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Perioperatives Management von Patienten mit Koronarstents bei nichtherzchirurgischen Eingriffen

Perioperative management of patients with coronary stents in non-cardiac surgery

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Zusammenfassung

Bei Patienten mit Koronarstents, die operiert werden müssen, stellt sich die Frage, ob und wie die Thrombozytenaggregationshemmung fortgesetzt werden soll. Dabei gilt es, das Risiko perioperativer Blutungen gegen das einer akuten Stentthrombose abzuwägen. Das Blutungsrisiko hängt in erster Linie von der Art der geplanten Operation und von den Komorbiditäten des Patienten ab. Das Thromboserisiko ist aufgrund der thrombogenen Oberfläche der Stents erhöht. Dabei spielen die Zeitdauer, die seit der Stentimplantation vergangen ist, die Art des Stents [unbeschichtet („bare-metal stent“, BMS) oder beschichtet (z. B. „drug-eluting stent“, DES)] sowie angiographische und klinische Patientenfaktoren eine Rolle. Die perioperative antiaggregatorische Therapie muss daher bei jedem Patienten individuell angepasst werden. Ein „Bridging“ mit Heparin ist unwirksam. Die Zeit der perioperativen Unterbrechung der oralen Antiplättchentherapie kann bei Hochrisikopatienten mit i.v. Thromobozytenaggregationshemmern überbrückt werden. Ob ein bettseitiges Monitoring der Thrombozytenfunktion die perioperative Führung dieser Patienten verbessern und zur Reduktion von Komplikationen beitragen kann, ist Gegenstand aktueller Studien.

Abstract

In patients with coronary stents scheduled for surgery the question arises whether and how antiplatelet therapy should be continued. Risks of perioperative bleeding and of acute stent thrombosis have to be considered simultaneously. The bleeding risk depends primarily on the kind of surgery and on patient comorbidity. The risk of stent thrombosis is increased in these patients due to the thrombogenic surface of the stents. The main determinants are hereby the time duration after stent implantation, the kind of the stent [uncoated (bare-metal stent, BMS) or coated (drug-eluting stent, DES)], as well as angiographic and clinical patient factors. Therefore, perioperative antiplatelet therapy has to be individually adapted for each patient. Bridging with heparin is ineffective. Bridging with intravenous antiplatelet drugs during the perioperative interruption of oral antiplatelet therapy might be a potential procedure in high-risk patients. Whether bedside monitoring of antiplatelet therapy improves the perioperative management of these patients and reduces adverse outcome is object of current studies.

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Abbreviations

ACC:

American College of Cardiology

ACCP:

American College of Chest Physicians

ADP:

Adenosindiphosphat

AHA:

American Heart Association

ARC:

Academic Research Consortium

ASS:

Azetylsalizylsäure

BMS:

„bare-metal stent“

COX-1:

Zyklooxygenase-1

DGAI:

Deutsche Gesellschaft für Anästhesiologie und Intensivtherapie

DES:

„drug-eluting stent“

EMEA:

European Medicines Agency

ESC:

European Society of Cardiology

FDA:

Food and Drug Administration

GpIIb/IIIa:

Glykoprotein IIb/IIIa

LMWH:

Niedermolekulares Heparin („low molecular weight heparin“)

PCI:

Perkutane Koronarintervention

POC:

„point-of-care“

PTCA:

Perkutane transluminale Koronarangioplastie

TRAP-6:

Thrombinrezeptor aktivierendes Peptid

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Der korrespondierende Autor weist auf folgende Beziehung/en hin: Frau Dr. Cs. Jámbor hat von den Firmen IL und Dynabyte Honorare für wissenschaftliche Vorträge bzw. Beratertätigkeit erhalten. Herr Prof. Michael Spannagl erhielt Vortragshonorare von den Firmen Sanofi, Eli Lilly und Daiichi-Sankyo. Die Präsentation des Themas ist unabhängig und in der Darstellung der Inhalte produktneutral.

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  1. Arbeitsgruppe „Perioperative Hämostase“, Klinik für Anaesthesiologie, Ludwig-Maximilians-Universität München, Max-Lebsche-Platz 32, 81377, München, Deutschland

    C. Jámbor, M. Spannagl & B. Zwissler

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  1. C. Jámbor
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Jámbor, C., Spannagl, M. & Zwissler, B. Perioperatives Management von Patienten mit Koronarstents bei nichtherzchirurgischen Eingriffen. Anaesthesist 58, 971–985 (2009). https://doi.org/10.1007/s00101-009-1628-7

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  • DOI: https://doi.org/10.1007/s00101-009-1628-7

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