Der Kardiologe

, Volume 4, Issue 2, pp 84–92 | Cite as

Kommentare zu den Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Diagnostik und Therapie von Patienten mit ST-Streckenhebungsinfarkt (STEMI)

  • S. Silber
  • M. Borggrefe
  • G. Hasenfuß
  • V. Falk
  • A. Kastrati
  • M. Weis
  • C.W. Hamm
Leitlinien
First Online:

Zusammenfassung

Die möglichst unverzügliche Wiedereröffnung des verschlossenen Infarktgefäßes steht nach wie vor im Mittelpunkt der Behandlung von Patienten mit STEMI. Die möglichst rasche prähospitale klinische und EKG-Diagnose eines STEMI ist für die Optimierung des Zeitablaufs zwischen Symptom- und Reperfusionsbeginn unerlässlich. Dies wird am besten durch die Etablierung eines Netzwerkes von Kliniken mit und ohne PCI-Bereitschaft erreicht, die durch ein effizientes Rettungswagensystem verknüpft sind. Kliniken mit PCI-Bereitschaft müssen diese durchgehend (24 h/7 Tage) vorweisen. Die beste Reperfusionsstrategie ist die durch ein erfahrenes Team durchgeführte primäre PCI mit Stentimplantation. Die primäre PCI sollte so rasch wie möglich, aber spätestens noch innerhalb von 2 h nach der EKG-Diagnose (sog. „medizinischer Erstkontakt“) durchgeführt werden. Bei Patienten mit großem Infarkt ist diese Zeitspanne mit maximal 90 min kürzer. Alle Patienten sollten grundsätzlich möglichst sofort Acetylsalicylsäure (i.v. oder zum Kauen), eine Bolusdosis eines Thienopyridinderivates sowie eines der folgenden Antikoagulanzien erhalten: bei geplanter primärer PCI: vorzugsweise Bivalirudin oder (unfraktioniertes) Heparin; nach Einleitung einer Fibrinolyse (wenn keine PCI innerhalb von 2 h möglich ist): Enoxaparin oder Heparin. Die routinemäßige i.v.-Verabreichung eines β-Blockers ist nicht indiziert. Auch bei einer erfolgreichen Thrombolyse soll der Transport in eine PCI-Klinik möglichst rasch erfolgen, um 3–24 h nach Lysebeginn eine invasive Koronarangiographie in PCI-Bereitschaft durchzuführen. Neuere Untersuchungen weisen darauf hin, dass (sofern keine Kontraindikationen vorliegen) bei Patienten mit STEMI das Clopidogrel durch Prasugrel ersetzt werden kann.

Schlüsselwörter

Herzinfarkt STEMI PCI Clopidogrel Prasugrel 

Commentary on the guidelines of the European Society of Cardiology (ESC) regarding the diagnosis and treatment of patients with ST-segment elevation myocardial infarction (STEMI)

Abstract

Very early reperfusion of the occluded infarct artery is the mainstay in the treatment of an acute myocardial infarction with persistent ST-segment elevation (STEMI). Pre-hospital (ambulance) clinical and ECG diagnosis is critical for reducing the time delays between onset of symptoms and start of reperfusion. This can best be achieved by establishing a network of non-PCI-capable and PCI-capable (24 h/7 days) hospitals connected by an efficient ambulance service. Primary PCI with stenting, when performed by an experienced team within the recommended time, is the best reperfusion treatment to save lives. Primary PCI should be performed within 120 min after ECG diagnosis (first medical contact) in all patients and within 90 min in patients presenting within 2 h and with a large infarct. In the absence of contraindications, all patients should receive aspirin, a thienopyridine and one of the following anticoagulants as soon as possible: bivalirudin or heparin, if primary PCI is planned; enoxaparin or heparin, if a fibrin-specific lytic agent is given. Routine i.v. administration of a beta-blocker is not indicated. Even after successful fibrinolysis, transfer to a PCI-capable hospital for coronary angiography, ideally between 3 and 24 h after start of fibrinolytic therapy, is indicated. Recent studies have shown that (if no contraindications exist), in patients with STEMI, clopidogrel may be replaced by prasugrel.

Keywords

Myocardial infarction STEMI PCI Clopidogrel Prasugrel 
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Notes

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Vortragshonorare und Studienunterstützung sowie Beratungstätigkeit diverser Firmen der hier genannten Produkte.

Literatur

  1. 1.
    Van de Werf F, Bax J, Betriu A et al (2008) Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 29:2909–2945CrossRefGoogle Scholar
  2. 2.
    Van de Werf F, Ardissino D, Betriu A et al (2003) Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 24:28–66Google Scholar
  3. 3.
    Pinto DS, Kirtane AJ, Nallamothu BK et al (2006) Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 114:2019–2025CrossRefPubMedGoogle Scholar
  4. 4.
    Nallamothu BK, Antman EM, Bates ER (2004) Primary percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: does the choice of fibrinolytic agent impact on the importance of time-to-treatment? Am J Cardiol 94:772–774CrossRefPubMedGoogle Scholar
  5. 5.
    Betriu A, Masotti M (2005) Comparison of mortality rates in acute myocardial infarction treated by percutaneous coronary intervention versus fibrinolysis. Am J Cardiol 95:100–101CrossRefPubMedGoogle Scholar
  6. 6.
    Boersma E (2006) Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 27:779–788CrossRefPubMedGoogle Scholar
  7. 7.
    Di Mario C, Dudek D, Piscione F et al (2008) Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 371:559–568CrossRefGoogle Scholar
  8. 8.
    Silber S, Albertsson P, Aviles FF et al (2005) Guidelines for percutaneous coronary interventions: the Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26:804–847CrossRefPubMedGoogle Scholar
  9. 9.
    Cantor WJ, Fitchett D, Borgundvaag B et al (2009) Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 360:2705–2718CrossRefPubMedGoogle Scholar
  10. 10.
    van de Werf et al (2006) ASSENT-4: Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet 367:569–578CrossRefGoogle Scholar
  11. 11.
    Bassand JP, Danchin N, Filippatos G et al (2005) Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology. Eur Heart J 26:2733–2741CrossRefPubMedGoogle Scholar
  12. 12.
    Widimsky P, Wijns W, Fajadet J et al (2009) Reperfusion therapy for ST-elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J (Epub ahead of print)Google Scholar
  13. 13.
    Montalescot G, Barragan P, Wittenberg O et al for the ADMIRAL investigators (2001) Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 344:1895–1903CrossRefPubMedGoogle Scholar
  14. 14.
    Lee DP, Herity NA, Hiatt BL et al (2003) Adjunctive platelet glycoprotein IIb/IIIa receptor inhibition with tirofiban before primary angioplasty improves angiographic outcomes: results of the TIrofiban Given in the Emergency Room before Primary Angioplasty (TIGER-PA) pilot trial. Circulation 107:1497–1501CrossRefPubMedGoogle Scholar
  15. 15.
    Gyöngyösi M, Domanovits H, Benzer W et al (2004) Use of abciximab prior to primary angioplasty in STEMI results in early recanalization of the infarct-related artery and improved myocardial tissue reperfusion – results of the Austrian multi-centre randomized ReoPro-BRIDGING Study. Eur Heart J 25:2125–2133CrossRefPubMedGoogle Scholar
  16. 16.
    Van’t Hof AW, Ernst N, De Boer MJ et al (2004) Facilitation of primary coronary angioplasty by early start of a glycoprotein 2b/3a inhibitor: results of the ongoing tirofiban in myocardial infarction evaluation (On-TIME) trial. Eur Heart J 25:837–846CrossRefGoogle Scholar
  17. 17.
    Van’t Hof AW, Ten Berg J, Heestermans T et al (2008) Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (On-TIME 2): a multicentre, double-blind, randomised controlled trial. Lancet 372:537–546CrossRefGoogle Scholar
  18. 18.
    Ellis SG, Tendera M, Belder MA de et al (2008) Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med 358:2205–2217CrossRefPubMedGoogle Scholar
  19. 19.
    Widimsky P, Tousek P, Rokyta R et al (2009) Routine upfront abciximab vs. standard peri-procedural therapy in patients undergoing primary PCI for cardiogenic shock: the PRAGUE-7 Study. ESC Annual Meeting, Hotline Session, BarcelonaGoogle Scholar
  20. 20.
    Mehilli J, Kastrati A, Schulz S et al (2009) Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: a randomized double-blind trial. Circulation 119:1933–1940CrossRefPubMedGoogle Scholar
  21. 21.
    Henriques JP, Zijlstra F, Ottervanger JP et al (2002) Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J 23:1112–1117CrossRefPubMedGoogle Scholar
  22. 22.
    Fokkema ML, Vlaar PJ, Svilaas T et al (2009) Incidence and clinical consequences of distal embolization on the coronary angiogram after percutaneous coronary intervention for ST-elevation myocardial infarction. Eur Heart J 30:908–915CrossRefPubMedGoogle Scholar
  23. 23.
    Stone GW, Webb J, Cox DA et al (2005) Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA 293:1063–1072CrossRefPubMedGoogle Scholar
  24. 24.
    Dangas G, Stone GW, Weinberg MD et al (2008) Contemporary outcomes of rescue percutaneous coronary intervention for acute myocardial infarction: comparison with primary angioplasty and the role of distal protection devices (EMERALD trial). Am Heart J 155:1090–1096CrossRefPubMedGoogle Scholar
  25. 25.
    Gick M, Jander N, Bestehorn HP et al (2005) Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation. Circulation 112:1462–1469CrossRefPubMedGoogle Scholar
  26. 26.
    Cura FA, Escudero AG, Berrocal D et al (2007) Protection of Distal Embolization in High-Risk Patients with Acute ST-Segment Elevation Myocardial Infarction (PREMIAR). Am J Cardiol 99:357–363CrossRefPubMedGoogle Scholar
  27. 27.
    Kelbaek H, Terkelsen CJ, Helqvist S et al (2008) Randomized comparison of distal protection versus conventional treatment in primary percutaneous coronary intervention: the drug elution and distal protection in ST-elevation myocardial infarction (DEDICATION) trial. J Am Coll Cardiol 51:899–905CrossRefPubMedGoogle Scholar
  28. 28.
    Silva-Orrego P, Colombo P, Bigi R et al (2006) Thrombus aspiration before primary angioplasty improves myocardial reperfusion in acute myocardial infarction: the DEAR-MI (Dethrombosis to Enhance Acute Reperfusion in Myocardial Infarction) study. J Am Coll Cardiol 48:1552–1559CrossRefPubMedGoogle Scholar
  29. 29.
    Svilaas T, Vlaar PJ, Horst IC van der et al (2008) Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 358:557–567CrossRefPubMedGoogle Scholar
  30. 30.
    Vlaar PJ, Svilaas T, Horst IC van der et al (2008) Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet 371:1915–1920CrossRefPubMedGoogle Scholar
  31. 31.
    Spaulding C, Henry P, Teiger E et al (2006) Sirolimus-eluting versus uncoated stents in acute myocardial infarction. N Engl J Med 355:1093–1104CrossRefPubMedGoogle Scholar
  32. 32.
    Di Lorenzo E, De Luca G, Sauro R et al (2009) The PASEO (PaclitAxel or Sirolimus-Eluting Stent Versus Bare Metal Stent in Primary Angioplasty) randomized trial. JACC Cardiovasc Interv 2:515–523CrossRefGoogle Scholar
  33. 33.
    Stone GW, Lansky AJ, Pocock SJ et al (2009) Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 360:1946–1959CrossRefPubMedGoogle Scholar
  34. 34.
    Grines CL, Cox DA, Stone GW et al (1999) Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 341:1949–1956CrossRefPubMedGoogle Scholar
  35. 35.
    Stone GW, Grines CL, Cox DA et al (2002) Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 346:957–966CrossRefPubMedGoogle Scholar
  36. 36.
    Silber S, Borggrefe M, Böhm M et al (2007) Positionspapier der DGK zur Wirksamkeit und Sicherheit von Medikamente freisetzenden Koronarstents (DES): Eine evidenzbasierte Analyse von 71 randomisierten Studien mit 28.984 Patienten. Kardiologe 1:84–111CrossRefGoogle Scholar
  37. 37.
    Silber S, Borggrefe M, Böhm M et al (2008) Medikamente freisetzende Koronarstents (DES) und Medikamente freisetzende Ballonkatheter (DEB): Aktualisierung des Positionspapiers der DGK. Clin Res Cardiol 97:548–563CrossRefPubMedGoogle Scholar
  38. 38.
    Kirtane AJ, Gupta A, Iyengar S et al (2009) Safety and efficacy of drug-eluting and bare metal stents: comprehensive meta-analysis of randomized trials and observational studies. Circulation 119:3198–3206CrossRefPubMedGoogle Scholar
  39. 39.
    Airoldi F, Colombo A, Morici N et al (2007) Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment. Circulation 116:745–754CrossRefPubMedGoogle Scholar
  40. 40.
    Daemen J, Wenaweser P, Tsuchida K et al (2007) Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 369:667–678CrossRefPubMedGoogle Scholar
  41. 41.
    Schulz S, Schuster T, Mehilli J et al (2009) Stent thrombosis after drug-eluting stent implantation: incidence, timing, and relation to discontinuation of clopidogrel therapy over a 4 year period. Eur Heart J 30:2714–2721CrossRefPubMedGoogle Scholar
  42. 42.
    Patti G, Colonna G, Pasceri V et al (2005) Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study. Circulation 111:2099–2106CrossRefPubMedGoogle Scholar
  43. 43.
    Sabatine MS, Cannon CP, Gibson CM et al (2005) Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 52:1179–1189CrossRefGoogle Scholar
  44. 44.
    Sabatine MS, Cannon CP, Gibson CM et al (2005) Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA 294:1224–1232CrossRefPubMedGoogle Scholar
  45. 45.
    Chen ZM, Jiang LX, Chen YP et al (2005) Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial (COMMIT/CCS-2). Lancet 366:1607–1621CrossRefPubMedGoogle Scholar
  46. 46.
    Bhatt DL, Flather MD, Hacke W et al (2007) Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol 49:1982–1988CrossRefPubMedGoogle Scholar
  47. 47.
    Zeymer U, Gitt AK, Junger C et al (2006) Effect of clopidogrel on 1-year mortality in hospital survivors of acute ST-segment elevation myocardial infarction in clinical practice. Eur Heart J 27:2661–2666CrossRefPubMedGoogle Scholar
  48. 48.
    Gilard M, Arnaud B, Cornily JC et al (2008) Influence of omeprazole on the antiplatelet action of clopidogrel associated with aspirin: the randomized, double-blind OCLA (Omeprazole CLopidogrel Aspirin) study. J Am Coll Cardiol 51:256–260CrossRefPubMedGoogle Scholar
  49. 49.
    Siller-Matula JM, Spiel AO, Lang IM et al (2009) Effects of pantoprazole and esomeprazole on platelet inhibition by clopidogrel. Am Heart J 157:148.e1–148.e5CrossRefPubMedGoogle Scholar
  50. 50.
    O’Donoghue M, Wiviott SD, Antman E et al (2009) The risk of CV events for patients treated with clopidogrel or prasugrel in combination with a proton pump inhibitor. Results from the TRITON-TIMI 38 trial. ESC Annual Meeting, Hotline, BarcelonaGoogle Scholar
  51. 51.
    Mehta N (2009) CURRENT OASIS 7: a 2X2 factorial randomized trial of optimal clopidogrel and aspirin dosing in patients with ACS undergoing an early invasive strategy with intent for PCI. ESC Annual Meeting, Hotline, BarcelonaGoogle Scholar
  52. 52.
    Bhatt DL, Cryer B, Contant CF et al (2009) The COGENT trial. TCT, Late Breaking Trials, San FranciscoGoogle Scholar
  53. 53.
    Wiviott SD, Braunwald E, McCabe CH et al (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357:2001–2015CrossRefPubMedGoogle Scholar
  54. 54.
    Wiviott SD, Trenk D, Frelinger AL et al (2007) Prasugrel compared with high loading- and maintenance-dose clopidogrel in patients with planned percutaneous coronary intervention: the Prasugrel in Comparison to Clopidogrel for Inhibition of Platelet Activation and Aggregation-Thrombolysis in Myocardial Infarction 44 trial. Circulation 116:2923–2932CrossRefPubMedGoogle Scholar
  55. 55.
    Farid NA, Payne CD, Small DS et al (2007) Cytochrome P450 3A inhibition by ketoconazole affects prasugrel and clopidogrel pharmacokinetics and pharmacodynamics differently. Clin Pharmacol Ther 81:735–741CrossRefPubMedGoogle Scholar
  56. 56.
    Montalescot G, Wiviott SD, Braunwald E et al (2009) Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 373:723–731CrossRefPubMedGoogle Scholar
  57. 57.
    Wiviott SD, Braunwald E, Angiolillo DJ et al (2008) Greater clinical benefit of more intensive oral antiplatelet therapy with prasugrel in patients with diabetes mellitus in the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel – Thrombolysis in Myocardial Infarction 38. Circulation 118:1626–1636CrossRefPubMedGoogle Scholar
  58. 58.
    Wiviott SD, Braunwald E, McCabe CH et al (2008) Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. Lancet 371:1353–1363CrossRefPubMedGoogle Scholar
  59. 59.
    NICE (2009) Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention. http://www.nice.org.ukGoogle Scholar
  60. 60.
    Steg G, James S, Harrington RA et al (2009) PLATO-STEMI: outcomes in patients with STEMI and planned PCI. AHA, late breaking trials, OrlandoGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • S. Silber
    • 1
  • M. Borggrefe
    • 1
  • G. Hasenfuß
    • 1
  • V. Falk
    • 1
  • A. Kastrati
    • 1
  • M. Weis
    • 1
  • C.W. Hamm
    • 1
  1. 1.Kardiologische Praxis und PraxisklinikAkademische Lehrpraxis der Ludwig-Maximilians-UniversitätMünchenDeutschland

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