse] benötigen bei interventionellen oder chirurgischen Eingriffen eine vorübergehende Umstellung auf entsprechende Medikamente mit einer kurzen Wirkungsdauer. Die aktuellen Empfehlungen für das praktische Vorgehen drücken sich aufgrund einer begrenzten Datenlage in schwachen Empfehlungsgraden aus, sodass zur Planung einer überbrückenden gerinnungshemmenden Therapie [„Bridging“] bei jedem Patienten das Blutungs- und Thromboembolierisiko gegeneinander abgewogen werden müssen. Bei einem mittleren Thromboembolierisiko bestimmt das individuell zu ermittelnde Blutungsrisiko der geplanten Intervention die überbrückende Therapie: Ist das Blutungsrisiko durch die geplante Intervention gering, kann die orale Antikoagulation/PH-Therapie in den meisten Fällen unverändert weitergeführt oder in ihrer Intensität geringfügig reduziert werden. Ist bei mittlerem bis hohem Blutungsrisiko das Thromboserisiko gering, kann die gerinnungshemmende Therapie auch kurzfristig pausiert werden. Bei hohem Thromboembolie- und Blutungsrisiko wird die Umstellung der oralen Antikoagulation mit unfraktioniertem [eingeschränkte Nierenfunktion] oder fraktioniertem Heparin durchgeführt. Die PH-Therapie kann bei hohem Thromboembolie- und Blutungsrisiko mit kurzwirksamen GPIIb-IIIa Antagonisten [Eptifibatide; Tirofiban] überbrückt werden. Patienten, die auf die neuen oralen Antikoagulanzien [Dabigatran, Rivaroxaban, Apixaban] eingestellt sind, benötigen vor elektiven Interventionen in Abhängigkeit von der Halbwertszeit und der individuellen Nierenfunktion eine Behandlungspause und müssen vor OP nicht mit Heparinen überbrückt werden.

Abstract

Oral anticoagulants [Vitamin-K-Antagonists, Dabigatran, Rivaroxaban, Apixaban] or antiplatelet agents [Aspirin, Clopidogrel, Prasugrel, Ticagrelor] are effective in preventing thromboembolic diseases. In case of interventional of surgical procedures patients with indications for chronic anticoagulation [atrial fibrillation, valve prosthesis, venous thromboembolism] or use of antiplatelet agents [cerebrovascular events, cardiovascular events] will require interruption of antithrombotic/antiplatelet therapy with the need of replacement with a short-acting agent. Due to limited data available from randomized studies and meta-analyses the evidence level is low in the majority of recommendations. Therefore for each patient the bleeding and thrombosis risk depending on the individual patient constitution and the planned intervention must be weighted. In patients with an intermediate risk for thrombosis the bleeding risk of the scheduled intervention will influence the bridging recommendation: In patients with a low bleeding risk oral anticoagulation/antiplatelet therapy can be continued or reduced in intensity. In patients with an intermediate or high bleeding risk along with a low thrombosis risk a temporary interruption of the anticoagulation/antiplatelet therapy is feasible. In patients with a high thrombosis and bleeding risk anticoagulation should be bridged with unfractionated heparin [renal insufficiency] or low molecular weight heparin. In the latter risk situation, inhibition of platelet function can be achieved with short-lasting GPIIb-IIIa inhibitors [Eptifibatide, Tirofiban]. Prior to intervention patients treated with the new oral anticoagulants [Dabigatran; Rivaroxaban; Apixaban] are requested to temporary interrupt the anticoagulation depending on the individual drug half-life and their renal function. Bridging therapy with heparin prior to intervention is not necessary with the new oral anticoagulants.

Schlüsselwörter

Bridging - orale Antikoagulation - Plättchenfunktionshemmer - neue orale Antikoagulanzien

Keywords

bridging - oral anticoagulants - platelet function inhibition - new oral anticoagulants

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