Perioperative Thromboseprophylaxe – Thrombozytenaggregationshemmer – Bedeutung für die Anästhesie

Zusammenfassung

Aspirin und Thienopyridine gehören zur Standardtherapie bei Patienten mit einem akuten Koronarsyndrom und nach koronarer Stentimplantation. Eine duale Thrombozytenaggregationshemmung wird nach Metall-Stent-Implantation für mindestens 6-12 Wochen, nach einem Medikamenten-freisetzenden Stent für 12 Monate durchgeführt, um das Risiko einer akuten Stentthrombose zu reduzieren. In der Phase der dualen Thrombozytenaggregationshemmung sollen Patienten nicht elektiv operiert werden. Probleme entstehen bei dringlichen Operationen, die keine Verschiebung um Wochen bis Monate erlauben. In diesen Fällen ist eine sorgfältige Nutzen-Risiko-Analyse unter Berücksichtigung des operativen Blutungsrisikos und des Risikos der akuten Stentthrombose erforderlich. Aspirin sollte in dieser Phase mit wenigen Ausnahmen fortgeführt werden. Es gibt bisher keine Evidenz, dass Thrombozytenfunktionstests in dieser Phase bezüglich des Risikos von Stentthrombosen oder Blutungen in der Therapiesteuerung von Vorteil sind. Bei schwerwiegenden Blutungen sind Antifibrinolytika wie Tranexamsäure oder als ultima ratio die Transfusion von Thrombozyten indiziert.

Abstract

Aspirin and thienopyridines are the mainstay of platelet aggregation inhibition in patients with acute coronary syndromes and patients receiving coronary artery stents. After elective coronary artery stenting, they are prescribed for up to 3 months after bare metall stents and for at least 12 months after drug-eluting stents, thereby significantly reducing the risk of acute stent thrombosis. During this time period, patients should not undergo elective surgery. However, they may present with surgically amenable diseases that do not allow further delay. In these cases a careful risk-benefit analysis is required to elucidate the risk of major surgical bleeding versus the risk of major cardiovascular events with aspirin to be continued throughout the perioperative period. Current evidence does not suggest to use platelet function tests to guide therapy under these circumstances. If major bleeding occurs under dual platelet aggregation inhibition, the most appropriate interventions are antifibrinolytics such as tranexamic acid and transfusion of platelets to counteract the platelet aggregation inhibitory effects.

Kernaussagen

• Das Risiko von Stentthrombosen wird durch die Länge des gestenteten Gefäßes, die Stentimplantation an Bifurkationen, eine Reststenose des Gefäßes sowie durch das Vorliegen einer Herz- oder Niereninsuffizienz und Diabetes mellitus beeinflusst.

• Das perioperative Absetzen von Aspirin führt zu einer erhöhten Rate an kardiovaskulären Ereignissen. Das Risiko tritt bereits innerhalb weniger Tage nach Absetzen auf. Bereits abgesetztes Aspirin sollte dementsprechend präoperativ wieder begonnen werden.

• Neue Thrombozytenaggregationshemmer wie Prasugrel und Ticagrelor sind gegenüber einer herkömmlichen Dosis von Clopidogrel effektiver, können aber ein höheres Blutungsrisiko bergen.

• Nach Metallstent-Implantation sollen keine elektiven Eingriffe für 6–12 Wochen durchgeführt werden. Nach medikamentenfreisetzenden Stents beträgt das Intervall ein Jahr.

• Das perioperative Blutungsrisiko ist unter einer dualen Thrombozytenaggregationshemmung deutlich höher als unter der alleinigen Gabe von Aspirin.

• Bei Blutungen unter Thrombozytenaggregationshemmern sind Antifibrinolytika Mittel erster Wahl. Bei persistierender Blutung besteht eine kausale Therapie in der Transfusion von Thrombozytenkonzentraten unter Inkaufnahme einer erhöhten Rate an Stentthrombosen.

• Der Platelet-Function-Analyzer (PFA-100) ist nicht geeignet, kardiovaskuläre Ereignisse oder Blutungskomplikationen unter einer dualen Thrombozytenaggregationshemmung vorherzusagen.

• Die Therapiesteuerung von Thrombozytenaggregationshemmern mittels Thrombozytenfunktionstests wird aufgrund des geringen prädiktiven Wertes derzeit nicht empfohlen.

• Bei Patienten mit einer koronaren Herzerkrankung führen nicht selektive und selektive Zyklooxygenasehemmer zu einer erhöhten Rate an kardiovaskulären Ereignissen. Unter den Nichtopioidanalgetika wird Paracetamol als Mittel erster Wahl empfohlen.

• Unter einer dualen Thrombozytenaggregationshemmung ist die Durchführung rückenmarksnaher Regionalanästhesien und tiefer peripherer Nervenblockaden kontraindiziert.

Schlüsselwörter:

Aspirin - Clopidogrel - Prasugrel - Ticagrelor - Blutung - Thrombozytenfunktionstests - Stentthrombose

Keywords:

Aspirin - clopidogrel - prasugrel - ticagrelor - bleeding - platelet function tests - stent thrombosis

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