Advertisement

Der Kardiologe

, Volume 10, Issue 6, pp 351–358 | Cite as

Kommentar zu den 2015‑Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zum Management des akuten Koronarsyndroms ohne ST‑Hebungen (NSTE-ACS)

  • J. MehilliEmail author
  • C. W. Hamm
  • U. Landmesser
  • S. Massberg
Leitlinien

Zusammenfassung

Die neue NSTE-ACS (akutes Koronarsyndrom ohne ST-Hebungen)-Leitlinie der Europäischen Gesellschaft für Kardiologie (ESC) inkorporiert wichtige aktuelle Erkenntnisse insbesondere hinsichtlich der Früherkennung des NSTE-ACS und erleichtert über einen 0‑h/1-h-Algorithmus die Triage in den „chest pain units“. Bezüglich der Dauer der antithrombotischen Therapie nach perkutaner Koronarintervention bei NSTE-ACS bleiben 12 Monate der Standard, kürzere wie auch längere Therapiephasen sind jedoch entsprechend aktueller Studienergebnisse nach individueller Risiko-Nutzen-Abwägung in Ausnahmefällen möglich. Bei ACS-Patienten mit zusätzlicher Indikation zur oralen Antikoagulation wird weiterhin eine Triple-Therapie empfohlen, deren Dauer sich nach dem individuellen Blutungs- und Ischämierisiko richten muss. Bei Patienten mit nichtvalvulärem Vorhofflimmern sind aufgrund ihres günstigeren Risikoprofils hinsichtlich Blutung nun auch neue orale Antikoagulanzien (NOAKs) als Alternative zu Vitamin-K-Antagonisten (VKA) in den Leitlinien verankert. Randomisierte Studien prüfen derzeit den Stellenwert von NOAKs, aber auch dualer Behandlungskonzepte (orale Antikoagulation plus antithrombozytäre Monotherapie) in der akuten und chronischen Phase.

Schlüsselwörter

Risikostratifizierung Troponin Plättchenhemmung Antikoagulation Revaskularisation 

Comments on the 2015 guidelines of the European Society of Cardiology (ESC) for management of non-ST elevation acute coronary syndrome (NSTE-ACS)

Abstract

The new European Society of Cardiology (ESC) guidelines on non-ST elevation acute coronary syndrome (NSTE-ACS) reflect important current scientific evidence regarding early diagnosis of NSTE-ACS and facilitate better patient triage in chest pain units using a 0 h/1 h rule in/rule out algorithm. Furthermore, 12 months remain the standard duration of antithrombotic therapy after percutaneous coronary intervention (PCI) for NSTE-ACS, while based on current evidence shorter or longer treatment duration is possible in exceptional cases after careful consideration of the individual patient risks and benefits. For ACS patients with additional indications for oral anticoagulation, triple therapy is still recommended and the duration strongly depends on individual risks of bleeding and ischemia. In addition, due to a favorable safety profile, non-vitamin K oral anticoagulants (NOAC) might be considered in patients with non-valvular atrial fibrillation as an alternative to vitamin K antagonists (VKA). There are several randomized trials currently investigating both NOAC and different dual antithrombotic treatment strategies (e.g. OAC plus antiplatelet monotherapy) in the acute and chronic phases of ACS.

Keywords

Risk stratification Troponin Platelet inhibitors Anticoagulation Revascularisation 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

Den Interessenkonflikt der Autoren finden Sie online auf der DGK-Homepage unter http://leitlinien.dgk.org/ bei der entsprechenden Publikation.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, Katus HA, Lindahl B, Morrow DA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand J‑P, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon J‑L, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S (2012) Third universal definition of myocardial infarction. Lippincott Williams & Wilkins, Philadelphia, S 2020–2035Google Scholar
  2. 2.
    Libby P (2013) Mechanisms of acute coronary syndromes and their implications for therapy. N Engl J Med 368:2004–2013CrossRefPubMedGoogle Scholar
  3. 3.
    Roffi M, Patrono C, Collet J‑P, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S, Baumgartner H, Gaemperli O, Achenbach S, Agewall S, Badimon L, Baigent C, Bueno H, Bugiardini R, Carerj S, Casselman F, Cuisset T, Erol Ç, Fitzsimons D, Halle M, Hamm C, Hildick-Smith D, Huber K, Iliodromitis E, James S, Lewis BS, Lip GYH, Piepoli MF, Richter D, Rosemann T, Sechtem U, Steg PG, Vrints C, Luis Zamorano J (2015) ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 37:267–315CrossRefPubMedGoogle Scholar
  4. 4.
    Thygesen K, Mair J, Giannitsis E, Mueller C, Lindahl B, Blankenberg S, Huber K, Plebani M, Biasucci LM, Tubaro M, Collinson P, Venge P, Hasin Y, Galvani M, Koenig W, Hamm C, Alpert JS, Katus H, Jaffe AS, Study Group on Biomarkers in Cardiology of ESC Working Group on Acute Cardiac Care (2012) How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J 33:2252–2257CrossRefPubMedGoogle Scholar
  5. 5.
    Keller T, Zeller T, Ojeda F, Tzikas S, Lillpopp L, Sinning C, Wild P, Genth-Zotz S, Warnholtz A, Giannitsis E, Möckel M, Bickel C, Peetz D, Lackner K, Baldus S, Münzel T, Blankenberg S (2011) Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA 306:2684–2693CrossRefPubMedGoogle Scholar
  6. 6.
    Reichlin T, Schindler C, Drexler B, Twerenbold R, Reiter M, Zellweger C, Moehring B, Ziller R, Hoeller R, Rubini Gimenez M, Haaf P, Potocki M, Wildi K, Balmelli C, Freese M, Stelzig C, Freidank H, Osswald S, Mueller C (2012) One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac Troponin T. Arch Intern Med 172:1211–1218CrossRefPubMedGoogle Scholar
  7. 7.
    Rahimi K, Watzlawek S, Thiele H, Secknus M‑A, Hayerizadeh B‑F, Niebauer J, Schuler G (2006) Incidence, time course, and predictors of early malignant ventricular arrhythmias after non-ST-segment elevation myocardial infarction in patients with early invasive treatment. Eur Heart J 27:1706–1711CrossRefPubMedGoogle Scholar
  8. 8.
    Katritsis DG, Siontis GCM, Kastrati A, van’t Hof AWJ, Neumann F‑J, Siontis KCM, Ioannidis JPA (2011) Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. Eur Heart J 32:32–40CrossRefPubMedGoogle Scholar
  9. 9.
    Mehta SR, Granger CB, Boden WE, Steg PG, Bassand J‑P, Faxon DP, Afzal R, Chrolavicius S, Jolly SS, Widimsky P, Avezum A, Rupprecht H‑J, Zhu J, Col J, Natarajan MK, Horsman C, Fox KAA, Yusuf S, TIMACS Investigators (2009) Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 360:2165–2175CrossRefPubMedGoogle Scholar
  10. 10.
    Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, Rubartelli P, Briguori C, Andò G, Repetto A, Limbruno U, Cortese B, Sganzerla P, Lupi A, Galli M, Colangelo S, Ierna S, Ausiello A, Presbitero P, Sardella G, Varbella F, Esposito G, Santarelli A, Tresoldi S, Nazzaro M, Zingarelli A, de Cesare N, Rigattieri S, Tosi P, Palmieri C, Brugaletta S, Rao SV, Heg D, Rothenbühler M, Vranckx P, Jüni P, MATRIX Investigators (2015) Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet 385:2465–2476CrossRefPubMedGoogle Scholar
  11. 11.
    Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay J‑F, ten Berg JM, Miller DL, Costigan TM, Goedicke J, Silvain J, Angioli P, Legutko J, Niethammer M, Motovska Z, Jakubowski JA, Cayla G, Visconti LO, Vicaut E, Widimsky P, ACCOAST Investigators (2013) Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med 369:999–1010CrossRefPubMedGoogle Scholar
  12. 12.
    Montalescot G, van ’t Hof AW, Lapostolle F, Silvain J, Lassen JF, Bolognese L, Cantor WJ, Cequier A, Chettibi M, Goodman SG, Hammett CJ, Huber K, Janzon M, Merkely B, Storey RF, Zeymer U, Stibbe O, Ecollan P, Heutz WMJM, Swahn E, Collet J‑P, Willems FF, Baradat C, Licour M, Tsatsaris A, Vicaut E, Hamm CW, ATLANTIC Investigators (2014) Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 371:1016–1027CrossRefPubMedGoogle Scholar
  13. 13.
    Fiedler KA, Maeng M, Mehilli J, Schulz-Schüpke S, Byrne RA, Sibbing D, Hoppmann P, Schneider S, Fusaro M, Ott I, Kristensen SD, Ibrahim T, Massberg S, Schunkert H, Laugwitz K‑L, Kastrati A, Sarafoff N (2015) Duration of triple therapy in patients requiring oral Anticoagulation after drug-Eluting Stent implantation: the ISAR-TRIPLE trial. J Am Coll Cardiol 65:1619–1629CrossRefPubMedGoogle Scholar
  14. 14.
    Sarafoff N, Martischnig A, Wealer J, Mayer K, Mehilli J, Sibbing D, Kastrati A (2013) Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. J Am Coll Cardiol 61:2060–2066CrossRefPubMedGoogle Scholar
  15. 15.
    Jackson LR, Ju C, Zettler M, Messenger JC, Cohen DJ, Stone GW, Baker BA, Effron M, Peterson ED, Wang TY (2015) Outcomes of patients with acute myocardial infarction undergoing percutaneous coronary intervention receiving an oral anticoagulant and dual antiplatelet therapy: A comparison of Clopidogrel versus Prasugrel from the TRANSLATE-ACS Study. JACC Cardiovasc Interv 8:1880–1889CrossRefPubMedGoogle Scholar
  16. 16.
    Valgimigli M, Patialiakas A, Thury A, McFadden E, Colangelo S, Campo G, Tebaldi M, Ungi I, Tondi S, Roffi M, Menozzi A, de Cesare N, Garbo R, Meliga E, Testa L, Gabriel HM, Airoldi F, Ferlini M, Liistro F, Dellavalle A, Vranckx P, Briguori C, Investigators ZEUS (2015) Zotarolimus-eluting versus bare-metal stents in uncertain drug-eluting stent candidates. J Am Coll Cardiol 65:805–815CrossRefPubMedGoogle Scholar
  17. 17.
    Alexander JH, Lopes RD, James S, Kilaru R, He Y, Mohan P, Bhatt DL, Goodman S, Verheugt FW, Flather M, Huber K, Liaw D, Husted SE, Lopez-Sendon J, De Caterina R, Jansky P, Darius H, Vinereanu D, Cornel JH, Cools F, Atar D, Leiva-Pons JL, Keltai M, Ogawa H, Pais P, Parkhomenko A, Ruzyllo W, Diaz R, White H, Ruda M, Geraldes M, Lawrence J, Harrington RA, Wallentin L, APPRAISE-2 Investigators (2011) Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med 365:699–708CrossRefPubMedGoogle Scholar
  18. 18.
    Mega JL, Braunwald E, Wiviott SD, Bassand J‑P, Bhatt DL, Bode C, Burton P, Cohen M, Cook-Bruns N, Fox KAA, Goto S, Murphy SA, Plotnikov AN, Schneider D, Sun X, Verheugt FWA, Gibson CM, ATLAS ACS 2–TIMI 51 Investigators (2012) Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med 366:9–19CrossRefPubMedGoogle Scholar
  19. 19.
    Lip GYH, Windecker S, Huber K, Kirchhof P, Marin F, ten Berg JM, Haeusler KG, Boriani G, Capodanno D, Gilard M, Zeymer U, Lane D, Storey RF, Bueno H, Collet J‑P, Fauchier L, Halvorsen S, Lettino M, Morais J, Mueller C, Potpara TS, Rasmussen LH, Rubboli A, Tamargo J, Valgimigli M, Zamorano JL (2014) Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 35(45):3155–3179Google Scholar
  20. 20.
    Ruff CT, Giugliano RP, Braunwald E, Morrow DA, Murphy SA, Kuder JF, Deenadayalu N, Jarolim P, Betcher J, Shi M, Brown K, Patel I, Mercuri M, Antman EM (2015) Association between edoxaban dose, concentration, anti-Factor Xa activity, and outcomes: an analysis of data from the randomised, double-blind ENGAGE AF-TIMI 48 trial. Lancet 385:2288–2295CrossRefPubMedGoogle Scholar
  21. 21.
    Dans AL, Connolly SJ, Wallentin L, Yang S, Nakamya J, Brueckmann M, Ezekowitz M, Oldgren J, Eikelboom JW, Reilly PA, Yusuf S (2013) Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 127:634–640CrossRefPubMedGoogle Scholar
  22. 22.
    Lamberts M, Gislason GH, Olesen JB, Kristensen SL, Schjerning Olsen A‑M, Mikkelsen A, Christensen CB, Lip GYH, Køber L, Torp-Pedersen C, Hansen ML (2013) Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol 62:981–989CrossRefPubMedGoogle Scholar
  23. 23.
    Murphy SA, Cannon CP, Wiviott SD, McCabe CH, Braunwald E (2009) Reduction in recurrent cardiovascular events with intensive lipid-lowering statin therapy compared with moderate lipid-lowering statin therapy after acute coronary syndromes from the PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22) trial. J Am Coll Cardiol 54:2358–2362CrossRefPubMedGoogle Scholar
  24. 24.
    Cannon CP, Blazing MA, Giugliano RP, McCagg A, White JA, Theroux P, Darius H, Lewis BS, Ophuis TO, Jukema JW, De Ferrari GM, Ruzyllo W, De Lucca P, Im K, Bohula EA, Reist C, Wiviott SD, Tershakovec AM, Musliner TA, Braunwald E, Califf RM, IMPROVE-IT Investigators (2015) Ezetimibe added to Statin therapy after acute coronary syndromes. N Engl J Med 372:2387–2397CrossRefPubMedGoogle Scholar

Copyright information

© Deutsche Gesellschaft für Kardiologie - Herz- und Kreislaufforschung e.V. Published by Springer-Verlag Berlin Heidelberg - all rights reserved 2016

Authors and Affiliations

  • J. Mehilli
    • 1
    • 2
    Email author
  • C. W. Hamm
    • 3
  • U. Landmesser
    • 2
    • 4
  • S. Massberg
    • 1
    • 2
  1. 1.Medizinische Klinik und Poliklinik ILMU Klinikum der Universität MünchenMünchenDeutschland
  2. 2.Deutsches Zentrum für Herz-Kreislauf-ForschungDZHKBerlinDeutschland
  3. 3.Medizinische Klinik I – Kardiologie und AngiologieUniversitätsklinikum Gießen und Marburg GmbHGießenDeutschland
  4. 4.Medizinische Klinik für Kardiologie und PulmologieCharité – Universitätsmedizin BerlinBerlinDeutschland

Personalised recommendations