Abstract
The optimal antithrombotic strategy in patients with coronary artery disease gains increasing complexity along with the development of a variety of novel antiplatelet medications. Variable doses as well as combinations of the various treatment options allow a more and more individualised regimen with regard to the respective patient condition (e. g. stable angina, acute coronary syndrome), the treatment strategy (e. g. conservative, CABG, coronary stenting), the stent type (e. g. bare metal, drug eluting stent) and the individual comorbidities and comedications (e. g. indication for anticoagulation or individual bleeding risk).
Kernaussagen
Stabile koronare Herzerkrankung
Bei konservativer Therapie sollte ASS 75 – 100 mg/d die Standardtherapie darstellen. Clopidogrel 75 mg/d ist das Alternativpräparat. Nach Implantation eines BMS sollte für mindestens 4 Wochen, nach DES für mindestens 6 – 12 Monate mit ASS und Clopidogrel behandelt werden. Besteht bei Implantation eines BMS zusätzlich die Indikation zur permanenten Antikoagulation, wird eine 4-wöchige Dreifachtherapie mit ASS/Clopidogrel/Antikoagulation (meist Phenprocoumon) unter engmaschiger Kontrolle empfohlen.
Akutes Koronarsyndrom
Bei konservativer wie interventioneller Therapie sollte eine duale antithrombozytäre Therapie mit ASS und Clopidogrel für 12 Monate gegeben werden, gefolgt von einer dauerhaften Monotherapie. Prasugrel ist nach Stentimplantation eine vielversprechende Alternative zu Clopidogrel, wenn es sich um jüngere Patienten handelt, deren Blutungsrisiko nicht erhöht ist und die kein zerebrovaskuläres Ereignis (TIA/Schlaganfall) in der Anamnese aufweisen – insbesondere bei Patienten mit hohem Risiko für ischämische Komplikationen wie STEMI oder Diabetes mellitus.
Literatur
-
1
Antithrombotic Trialists Collaboration .
Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.
BMJ.
2002;
324
71-83
-
2
CAPRIE Steering Committee .
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).
Lancet.
1996;
348
1329-1339
-
3
Bhatt D L, Fox K A, Hacke W. et al. CHARISMA Investigators .
Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events.
N Engl J Med.
2006;
354
1706-1717
-
4
Kastrati A, Mehilli J, Pache J. et al .
Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal stents.
N Engl J Med.
2007;
356
1030-1039
-
5
Bhatt D L, Flather M D, Hacke W. et al .
Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial.
J Am Coll Cardiol.
2007;
49
1982-1988
-
6
Iakovou I, Schmidt T, Bonizzoni E. et al .
Incidence, predictors and outcome of thrombosis after successful implantation of drug-eluting stents.
JAMA.
2005;
293
2126-2130
-
7
Smith Jr. S C, Feldman T E, Hirshfeld Jr. J W. et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention .
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention).
Circulation.
2006;
113
e166-e286
-
8
Silber S, Borggrefe M, Böhm M. et al .
Positionspapier der DGK zur Wirksamkeit und Sicherheit von Medikamente freisetzenden Koronarstents (DES).
Der Kardiologe.
2007;
1
84-111
-
9
Grines C L, Bonow R O, Casey D E. et al .
Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians.
J Am Coll Cardiol.
2007;
49
734-739
-
10
Steinhubl S R, Berger P B, Mann T J. et al .
for the CREDO-Investigators. Early and sustained oral antiplatelet therapy following percutaneous coronary intervention. A randomized Trial.
JAMA.
2002;
288
2411-2420
-
11
May A E, Geisler T, Gawaz M.
Antithrombotic therapy after coronary stenting in cardiac risk patients.
Thromb Haemost.
2008;
99
487-493
-
12
Patrono C, Garcia Rodriguez L A, Landolfi R, Baigent C.
Low-dose aspirin for the prevention of atherothrombosis.
N Engl J Med.
2005;
353
2373-2383
-
13
Schomig A, Neumann F J, Kastrati A. et al .
A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents.
N Engl J Med.
1996;
334
1084-1089
-
14
Connolly S, Pogue J, Hart R. et al. ACTIVE Writing Group of the ACTIVE Investigators .
Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.
Lancet.
2006;
367
1903-1912
-
15
Gawaz M, Neumann F J, Schömig A.
Evaluation of platelet membrane glycoproteins in coronary artery disease: consequences for diagnosis and therapy.
Circulation.
1999;
99
E1-E11
-
16
Yusuf S, Zhao F, Mehta S R. et al .
Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.
N Engl J Med.
2001;
345
494-502
-
17
Bassand J P, Hamm C W, Ardissino D. et al .
Guidelines for the diagnosis and treatment of non-STsegment elevation acute coronary syndromes. Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology.
Eur Heart J.
2007;
28
1598-1660
-
18
Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators .
Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.
N Engl J Med.
2001;
345
494-502
-
19
Mehta S, Yusuf S, Peters R JG. et al .
Effects of pre-treatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.
Lancet.
2001;
358
527-533
-
20
Geisler T, Grass D, Bigalke B. et al .
The residual platelet aggregation after deployment of intracoronary stent (PREDICT) score.
J Thromb Haemost.
2008;
6
54-61
-
21
Wiviott S D, Braunwald E, McCabe C H. et al .
Prasugrel versus clopidogrel in patients with acute coronary syndromes. TRITON-TIMI 38 Investigators.
N Engl J Med.
2007;
357
2001-2015
-
22
Montalescot G, Wiviott S D, Braunwald E. et al .
Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-segment elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomized controlled trial.
Lancet.
2009;
373
723-731
-
23
Wiviott S D, Braunwald E, Angiolillo D J. et al. TRITON-TIMI 38 Investigators .
Greater clinical benefit of more intensive oral antiplatelet therapy with prasugrel in patients with diabetes mellitus in the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-Thrombolysis in Myocardial Infarction 38.
Circulation.
2008;
118
1626-1636
-
24
Wallentin L, Becker R C, Budaj A. et al. PLATO Investigators, Freij A, Thorsén M .
Ticagrelor versus clopidogrel in patients with acute coronary syndromes.
N Engl J Med.
2009;
361
1045-1057
Prof. Dr. Andreas E. May
Medizinische Klinik III
Eberhard-Karls-Universität Tübingen
Otfried-Müller-Straße 10
72076 Tübingen
eMail: andreas.may@med.uni-tuebingen.de
