Antithrombozytäre Therapie bei akutem Koronarsyndrom ohne ST-Strecken-Elevation

Zusammenfassung

Für Patienten mit akutem Koronarsyndrom ohne ST-Strecken-Elevation, aber mit Risikomerkmalen (positiver Troponin-Status, Diabetes mellitus, signifikante ST-Streckensenkungen, hoher TIMI-Risikoscore) empfehlen die nationalen und internationalen Fachgesellschaften eine frühinvasive Vorgehensweise (rasche Herzkatheteruntersuchung) und eine effiziente antithrombozytäre Therapie. Letztere basiert neben der obligaten Gabe von Acetylsalicylsäure auf Thienopyridinen (Clopidogrel) sowie Glykoprotein-IIb/IIIa-Rezeptorantagonisten (GPIIb/IIIa-Rezeptorantagonisten). Die Initiierung einer antithrombozytären Therapie sollte bei Risikopatienten schon vor Durchführung einer invasiven Diagnostik beginnen. Dieses Vorgehen wird als „Upstream-Therapie” bezeichnet und in den nationalen sowie internationalen Leitlinien für die GPIIb/IIIa-Rezeptorantagonisten empfohlen. Der Zeitpunkt der Clopidogrel-Erstgabe ist bislang noch nicht prospektiv evaluiert worden. Post-hoc-Analysen zeigen jedoch auch für Clopidogrel einen Vorteil der Upstream-Therapie. Eine antithrombozytäre „Downstream-Therapie” (Initiierung der Medikamentengabe erst kurz vor oder während der invasiven Diagnostik) ist nach den aktuellen Leitlinien hinsichtlich der GPIIb/IIIa-Rezeptorantagonisten bei solchen Patienten zu bevorzugen, die einer sofortigen Herzkatheteruntersuchung bedürfen (< 2,5 h nach Symptombeginn).

Summary

National and international guidelines recommend an early invasive strategy (cardiac catheterization) and efficacious inhibition of platelet aggregation in patients with acute coronary syndrome (ACS) without ST-segment elevation but with risk factors (raised troponin level, diabetes mellitus, significant ST-segment depression, high TIMI risk score). Platelet inhibition includes the administration of aspirin, thienopyridines (i.e. clopidogrel) and GPIIb/IIIa receptor antagonists. In patients at risk antithrombotic treatment should be started before invasive diagnostic procedures ("upstream" treatment) including GPIIb/GPIIIa receptor antagonists. The timing of clopidogrel administration has not been studied prospectively so far, however, post-hoc analyses suggest beneficial effects of a clopidogrel "upstream" management. According to current guidelines "downstream" GPIIb/GPIIIa (initiation of antithrombotic medication just before or during invasive diagnostic catheterization) is preferred in those patients who require immediate cardiac catheterization (< 2 hours after onset of symptoms).

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