Langzeit-Antiaggregation mit Clopidogrel statt ASS, Clopidogrel und ASS

Zusammenfassung

Eine dauerhafte Thrombozytenaggregationshemmung ist ein essenzieller Bestandteil der Sekundärprophylaxe nach akutem Koronarsyndrom (ACS). Seit Ende der 1980er Jahre des vergangenen Jahrhunderts ist die Thrombozytenaggregationshemmung mit Azetylsalizylsäure (ASS) als eine effektive und sichere Therapie für diese Indikation etabliert. Etwa ein Jahrzehnt später wurde mit der Einführung der Thienopyridine eine kombinierte synergistische Thrombozytenaggregationshemmung möglich, die insbesondere in der interventionellen Kardiologie neue Möglichkeiten eröffnete. Das zuerst verfügbare Ticlopidin ist mittlerweile, aufgrund der besseren pharmakologischen Eigenschaften und des günstigeren Profils an unerwünschten Arzneimittelwirkungen durch Clopidogrel weitgehend ersetzt. Nach wie vor hat die Standardtherapie mit ASS in niedriger Dosierung (mindestens 75 mg/d) als Langzeittherapie in der Sekundärprophylaxe einen hohen Stellenwert. Clopidogrel bietet nach den aktuellen Studien jedoch eine ebenso sichere und effektive Alternative. Nach PTCA mit Implantation eines herkömmlichen Metallstents sollte zur Verhinderung einer akuten Stentthrombose für mindestens vier Wochen eine Kombinationstherapie mit ASS und Clopidogrel durchgeführt werden. Bei ACS ohne ST-Strecken-Hebungsinfarkt ist die Kombination von ASS und Clopidogrel besser als die alleinige Gabe von ASS. Aktuelle Daten scheinen dies auch für das ACS mit ST-Strecken-Hebungsinfarkt zu belegen. Ob generell die dauerhafte Kombinationstherapie von ASS mit Clopidogrel zur Sekundärprophylaxe sicher und evtl. effektiver ist, wird diskutiert.

Summary

Long-term inhibition of platelet aggregation is essential for the secondary prevention after acute coronary syndromes (ACS). Inhibition of platelet aggregation with acetylsalicylic acid (ASA) has been established as a safe and effective therapy in this indication already end of the eighties in the preceeding century. A decade later, with the introduction of the thienopyridines, combined platelet aggregation inhibition became possible. This opened the door for new treatment strategies in interventional cardiology. The first substance, ticlopidine was more or less replaced by the newer substance clopidogrel, which has improved pharmacological properties and less side effects. Low dose ASA (75 mg/d) is still regarded as the standard therapy for secondary prevention after ACS. However, large clinical trials established clopidogrel as at least as effective and safe as ASA in this indication. Following PCI with bare metal stent implantation, a combined therapy of ASA and clopidogrel should be given for at least 4 weeks. After ACS with non- ST-elevation myocardial infarction the combined therapy with ASA and clopidogrel gives a better outcome than ASA alone. Recently published clinical trials show superiority of this strategy in patients with ST-elevation myocardial infarction, too. If a combined long-term platelet aggregation inhibition with ASA and clopidogrel will be safe and more effective for secondary prevention is discussed.

Schlüsselwörter

Akutes Koronarsyndrom - Azetylsalizylsäure - Clopidogrel

Keywords

Acute coronary syndrome - acetyl salicylic acid - clopidogrel

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