Myokardrevaskularisierung im infarktbedingten kardiogenen Schock

Zusammenfassung

Circa 10% der Patienten mit akutem Myokardinfarkt entwickeln einen kardiogenen Schock. Der wichtigste Eckpfeiler zur Therapie des infarktbedingten Schockes ist die frühzeitige Revaskularisierung. Es konnte in randomisierten Studien eine signifikante Verbesserung des Überlebens im Vergleich zu einer alleinigen medikamentösen Therapie belegt werden. Die perkutane Koronarintervention ist die dominierende Methode der Revaskularisierung. Bei mechanischen Komplikationen oder komplexer Koronaranatomie wird eine zeitnahe Konsultation des Heartteams empfohlen. Im Falle einer perkutanen Intervention bei koronarer Mehrgefäßerkrankung konnte in der randomisierten CULPRIT-SHOCK-Studie ein Überlebensvorteil für Patienten mit initial alleiniger Versorgung des infarktverursachenden Gefäßes im Vergleich zur sofortigen Mehrgefäßintervention gezeigt werden. Die Evidenz zu Therapieregimen bezüglich Antikoagulation und Thrombozytenaggregationshemmung ist gering.

Abstract

Acute myocardial infarction is complicated by cardiogenic shock in about 10% of patients. The most important causal treatment in these patients as shown in a randomized trial is early revascularization which is associated with improved survival in comparison to medical therapy alone. Percutaneous coronary intervention is the predominant method of revascularization in cardiogenic shock. In cases of mechanical infarct-related complications or complex coronary anatomy, early consultation of the heart team is recommended. The randomized CULRPIT-SHOCK study found that intervention of the culprit lesion only improves survival in patients with multivessel coronary artery disease compared to additional intervention of non-culprit lesions in the emergency setting. Evidence addressing anticoagulant and antiplatelet therapy in cardiogenic shock is scarce.

Was ist wichtig?

• In ca. 10% der Fälle entwickeln Patienten mit akutem Myokardinfarkt einen kardiogenen Schock. In den meisten Fällen liegt diesem ein Linksherzversagen zugrunde.

• Eine frühestmögliche Diagnostik und Therapie ist essenziell, um den entstehenden Circulus vitiosus der „Schockspirale“ zu durchbrechen. Die wichtigste Therapiesäule stellt die frühestmögliche Durchführung einer koronaren Revaskularisierung dar.

• Bei 70 – 80% der Patienten mit infarktbedingtem Schock besteht eine koronare Mehrgefäßerkrankung. In diesen Fällen sollte im akuten Setting lediglich das infarktverursachende Gefäß („Culprit Lesion“) wiedereröffnet werden.

Schlüsselwörter

akuter Myokardinfarkt - Revaskularisierung - kardiogener Schock

Key words

acute myocardial infarction - revascularization - cardiogenic shock

• Literatur

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