Akutes Koronarsyndrom – Zukünftiger Stellenwert der Thrombozytenhemmung und der DOAKs

Zusammenfassung

Wie weitreichend die Konsequenzen der Zulassung von Rivaroxaban in niedriger Dosierung (2 x 2,5 mg) durch die europäischen Behörden zur Behandlung von Patienten mit überlebtem akuten Koronarsyndrom (ACS) sein werden, ist noch unklar. Entsprechend des Designs der ATLAS-2-Studie wird sich die Anwendung auf die Kombinationstherapie mit ASS und Clopidogrel als antithrombotische Tripletherapie beschränken. Die meisten Patienten werden in Deutschland nach ACS jedoch mit einem der neueren Adenosindiphosphat (ADP)-Hemmer Ticagrelor oder Prasugrel und nicht mit Clopidogrel behandelt. Für diese Patienten wird in absehbarer Zeit noch keine plasmatische Antikoagulation in austitrierter, niedriger Dosierung zur Verfügung stehen, obwohl dieses Konzept zur Minimierung der Thrombinbildung pathophysiologisch sinnvoll ist. Überraschend war die negative Beurteilung der intravenösen ADP-Hemmung mit Cangrelor durch das Beratergremium der US-amerikanischen Zulassungsbehörde. Überraschend war aber auch die positive Bewertung der dreifachen Thrombozytenhemmung mit ASS, Clopidogrel und Vorapaxar, dem ersten Vertreter der neuen Substanzklasse der Thrombinrezeptor-Hemmer, zur Sekundärprophylaxe von Patienten mit überlebtem ACS (bei negativer Schlaganfall-Anamnese).

Summary

It is not yet clear how many patients will be treated with the recently approved rivaroxaban after acute coronary syndrome (ACS), because according to the design of the ATLAS-2 trial, it will be combined with aspirin and clopidogrel. Following the European guidelines, most ACS patients are currently treated with one of the newer adenosine diphosphate (ADP) receptor blockers ticagrelor or prasugrel however, and not with clopidogrel. Although the concept of limiting thrombin generation with low-dose anticoagulation is intriguing, it will not be available for these patients in the near future. It was surprising that the Food and Drug Administration advisory panel voted against approving cangrelor for intravenous ADP inhibition, but supported thrombin receptor inhibition with vorapaxar. Vorapaxar is a member of a novel antiplatelet agent class that was beneficial in ACS patients without history of stroke or transitoric ischemic attack in combination with aspirin and clopidogrel.

Key words

Acute coronary syndrome - new oral anticoagulants - antiplatelet therapy - rivaroxaban - cangrelor - vorapaxar

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