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Akuter Myokardinfarkt: Akut-PCI in jedem Krankenhaus versus Akut-PCI im spezialisierten Zentrum

Acute Myocardial Infarction: Acute Coronary Intervention at Any Hospital versus Acute Coronary Intervention at Specialized Centers Only

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Zusammenfassung

Das akute Koronarsyndrom (ACS) wird heute in ein akutes Koronarsyndrom mit ST-Hebungen (STE-ACS = ST-Hebungsinfarkt [STEMI]) und eines ohne ST-Hebungen (NSTE-ACS) unterteilt. Letzteres wird nochmals unterteilt in ein NSTE-ACS mit Risikomerkmalen und ein NSTE-ACS ohne Risikomerkmale.

Für das NSTE-ACS mit Risikomerkmalen wird allgemein eine frühe invasive Abklärung innerhalb von 72 h nach Diagnosestellung empfohlen, während das NSTE-ACS ohne Risikomerkmale zunächst rein medikamentös konservativ behandelt werden kann. Bezüglich des STE-ACS ist die Primärdilatation eindeutig Mittel der ersten Wahl. Dies gilt aber nur unter drei Voraussetzungen:

1. wenn die Primärdilatation beim STE-ACS innerhalb von 2 h nach Diagnosestellung durchgeführt werden kann;

2. wenn die Pforte-Ballon-Zeiten beim STE-ACS kurz, d.h. in der Regel < 60 min sind;

3. wenn die Interventionen von erfahrenen Untersuchern an Krankenhäusern mit einer ausreichenden Anzahl an Interventionen pro Jahr durchgeführt werden.

Der letzte Punkt beruht auf Studienergebnissen, die einen Zusammenhang zwischen der jährlichen Häufigkeit von perkutanen Koronarinterventionen (PCIs) eines Krankenhauses und der Krankenhausmortalität der PCIs, insbesondere bei ACS-Patienten, gefunden haben.

Da in Deutschland prinzipiell eine flächendeckende Versorgung von ACS-Patienten mittels einer invasiven Abklärung innerhalb der vorgegebenen Zeitfenster möglich ist, ist es zurzeit die primäre Aufgabe, lokale Netzwerke zur Gewährleistung dessen zu errichten. Dies sollte jedoch insbesondere in Ballungsgebieten mit einer hohen Dichte an PCI-Zentren unter Berücksichtigung der Erfahrung der Untersucher und des PCI-Aufkommens der Kliniken erfolgen.

Abstract

The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors.

For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions:

(1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS;

(2) door-to-balloon times for STE-ACS have to be < 60 min;

(3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume.

The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality.

In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators’ experience and the annual interventional volumes of the participating hospitals into account.

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Authors and Affiliations

  1. Kardiologie, Herzzentrum Ludwigshafen, Ludwigshafen, Germany

    Uwe Zeymer

  2. Chefarzt der Medizinischen Klinik B, Kardiologie/Pneumologie/Angiologie/Internistische Intensivmedizin, Herzzentrum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany

    Ralf Zahn

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Zahn, R., Zeymer, U. Akuter Myokardinfarkt: Akut-PCI in jedem Krankenhaus versus Akut-PCI im spezialisierten Zentrum. Herz 34, 211–217 (2009). https://doi.org/10.1007/s00059-009-3230-9

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