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Das akute Koronarsyndrom in der Prähospitalphase

Acute coronary syndrome in the prehospital phase

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Zusammenfassung

In der Bundesrepublik Deutschland verstarben im Jahr 2002 knapp 70.000 Menschen aufgrund eines akuten Myokardinfarkts (AMI), etwa 37% verstarben noch vor Erreichen der Klinik. Dies unterstreicht die besondere Relevanz einer adäquaten prähospitalen Versorgung. Anlass für die Einführung des gemeinsamen Oberbegriffes akutes Koronarsyndrom (ACS) ist der gemeinsame Pathomechanismus der verschiedenen ACS-Formen. Die Definition reicht von der instabilen Angina pectoris (iAP) über den Nicht-ST-Streckenhebungsinfarkt (NSTEMI) und den ST-Streckenhebungsinfarkt (STEMI) bis zum plötzlichen Herztod (PHT). Charakteristisch sind retrosternale Schmerzen, ggf. eine vegetative Symptomatik und Ausstrahlung des Schmerzes. Weiter differenziert wird das ACS nur durch das 12-Kanal EKG; herzspezifische Enzyme haben prähospital therapeutisch zurzeit keinen Stellenwert. Anamnese und Untersuchung sollten kurz und gezielt erfolgen, die Vitalparameter des Patienten engmaschig überwacht werden. Die Basistherapie besteht aus inhalativer Sauerstoffgabe, sublingualer Gabe von Glyceroltrinitrat, Morphin, Acetylsalicylsäure (ASS) und ggf. β-Blockern über einen peripher-venösen Zugang. Lässt sich die Diagnose STEMI durch 12-Kanal EKG und Anamnese eindeutig stellen, sollte bei allen Patienten ohne Kontraindikationen mit einer Fibrinolyse begonnen werden, sofern zu erwarten ist, dass die Verzögerung bis zu einer perkutanen koronaren (Katheter-)Intervention (PCI) >90 min und die Symptomdauer weniger als 12 h beträgt. Besonders günstig ist eine Symptomdauer <3 h. Patienten mit STEMI erhalten Heparin in Abhängigkeit von dem verwendeten Fibrinolytikum, eine Routinegabe von Heparin erhöht bei diesen Patienten die Blutungsrate, während Heparin bei Patienten mit iAP oder NSTEMI insgesamt das weitere Risiko senkt. Alle ACS-Patienten müssen vom Notarzt ins Krankenhaus begleitet werden. Patienten mit Komplikationen bzw. Kontraindikationen für eine Fibrinolyse sollten nach Möglichkeit in ein Zentrum mit akut verfügbarer Interventionsmöglichkeit (PCI) gebracht werden. Patienten mit unkompliziertem ACS können in jede Klinik mit einer geeigneten Intensivstation gebracht werden. Die Behandlung von Begleitkomplikationen richtet sich nach der Art und dem klinischem Schweregrad der Störung.

Abstract

Cardiovascular diseases are the number one cause of death in Germany. In 2002 about 70,000 people died of acute myocardial infarction (AMI) and of these 37% died before arrival at hospital which underlines the relevance of adequate prehospital care. The generic term acute coronary syndrome (ACS) was introduced because a single pathomechanism accounts for the different forms and comprises unstable angina pectoris (iAP), non-ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). Characteristic features are retrosternal pain, vegetative symptoms and radiation of pain into the adjoining regions. Further differentiation can only be achieved by the 12-lead ECG, as cardiac-specific enzymes do not play a role in prehospital decisions. Prehospital delays should be avoided, history and physical examination should be brief but focused, vital parameters should be assessed and monitored. Basic treatment for ACS should comprise inhalative oxygen, nitrates, morphine, aspirin and β-blockers. If STEMI is diagnosed, patients with symptoms <12 h should undergo fibrinolytic therapy unless there is primary percutaneous coronary intervention (PCI) available within 90 min or if contraindicated. Heparin should be given to patients with STEMI depending on the choice of fibrinolytic agent, it otherwise results in a higher risk of bleeding, but in patients with iAP or NSTEMI it reduces mortality. All patients must be accompanied by the emergency physician during transportation and should be brought to a hospital with primary PCI, especially those with complicated ACS. Treatment of complications depends largely on the type, persistence and severity.

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Interessenkonflikt:

Der korrespondierende Autor weist auf eine Verbindung mit folgender Firma/Firmen hin: Prof. Böttiger leitet die int. TROICA-Studie, die von der Fa. Boehringer-Ingelheim unterstützt wird.

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  1. Klinik für Anaesthesiologie, Universitätsklinikum, Heidelberg

    J.-H. Schiff & B. W. Böttiger

  2. Medizinische Klinik II Kardiologie und Pulmologie, Charite, Campus Benjamin Franklin, Berlin

    H. R. Arntz

  3. Klinik für Anaesthesiologie, Universitätsklinikum, Im Neuenheimer Feld 110, 69120, Heidelberg

    J.-H. Schiff

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Schiff, JH., Arntz, H.R. & Böttiger, B.W. Das akute Koronarsyndrom in der Prähospitalphase. Anaesthesist 54, 957–974 (2005). https://doi.org/10.1007/s00101-005-0897-z

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