Die Behandlung des akuten Koronarsyndroms (ACS) hat sich in den letzten Jahren erheblich gewandelt. Dies ist zum einen bedingt durch ein besseres Verständnis der Pathogenese und zum anderen durch Fortschritte der medikamentösen und der interventionellen Therapie.
Im Wesentlichen können folgende Ansätze der Akuttherapie unterschieden werden: 1) antianginöse, 2) gerinnungshemmende und 3) revaskularisierende Therapie (Katheterintervention, Bypassoperation). Ausschlaggebend für die Therapieentscheidung ist das individuelle Risiko des Patienten.
Im Folgenden werden die einzelnen therapeutischen Schemata dargestellt. Die üblichen Dosierungen der aufgeführten Substanzen sind in Tab. [1] und der Grad der Evidenz der verschiedenen Therapieempfehlungen ist in Tab. [2] aufgeführt.
Tab. 1 Medikamente und Dosierungen beim akuten Koronarsyndrom.
Medikament
Akuttherapie
Dauertherapie
Antianginöse Substanzen
Nitrate
Nitrospray 0,8 mg (2 Hübe)
1 - 2 x 20 - 60 mg tägl. unretardiert
Dauerinfusion 1 - 5 mg/h i. v.
1 x 60 - 120 mg tägl. retardiert
Betablocker
Metoprolol 50 mg i. v.
Metoprolol 2 x 50 - 100 mg tägl.
Bisoprolol 1 x 2,5 - 10 mg tägl.
Antikoagulation
Unfraktioniertes Heparin (UFH)
5000 IE Bolus i. v.
Dauerinfusion 1000 IE/h i. v.
aPTT 1,5 - 2,5fach (50 - 80 sec.)
Niedermolekulares Heparin (LMWH)
Enoxaparin 1 mg/kg KG s. c. 2 x tgl.
Antithrombo-zytäre Substanzen
Acetylsalicylsäure (ASS)
Aspisol® 500 mg i. v. Bolus
ASS 1 x 100 mg tägl. lebenslang
Clopidogrel (Plavix®, Iscover®)
„Loading dose” 300 mg (4 Tabletten)
1 x 75 mg tägl. Für 9 - 12 Monate
Abciximab (ReoPro®)
0,25 mg/kg KG i. v. Bolus
0,125 µg/kg KG/min Dauerinfusion
Tirofiban (Aggrastat®)
10 µg/kg KG i. v. Bolus
0,15 µg/kg KG/min Dauerinfusion
Eptifibatide (Integrilin®)
180 µg/kg KG/min i. v. Bolus
2 µg/kg KG/min Dauerinfusion
Literatur
1
Antman E M, Cohen M, Radley D. et al .
Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction. TIMI 11B-ESSENCE meta-analysis.
Circulation.
1999;
100
1602-1608
2
Boersma E, Harrington R A, Moliterno D J. et al .
Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials.
Lancet.
2002;
359
189-198
3
Cannon C P, Weintraub W S, Demopoulos L A. et al .
Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.
N Engl J Med.
2001;
344
1879-1887
4
CAPRIE Steering Committee .
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).
Lancet.
1996;
348
1329-1339
5
Eikelboom J W, Anand S S, Malmberg K. et al .
Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis.
Lancet.
2000;
355
1936-1942
6
FRISC II Investigators .
Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators.
Lancet.
1999;
354
708-715
7
GUSTO Investigators .
A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb investigators.
N Engl J Med.
1996;
335
775-782
8
Mehta S R, Yusuf S, Peters R J. et al .
Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study.
Lancet.
2001;
358
527-533
9
OASIS Investigators .
Effects of long-term, moderate-intensity oral anticoagulation in addition to aspirin in unstable angina. The Organization to Assess Strategies for Ischemic Syndromes (OASIS) Investigators.
J Am Coll Cardiol.
2001;
37
475-484
10
OASIS Investigators .
Effects of recombinant hirudin (lepirudin) compared with heparin on death, myocardial infarction, refractory angina, and revascularisation procedures in patients with acute myocardial ischaemia without ST elevation: a randomised trial. Organisation to Assess Strategies for Ischemic Syndromes (OASIS-2) Investigators.
Lancet.
1999;
353
429-438
11
Oler A, Whooley M A, Oler J, Grady D.
Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis.
JAMA.
1996;
276
811-815
12
Simoons M L.
Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial.
Lancet.
2001;
357
1915-1924
13
Steinhubl S R, Berger P, Mann J T. et al .
Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial.
JAMA.
2002;
288
2411-2420
14
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
71-86
15
Topol E J, Moliterno D J, Herrmann H C. et al .
Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization.
N Engl J Med.
2001;
344
1888-1894
16
Yusuf S, Zhao F, Mehta S R. et al .
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
