Neue STEMI-Leitlinien – Was ist neu in der Behandlung von ST-Hebungsinfarkten?

Die frühzeitige Diagnose und Behandlung von ST-Hebungsinfarkten (STEMI) ist unverändert die Kernforderung der neuen Leitlinien. Diese sehen vor, dass Zentren mit Herzkatheterlabor in der Lage sein sollten, an 7 Tagen pro Woche rund um die Uhr innerhalb von 60 Minuten nach dem telefonischen Kontakt eine interventionelle Therapie anzubieten. Die Leitlinien fordern auch, dass Rettungsteams in der Lage sein sollten, Patienten mit STEMI rasch zu identifizieren und eine initiale Therapie, wenn nötig auch die Durchführung einer Fibrinolyse, einzuleiten. Sie heben auch die Notwendigkeit koordinierter regionaler Netzwerke aus Ambulanzen und Krankenhäusern mit Herzkatheterlaboren hervor. Dadurch kann eine schnelle und effektive Reperfusionstherapie ermöglicht werden.

Zentrale zeitliche Ziele bzw. Vorgaben der Leitlinien sind: vom ersten medizinischen Kontakt (EMK) eines Patienten bis zur EKG-Diagnose maximal 10 Minuten, vom EMK bis zur Initiierung einer Fibrinolyse maximal 30 Minuten und vom ersten medizinischen Kontakt bis zur PCI maximal 90 Minuten. Diese Zeit verkürzt sich auf 60 Minuten, wenn sich der Patient direkt im Zentrum mit PCI-Bereitschaft vorstellt oder der Symptombeginn nur 2 Stunden zurückliegt oder ein großer Myokardinfarkt besteht.

An Antikoagulantien sollten periinterventionell Bivalirudin bzw. nicht fraktioniertes oder niedermolekulares Heparin zum Einsatz kommen, und an Antiplättchensubstanzen sollten zusätzlich zu ASS Prasugrel oder Ticagrelor für ein Jahr gegeben werden. Zum Schluss beinhalten die Leitlinien Empfehlungen zur medikamentösen Sekundärprävention und zu Lebensstiländerungen.

Timely diagnosis and treatment of STEMI is central to the new recommendations for management of acute myocardial infarction patients. The new guideline includes a recommendation that centers equipped to perform primary PCI should deliver care on a 24/7 basis and within 60 minutes of an initial call. The guideline also notes that ambulance teams should be trained and able to identify patients with STEMI and administer initial therapy, including fibrinolysis if applicable. The guideline also highlights the importance of regional networks, which include the ambulance service and the cath lab, that are designed to deliver reperfusion therapy quickly and effectively.

Key time targets set by the guidelines include first medical contact (FMC) to ECG - no longer than 10 minutes, FMC to fibrinolysis - no longer than 30 minutes, and FMC to primary PCI - no longer than 90 minutes (or one hour if patient presents in a PCI-able hospital, or within two hours of onset or has large area at risk).

Also of note: the periprocedural concomitant treatment. Antiplatelet therapy should include aspirin and prasugrel or ticagrelor. Bivalirudin, unfractioned heparin as well as enoxaparin can be used as anticoagulant agent. Finally, the guidelines mentioned the medical secondary prevention and lifestyle changes.

Key words

Acute myocardial infarction - STEMI - reperfusion therapy - primary PCI - secondary prevention

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