Zusammenfassung
Niedermolekulare Heparinpräparate werden zunehmend häufiger zur überbrückenden Antikoagulation bei Patienten mit mechanischen Herzklappenprothesen verwendet, obwohl die aktuellen Richtlinien der europäischen und amerikanischen Fachgesellschaften diese Therapie nicht empfehlen und nur wenige publizierte Erfahrungen hierzu vorliegen. Anhand bisher veröffentlichter Studien vergleichen wir die Sicherheit einer niedermolekularen im Vergleich zur unfraktionierten Heparintherapie bei Kunstklappenträgern, bei denen die orale Antikoagulation mit Cumarinderivaten aus verschiedenen Indikationen (Schwangerschaft, invasive Eingriffe, Blutungskomplikationen) pausiert werden muss. Engmaschige klinische und echokardiographische Kontrollen sowie Dosisanpassung entsprechend der anti-Faktor-Xa-Aktivität vorausgesetzt scheinen niedermolekulare Heparine unfraktionierten Heparinen nicht unterlegen zu sein. Die Inzidenz von Prothesenthrombosen ist während der Schwangerschaft aufgrund einer längeren Therapiedauer und gesteigerten thrombogenen Disposition möglicherweise erhöht, wobei auch die alleinige Therapie mit unfraktionierten Heparinen eine hohe Komplikationsrate aufweist. Insgesamt fehlen in der wissenschaftlichen Literatur bisher jedoch für jedes der obengenannten Indikationsgebiete einheitliche Richtlinien über Art und Umfang einer überbrückenden gerinnungshemmenden Therapie nach Unterbrechung der oralen Antikoagulation. Außerhalb klinischer Studien stellt eine niedermolekulare Heparingabe bei Kunstklappenträgern eine individuelle, bisher nicht evidenzbasierte Therapieentscheidung dar, die eine Aufklärung des Patienten und sorgfältige Überwachung erfordert. Zur abschliessenden Beurteilung sind prospektive und randomisierte klinische Studien dringend erforderlich.
Summary
The therapeutic safety and efficacy of coumarin derivatives for the chronic anticoagulation of patients with mechanical heart valves are well established. Low molecular weight heparins (LMWH) are increasingly used as a replacement anticoagulant when oral anticoagulation has to be discontinued because of pregnancy, invasive procedures or bleeding complications. However, current practice guidelines do not recommend this therapy, and published clinical experiences are limited to series with few patients or case reports. In a comprehensive analysis of all studies published so far, we assess the therapeutic role of LMWH as a substitute for coumarin derivatives in different clinical situations. If patients are under close clinical surveillance and LMWH dosage is adjusted regularly by anti-factor Xa level monitoring, LMWH appear not to be inferior to unfractionated heparins. The incidence of prosthetic valve thrombosis under LMWH treatment seems to be slightly higher during pregnancy, probably because of a longer duration of therapy and an increased prothrombotic predisposition. Use of unfractionated heparin throughout pregnancy, however, has also yielded unsatisfactory results. In general, no clear consensus exists in the medical literature with regard to the optimal regimen of replacement anticoagulation in the situations mentioned above. If patients with prosthetic cardiac valves are treated with LMWH outside clinical studies, they should be informed about potential risks of this therapy, and close supervision using transthoracic echocardiography and anti-factor Xa measurements is recommended. Prospective and randomized trials comparing unfractionated heparins and LMWH are urgently needed.
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Dr. med. Detlef Hering
Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik
der Ruhr-Universität Bochum, Kardiologische Klinik
Georgstraße 11
32545 Bad Oeynhausen
Telefon: 05731/971258
Fax: 05731/972194
eMail: akohlstaedt@hdz-nrw.de
