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Patienten mit kardialen und zerebralen Durchblutungsstörungen

Sekundärprophylaxe mit Antikoagulation und Plättchenhemmern

Patients with cardiac and cerebrovascular disorders

Secondary prophylaxis using anticoagulation and platelet inhibitors

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Der Kardiologe Aims and scope

Zusammenfassung

Die medikamentöse Behandlung des Herzinfarktes und ischämischen Schlaganfalls weist zahlreiche Überlappungen in der Sekundärprophylaxe auf. Ziel dieses Übersichtsbeitrags ist eine Darstellung von Grenzfällen zwischen Kardiologie und Neurologie, für die keine evidenzbasierten Therapieempfehlungen existieren. Schlaganfallpatienten mit einer absoluten Arrhythmie bei Vorhofflimmern profitieren bei fehlenden Kontraindikationen generell von einer oralen Antikoagulation (OAK). Eine zusätzliche Thrombozytenfunktionshemmung mit Acetylsalicylsäure (ASS) führt bei diesen Patienten zu einer Verdreifachung des Blutungsrisikos ohne Reduktion von vaskulären Ereignissen. Im Falle einer intrazerebralen Blutung sollte eine OAK je nach Rückbildung der neurologischen Defizite für 2–4 Wochen pausiert werden und kann anschließend mit einer Ziel-INR von 2–3 wieder fortgeführt werden. Kommt es unter Thrombozytenfunktionshemmern zu einer intrazerebralen Blutung, sollte diese unter Abwägung des gesamten vaskulären Risikos für zumindest 2 Wochen bzw. besser bis zur Resorption der Blutung pausiert werden.

Abstract

Strategies to prevent myocardial infarction and ischemic stroke often overlap in clinical practice. We therefore aim to present selected cases in the borderline area between cardiology and neurology for which no evidence-based guidelines exist. Oral anticoagulation (OAC) has been shown to be highly beneficial in stroke patients with atrial fibrillation in the absence of contraindications. Additional platelet inhibition with aspirin, however, triples the risk of bleeding without reducing vascular events and is thus not recommended except for patients after carotid stenting with concomitant atrial fibrillation. In the event of intracerebral hemorrhage, OAC should be discontinued for 2–4 weeks depending on the restitution of neurological symptoms and thereafter can be resumed with a target international normalized ratio (INR) of 2–3. In the event of intracerebral hemorrhage during antiplatelet therapy, treatment should be discontinued for at least 2 weeks, taking account of the overall vascular risk or, even better, until resorption of the hemorrhage.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Prof. Dr. H.-C. Diener erhielt Honorare für die Teilnahme an klinischen Studien, als Studienleiter, als Mitglied eines Advisory Board oder für Vorträge von: Abbott, Astra-Zeneca, Bayer Vital, Böhringer Ingelheim, CoAxia, D-Pharm, Fresenius, GlaxoSmithKline, Janssen Cilag, MSD, Novartis, Novo-Nordisk, Paion, Parke-Davis, Pfizer, Sanofi-Aventis, Sankyo, Servier, Solvay, Wyeth, Yamaguchi. Finanzielle Unterstützung für Forschungsprojekte wurde gewährt von: Astra/Zeneca, GSK, Böhringer Ingelheim, Novartis, Janssen-Cilag, Sanofi-Aventis. Die Universitätsklinik für Neurologie in Essen erhält Forschungsgelder der EU, der DFG, des BMBF, der Bertelsmann Stiftung und der Heinz-Nixdorf Stiftung. H.-C. Diener besitzt keine Anteile an Pharmafirmen und hat keine Aktien einer pharmazeutischen Firma.

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Authors and Affiliations

  1. Universitätsklinik für Neurologie, Hufelandstraße 55, 45147, Essen, Deutschland

    H.-C. Diener & C. Weimar

  2. Klinik für Innere Medizin III, Kardiologie, Angiologie, internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland

    M. Böhm

  3. Direktor der Klinik für Kardiologie, Angiologie, Innere Medizin III, Universitätsklinik Freiburg, Freiburg, Deutschland

    C. Bode

  4. Klinik für Neurologie, Kreiskrankenhaus Siegen, Siegen, Deutschland

    M. Grond

  5. Neurologische Klinik, Johannes Wesling Klinikum Minden, Minden, Deutschland

    J. Röther

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  1. H.-C. Diener
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  2. C. Weimar
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  3. M. Böhm
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  4. C. Bode
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  5. M. Grond
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  6. J. Röther
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Correspondence to H.-C. Diener.

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Diener, HC., Weimar, C., Böhm, M. et al. Patienten mit kardialen und zerebralen Durchblutungsstörungen. Kardiologe 2, 491–499 (2008). https://doi.org/10.1007/s12181-008-0104-y

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  • DOI: https://doi.org/10.1007/s12181-008-0104-y

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