Innovationen in der Kardiologie für Neurologen

Zusammenfassung

Die Behandlung häufiger kardiologischer Erkrankungen wie dem Vorhofflimmern, der arteriellen Hypertonie, des akuten Koronarsyndroms und der stabilen Angina pectoris werden die etablierten Therapieformen durch neue Substanzen ergänzt. Durch die Einführung des CHA₂D₂s-VASc-Scores und die damit entstandene neue Risikostratifizierung bei Vorhofflimmern wurde die Indikation zur oralen Antikoagulation erweitert. Neue orale Antikoagulanzien werden in Kürze die Zulassung für die Indikation Vorhofflimmern erhalten. Dabei handelt es sich zum einen um den direkten Thrombininhibitor Dabigatran, zum anderen um die Faktor-Xa-Inhibitoren Rivaroxaban und Apixaban. Auch in der Therapie des Vorhofflimmerns steht mit Dronedaron eine neue Substanz sowohl für die Rhythmusals auch Herzfrequenzkontrolle zur Verfügung. Aliskiren, der erste direkte Renininhibitor, bereichert die Therapieoptionen bei der arteriellen Hypertonie. Im Bereich der Thrombozytenaggregationshemmung haben Prasugrel, ein Thienpyridin der 3. Generation, und Ticagrelor, ein reversibler Thrombozytenaggregationshemmer, eine Überlegenheit gegenüber der empfohlenen Therapie beim akuten Koronarsyndrom mit Clopidogrel gezeigt. In der Behandlung der stabilen Angina pectoris hat Ranolazin als Monosubstanz und Kombination mit anderen Antianginosa die Verringerung der Angina-pectoris-Anfälle und die Reduktion des oralen Nitratverbrauchs nachgewiesen.

Summary

The therapy of some of the most common cardiological diseases like atrial fibrillation, hypertension, acute coronary syndrome, stable angina are changed by the approval of new drugs. The new CHA₂D₂s-VASc-Score implicates a change in risk stratification in patients with atrial fibrillation and widens the indication for oral anticoagulation. New oral drugs are ready for approval for anticoagulation in patients with atrial fibrillation. These new substances are the direct thrombin inhibitor dabigatran and the two factor Xa inhibitors Rivaroxaban and Apixaban. Dronedaron is a new antiarrhytmic drug to maintain sinus rhythm in the therapy of atrial fibrillation. The first substance, that acts as a direct renin-inhibitor is aliskiren. Aliskiren is an additional option in the treatment of hypertension. Concerning the inhibition of thrombocytes, there are two new substances (prasugrel, ticagrelor) that have shown benefitial effect in the treatment of acute coronary syndromes in comparison to clopidogrel. Ranolazin alone or in combination with other antianginal substrates lowers the frequency of angina pectoris episodes and the consumption of nitrates.

Schlüsselwörter

Vorhofflimmern - orale Antikoagulation und antiarrhythmische Therapie - arterielle Hypertonie - antianginöse Therapie

Keywords

Atrial fibrillation - oral anticoagulation and antiarrhythmic treatment - hypertension - treatment of stable angina

• Literatur

• 1 Study group. Rivaroxaban-once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study. Am Heart J 2010; 159: 340-7.
• 2 Camm AJ. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-429.
• 3 Chaitman BR. et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004; 291: 309-16.
• 4 Christiansen CB, Torp-Pedersen C, Kober L. Impact of dronedarone in atrial fibrillation and flutter on stroke reduction. Clin Interv Aging 2010; 05: 63-9.
• 5 Connolly SJ. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-51.
• 6 Eikelboom JW. et al. Rationale and design of AVERROES: apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment. Am Heart J 2010; 159: 348-53.
• 7 Hohnloser SH. et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009; 360: 668-78.
• 8 James S. et al. Comparison of ticagrelor, the first reversible oral P2Y(12) receptor antagonist, with clopidogrel in patients with acute coronary syndromes: Rationale, design, and baseline characteristics of the PLATelet inhibition and patient Outcomes (PLATO) trial. Am Heart J 2009; 157: 599-605.
• 9 Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982; 306: 1018-22.
• 10 Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 1998; 82: 2N-9N.
• 11 Madden KP, Karanjia PN, Adams Jr HP, Clarke WR. Accuracy of initial stroke subtype diagnosis in the TOAST study. Trial of ORG 10172 in Acute Stroke Treatment. Neurology 1995; 45: 1975-9.
• 12 McMurray JJ. et al. Effects of the oral direct renin inhibitor aliskiren in patients with symptomatic heart failure. Circ Heart Fail 2008; 01: 17-24.
• 13 Montalescot G. et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 2009; 373: 723-31.
• 14 Parving HH, Persson F, Lewis JB, Lewis EJ, Hollenberg NK. Aliskiren combined with losartan in type 2 diabetes and nephropathy. N Engl J Med 2008; 358: 2433-46.
• 15 Pepi M. et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2010; 11: 461-76.
• 16 Riche DM, Minor DS, Holdiness AS, East HE. An issue of dependence: implications from the Aliskiren in the Evaluation of Proteinuria in Diabetes (AVOID) trial. J Clin Hypertens (Greenwich) 2009; 11: 89-93.
• 17 Rose G, Baxter PJ, Reid DD, McCartney P. Prevalence and prognosis of electrocardiographic findings in middle-aged men. Br Heart J 1978; 40: 636-43.
• 18 sanofi-aventis. Important information on the use of Multaq (dornedarone). online. 2010
• 19 Stone PH, Gratsiansky NA, Blokhin A, Huang IZ, Meng L. Antianginal efficacy of ranolazine when added to treatment with amlodipine: the ERICA (Efficacy of Ranolazine in Chronic Angina) trial. J Am Coll Cardiol 2006; 48: 566-75.
• 20 Wilson SR. et al. Efficacy of ranolazine in patients with chronic angina observations from the randomized, double-blind, placebo-controlled MERLIN-TIMI (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Segment Elevation Acute Coronary Syndromes) 36 Trial. J Am Coll Cardiol 2009; 53: 1510-6.
• 21 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med 1987; 147: 1561-4.
• 22 Gregory YH. Lip et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation factor-based approach: The Euro Heart Survey on atrial fibrillation. Chest 2010; 137 (02) 263-72.