Akuter Myokardinfarkt – Thrombolyse versus interventionelle Therapie

Zusammenfassung

Die frühe, vollständige und anhaltende Rekanalisation des Infarktgefäßes ist das entscheidende therapeutische Ziel in der Behandlung des akuten Myokardinfarkts. Durch die Einführung der intravenösen Thrombolysetherapie ist die Letalität signifikant gesunken. In prospektiven Studien sind die Thrombolytika Streptokinase und rt-PA umfassend geprüft. Ihr Differentialeinsatz in der Akuttherapie ist heute genau definiert. Das Wissen um die Bedeutung der Thrombozytenaggregation in der Thrombogenese führte zur Untersuchung von Kombinationen moderner GPIIb/IIIa-Inhibitoren mit Plasminogen-Aktivatoren. Als wirksame Alternative zur Thrombolyse hat sich in den letzten Jahren die akute, kathetertechnische Ballondilatation etabliert. In Kombination mit einer Thrombozyteninhibition mit dem monoklonalen Antikörper Abciximab und einer Stentimplantation können exzellente Ergebnisse erzielt werden. Nachteil dieses Vorgehens ist der höhere wirtschaftliche Aufwand sowie die Beschränkung auf entsprechend ausgestattete Zentren. Zukünftige Strategien werden darauf hinzielen, thrombolytische Therapien so zu entwickeln, daß sie sich im Einzelfall optimal durch mechanische Rekanalisationsverfahren ergänzen lassen. Patienten, die besonders von einem solchen kooperativen Konzept zwischen Krankenhäusern der Regelversorgung, Notärzten und interventionell aktiven Zentren profitieren, müssen identifiziert werden.

Summary

The dominant goal of therapy in acute myocardial infarction is to achieve early, complete and persistent patency of the infarct related coronary artery. As the occluding thrombus was identified to cause 90% of myocardial infarctions intravenous thrombolytic therapy was developed. Infarct related mortality decreased significantly. Among various substances that have been developed Streptokinase and recombinant tissue Plasminogen Activator are well established. Increasing knowledge about the importance of platelet aggregation during the process of thrombus formation and dissolution led to concepts combining Plasminogen activators and Glycoprotein IIb/IIIa – Inhibitors as thrombolytic agents. Primary balloon angioplasty with or without stent implantation and pharmacological platelet inhibition has emerged as a convincing alternative concept to achieve patent coronary arteries after myocardial infarction. However its obvious advantages (known coronary anatomy, immediate complete interventional therapy) are restricted to some well equipped centers. Currently therapeutic strategies are under investigation that allow immediate thrombolytic therapy in peripheral hospitals and support interventional treatment in case of failure of the thrombolytic approach. Patients that specially profit from cooperative mangement between emergency teams, primary care hospitals and interventional centers will be identified.

Stichwörter

Herzinfarkt - Koronarangioplastie - Thrombolyse

Keywords

Myocardial infarction - coronary angioplasty - thrombolysis

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