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DOI: 10.1055/s-2001-12521
© Georg Thieme Verlag Stuttgart · New York
Intravenöse Heparintherapie beim akuten ischämischen Hirninfarkt - Contra
Intravenous Heparin Therapy in Acute Ischaemic Cerebral Infarct: ContraPublication History
Publication Date:
31 December 2001 (online)
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Einleitung
War in den Jahren bis ca. 1988 die Hämodilution in Deutschland die Standardtherapie des normalen ischämischen Schlaganfalls, verschob sich der Schwerpunkt eines Standardvorgehens in den 90er Jahren hin zum Heparin [1]. In einigen Kliniken werden bis zu 80 % aller akuten Schlaganfallpatienten mit Heparin behandelt (unveröffentlichte Ergebnisse der Deutschen Schlaganfalldatenbank). Ähnlich ist die Situation in den USA, wo je nach Krankenhaus 10 % bis zu 90 % aller Schlaganfallpatienten intravenöses Heparin erhalten [2] [3]. Dabei ist den meisten Ärzten bewusst, dass die derzeit in Deutschland gebräuchliche PTT-wirksame Vollheparinisierung (intravenöse Gabe von unfraktioniertem Heparin mit PTT-Kontrolle und dem Ziel der 1,5 - 2fachen PTT-Verlängerung) keine gesicherte Therapieform im Sinne eines evidence-based Konzeptes ist. So glaubten nur 6,4 % aller befragten Ärzte in USA, dass Heparin wirkt, aber ca. ⅔ der Kollegen benützten Heparin als Therapie [4].
Triebfedern der intravenösen Heparintherapie ohne gesicherte wissenschaftliche Basis sind derzeit neben dem Gewohnheitsrecht einer eingeschliffenen Behandlung, persönliche Erfahrungen mit emotional verständlichem Ausklammern negativer Ergebnisse, wie z. B. Blutungen oder Thrombopenien, Sicherheitsdenken mit dem Motto „trotz Heparingabe verschlechterte sich der Patient” und die zugegebenermaßen weitgehend fehlenden Alternativtherapien.
In dieser Gegenposition zu der Zusammenfassung von Busse und Haberl soll gezeigt werden, dass Heparin intravenös und PTT-wirksam verabreicht generell beim ischämischen Schlaganfall weder hilfreich noch indiziert, sondern problematisch und risikobeladen ist.
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Prof. Dr. med. Gerhard F. Hamann
Neurologische Klinik
Ludwig-Maximilians-Universität
Klinikum Großhadern
Marchioninistraße 15
81377 München
Email: hamann@brain.nefo.med.uni-muenchen.de