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Betreuung von Patienten nach Koronarstentimplantation

Was ist wichtig für die Praxis

Care of patients after coronary stent implantation: What is important in practice?

  • Schwerpunkt: Was ist gesichert in der Therapie?
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Zusammenfassung

Die Einführung von medikamentenfreisetzenden Stents war ein wesentlicher Fortschritt in der Reduktion der Restenoserate nach koronarer Stentimplantation. Leider gibt es Hinweise, dass die Reduktion der Restenose durch ein prolongiertes spätes (>30 Tage) Stentthromboserisiko erkauft wird. Die bisherigen Daten sind jedoch nicht vollständig konklusiv bezüglich der Höhe und Dauer des Stentthromboserisikos und der damit assoziierten kardiovaskulären Ereignisse. Vorerst wird vor allem bei Risikopatienten (z. B. lange oder mehrere Stents, Diabetes mellitus) eine prolongierte (12 statt 6 Monate) duale Thrombozytenaggregationshemmung mit Acetylsalicylsäure (ASS) und Clopidogrel empfohlen. Einfache Operationen (z. B. Zahnextraktionen) sind auch unter dualer Aggregationshemmung möglich. Besondere Aufmerksamkeit gilt Patienten, die gleichzeitig noch Marcumar benötigen, da bei einer Tripeltherapie (ASS, Clopidogrel und Marcumar) das Blutungsrisiko exzessiv ansteigt. Eine elektive Kontrollangiographie ist nicht routinemäßig nach koronarer Stentimplantation notwendig, erscheint jedoch bei ausgewählten Risikopatienten (z. B. Hauptstamm- oder Mehrgefäßintervention) im Einzelfall sinnvoll. Die medikamentöse Einstellung der kardiovaskulären Risikofaktoren (Lipide, Hypertonie und Diabetes mellitus) ist nach einer koronaren Intervention obligat. Wichtig ist dabei auch auf einen Diabetes mellitus oder eine Glukosetoleranzstörung zu untersuchen, da diese bei ca. 1/3 der Patienten vorliegt, aber übersehen wird.

Abstract

The introduction of Drug Eluting Stents was an important step to reduce restenosis rate after coronary stent implantation. Unfortunately, reduction of restenosis was paid off by the price of potential increased late (>30 days) stent thrombosis. However, current data are not completely conclusive with respect to extent and duration of stent thrombosis and cardiovascular risk after drug eluting stent implantation. Until now, especially for patients at risk for stent thrombosis a prolonged (12 instead of 6 months) dual antiplatelet therapy with aspirin and clopidogrel is recommended. Thereby, the quality of physician instructions is predictive for patient’s compliance. Premature termination of dual antiplatelet therapy should be avoided; many small surgical interventions (e.g. tooth extraction) can be performed under dual antiplatelet therapy. Patients with “triple therapy” (aspirin, clopidogrel and coumarin derivate) should be monitored carefully, since they have an excessive bleeding risk. An elective coronary angiography after coronary stent implantation is not routinely necessary. However in selected high-risk patients (e.g. left main or multivessel stent implantation) control angiography may be useful. Medical therapy of risk factors (hyperlipidemia, hypertension, and diabetes mellitus) is essential also after coronary stent implantation. It is important to screen patients for diabetes mellitus, since approximately 1/3 of patients after coronary intervention have an otherwise unrecognized diabetes mellitus or glucose tolerance disturbance.

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Abb. 1

Abbreviations

ARC:

Einheitliche Definition für Stentthrombose

BMS:

Unbeschichteter Metallstent („Bare Metal Stent“)

DES:

Medikamentenbeschichteter Stent („Drug Eluting Stent“)

PCI:

Perkutane koronare Intervention

PES:

Paclitaxel Eluting Stent (z. B. Taxus)

SES:

Sirolimus Eluting Stent (z. B. Cypher)

Literatur

  1. Ambrose JA (2006) Myocardial ischemia and infarction. J Am Coll Cardiol 47: D13–D17

    Article  PubMed  Google Scholar 

  2. Bartnik M, Ryden L, Ferrari R et al. (2004) The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe. The Euro Heart Survey on diabetes and the heart. Eur Heart J 25: 1880–1890

    Article  PubMed  CAS  Google Scholar 

  3. 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: 1982–1988

    Article  PubMed  Google Scholar 

  4. Bonow RO, Carabello BA, Chatterjee K et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 48: e1–e148

    Article  PubMed  Google Scholar 

  5. Buonamici P, Marcucci R, Migliorini A et al. (2007) Impact of platelet reactivity after clopidogrel administration on drug-eluting stent thrombosis. J Am Coll Cardiol 49: 2312–2317

    Article  PubMed  CAS  Google Scholar 

  6. Camenzind E, Steg PG, Wijns W (2007) Stent thrombosis late after implantation of first-generation drug-eluting stents: a cause for concern. Circulation 115: 1440–1455

    Article  PubMed  Google Scholar 

  7. CARS Investigators (1997) Randomised double-blind trial of fixed low-dose warfarin with aspirin after myocardial infarction. Coumadin Aspirin Reinfarction Study (CARS) Investigators. Lancet 350: 389–396

    Article  Google Scholar 

  8. Connolly S, Pogue J, Hart R et al. (2006) Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 367: 1903–1912

    Article  PubMed  CAS  Google Scholar 

  9. Corpus RA, George PB, House JA et al. (2004) Optimal glycemic control is associated with a lower rate of target vessel revascularization in treated type II diabetic patients undergoing elective percutaneous coronary intervention. J Am Coll Cardiol 43: 8–14

    Article  PubMed  Google Scholar 

  10. 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: 667–678

    Article  PubMed  CAS  Google Scholar 

  11. DeEugenio D, Kolman L, DeCaro M et al. (2007) Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy 27: 691–696

    Article  PubMed  CAS  Google Scholar 

  12. Eisenstein EL, Anstrom KJ, Kong DF et al. (2007) Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 297: 159–168

    Article  PubMed  CAS  Google Scholar 

  13. Fox KM (2003) Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 362: 782–788

    Article  PubMed  CAS  Google Scholar 

  14. Grines CL, Bonow RO, Casey DE Jr et al. (2007) Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 115: 813–818

    Article  PubMed  Google Scholar 

  15. Grundy SM, Cleeman JI, Merz CN et al. (2004) Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 110: 227–239

    Article  PubMed  Google Scholar 

  16. LaRosa JC, Grundy SM, Waters DD et al. (2005) Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 352: 1425–1435

    Article  PubMed  CAS  Google Scholar 

  17. Laskey WK, Yancy CW, Maisel WH (2007) Thrombosis in coronary drug-eluting stents: report from the meeting of the Circulatory System Medical Devices Advisory Panel of the Food and Drug Administration Center for Devices and Radiologic Health, December 7–8, 2006. Circulation 115: 2352–2357

    Article  PubMed  Google Scholar 

  18. Nissen SE, Wolski K (2007) Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 356: 2457–2471

    Article  PubMed  CAS  Google Scholar 

  19. O’Keefe JH Jr, Hartzler GO, Rutherford BD et al. (1989) Left main coronary angioplasty: early and late results of 127 acute and elective procedures. Am J Cardiol 64: 144–147

    Article  Google Scholar 

  20. Schuhlen H, Hadamitzky M, Walter H et al. (1997) Major benefit from antiplatelet therapy for patients at high risk for adverse cardiac events after coronary Palmaz-Schatz stent placement: analysis of a prospective risk stratification protocol in the Intracoronary Stenting and Antithrombotic Regimen (ISAR) trial. Circulation 95: 2015–2021

    PubMed  CAS  Google Scholar 

  21. Schuhlen H, Kastrati A, Mehilli J et al. (2004) Restenosis detected by routine angiographic follow-up and late mortality after coronary stent placement. Am Heart J 147: 317–322

    Article  PubMed  Google Scholar 

  22. Silber S, Böhm M, Gottwik M et al. (2007) Akutes Herzinfarktrisiko bei mangelnder Clopidogrelgabe nach koronarer Stentimplantation. Dtsch Arztebl 103: A-2863–A-2868

    Google Scholar 

  23. Silber S, Borggrefe M, Böhm M et al. (2007) Positionspapier der DGK zur Wirksamkeit und Sicherheit von Medikamenten freisetzenden Koronarstents (DES). Eine evidenzbasierte Analyse von 71 randomisierten Studien mit 28.984 Patienten. Kardiologe 1: 84–111

    Article  Google Scholar 

  24. Stone GW, Ellis SG, Colombo A et al. (2007) Offsetting impact of thrombosis and restenosis on the occurrence of death and myocardial infarction after paclitaxel-eluting and bare metal stent implantation. Circulation 115: 2842–2847

    Article  PubMed  Google Scholar 

  25. Stone GW, Moses JW, Ellis SG et al. (2007) Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med 356: 998–1008

    Article  PubMed  CAS  Google Scholar 

  26. Takagi T, Akasaka T, Yamamuro A et al. (2000) Troglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with non-insulin dependent diabetes mellitus: a serial intravascular ultrasound study. J Am Coll Cardiol 36: 1529–1535

    Article  PubMed  CAS  Google Scholar 

  27. UKPDS group (1998) Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet 352: 854–865

    Article  Google Scholar 

  28. Van Belle E, Ketelers R, Bauters C et al. (2001) Patency of percutaneous transluminal coronary angioplasty sites at 6-month angiographic follow-up: A key determinant of survival in diabetics after coronary balloon angioplasty. Circulation 103: 1218–1224

    Google Scholar 

  29. Walter DH, Schächinger V, Elsner M et al. (2000) Effect of statin therapy on restenosis after coronary stent implantation. Am J Cardiol 85: 962–968

    Article  PubMed  CAS  Google Scholar 

  30. Yusuf S, Hawken S, Ounpuu S et al. (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 364: 937–952

    Article  PubMed  Google Scholar 

  31. Yusuf S, Sleight P, Pogue J et al. (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342: 145–153

    Article  PubMed  CAS  Google Scholar 

  32. Yusuf S, Zhao F, Mehta SR et al. (2001) Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 345: 494–502

    Article  PubMed  CAS  Google Scholar 

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  1. Med. Klinik III – Kardiologie, Klinikum der J. W. Goethe Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland

    V. Schächinger

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Schächinger, V. Betreuung von Patienten nach Koronarstentimplantation. Internist 48, 1365–1375 (2007). https://doi.org/10.1007/s00108-007-1975-x

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