Herz

, Volume 24, Issue 5, pp 353–362

Therapie des akuten Koronarsyndroms

ASS, Heparin, LMWH, Hirudin und GP-IIb/IIIa-Blocker
  • Andreas Gaede
  • Wolfram Terres
Article

Zusammenfassung

Das akute Koronarsyndrom beruht in den meisten Fällen auf einer intrakoronaren Plaqueruptur mit konsekutiver Bildung eines thrombozytenreichen Thrombus, der zur kritischen Reduktion des koronaren Blutflusses führt. Ziel der therapeutischen Strategien ist es, die Aktivierung von Plättchen und Gerinnungskaskade zu bemmen und die Aggregation der Thrombozyten und die Fibrinbildung zu unterdrücken. Der Einsatz von Acetylsalicylsäure (ASS) ist dabei seit längerem etabliert und hinsichtlich seiner Wirksamkeit durch große klinische Studien gestützt. Ebenso ist eine weitere Risikoreduktion durch die zusätzliche Applikation von Heparin für die Frühphase des akuten Koronarsyndroms wahrscheinlich. Hirudin und Analoga konnten in der Vergangenheit keine wesentliche Überlegenheit als Begleitmedikation zur Lysetherapie des akuten Myokardinfarkts bei zum Teil deutlich erhöhtem Blutungsrisiko zeigen. Erst in der kürzlich veröffentlichten OASIS-2-Studie ließ sich bei Patienten mit instabiler Angina pectoris eine Reduktion des Risikos mit Hirudin im Vergleich zu Heparin nachweisen. Ebenso weisen Studien zum Einsatz von niedermolekularem Heparin (LMWH) und Glykoprotein-(GP-)IIb/IIIa-Blockern bei akutem Koronarsyndrom vielversprechende Ergebnisse auf. Für LMWH konnte dabei eine dem Heparin zumindest gleichwertige Wirksamkeit nachgewiesen werden. Die Gabe von GP-IIb/IIIa-Blockern zusätzlich zu ASS und Heparin führte in mehreren Studien zu einer deutlichen weiteren Reduktion kardiovaskulärer Ereignisse.

Schlüsselwörter

Koronarsyndrome ASS Heparin LMWH Hirudin GP-IIb/IIIa-Blocker 

Therapy of the acute coronary syndrome. ASA, heparin, LMWH, hirudin and the GP-IIb/IIIa blockers

Abstract

Plaque rupture with consecutive formation of an intraluminal, platelet-rich thrombus is the central mechanism leading to critical reduction of coronary perfusion in the acute coronary syndrome. Current therapeutic strategies aim at the inhibition of activation of platelets and the coagulation cascade and the suppression of platelet aggregation and fibrin formation. The use of acetylsalicylic acid (ASA) is well established in the therapy of the acute coronary syndrome and its efficacy is documented in several large clinical studies. The results of a respective metaanalysis by the Antiplatelet Trialists’ Collaboration are shown in Table 1. Further risk reduction has been achieved with the additional application of heparin during the early phase of treatment. Table 2 shows the results of the Montreal Heart Study of combined vs single drug treatment, and Figure 1 a metaanalysis by Oler et al. of combination therapy with heparin plus ASA compared to monotherapy with ASA. In the past, hirudin and analogues were not superior to heparin as adjunctive treatments to lysis in acute myocardial infarction, but bleeding complications were more frequent. In contrast, in the recently published OASIS-2 study, outcome in patients with unstable angina pectoris was significantly better with hirudin than with heparin. Several large studies have demonstrated at least equivalent efficacy of LMWHs compared to standard heparin. For the early phase of the acute coronary syndrome, the FRIC and ESSENCE studies have even demonstrated improved clinical outcome without increase in bleeding complications. However, in TIMI 11 and FRAXIS, long-term application of LMWH resulted in more bleeding complications and, in FRAXIS, in a trend to a worse clinical outcome. The use of GP-IIb/IIIa blockers, especially the chimeric antibody fragment abciximab, is well established in interventional cardiology. Figure 2 shows the mechanism of action of the GP-IIb/IIIa blockers on platelet aggregation. In addition, their use in conjunction with ASA and heparin in the acute coronary syndrome led to further significant reduction of cardiovascular events in several studies. For example, the reduction of events by abciximab in the CAPTURE-study is delineated in Table 3. The results obtained with several of the new competitive GP-IIb/IIIa receptor antagonists are shown in Table 4.

Key Words

Coronary syndrome ASA Heparin Hirudin GP-IIb/IIIa blockers 

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Copyright information

© Urban & Vogel 1999

Authors and Affiliations

  • Andreas Gaede
    • 1
  • Wolfram Terres
    • 1
  1. 1.Klinik für KardiologieAllgemeines Krankenhaus CelleCellè

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