Zusammenfassung
Thrombozytenaggregationshemmer werden zur Verhinderung arterieller thromboembolischer Komplikationen eingesetzt. Im klinischen Alltag müssen die Risiken perioperativer Blutung und schwerwiegender thromboembolischer Komplikationen abgewogen werden, wenn Plättchenhemmer abgesetzt werden. Bei der Beendigung der Therapie müssen sowohl die Indikation als auch der Zeitpunkt des Absetzens sorgfältig gewählt werden. In keinem Fall sollte das individuelle Risiko unterschätzt werden. Vor allem Patienten mit stattgehabter koronarer Stentimplantation sind vital gefährdet, wenn die duale Plättchenhemmung vorzeitig, d. h. vor kompletter Endothelialisierung des Stents beendet wird.
Abstract
Antiplatelet therapy is used to prevent thromboembolic complications in patients with artherothrombotic disease. In clinical routine an assessment of the risk of perioperative bleeding must be weighed against the risk of thromboembolic complications in the event of discontinuation of antiplatelet agents. The indications as well as the timepoint for the termination of antiplatelet therapy are important issues to consider. The premature interruption of oral antiplatelet therapy with recovery of platelet function may lead to recurrence of thromboembolic events. Especially patients with intracoronary stents are at threat when the dual platelet therapy is interrupted before complete endothelialization of the stent.
Literatur
Albaladejo P, Marret E, Piriou V, Samama CM (2006) Perioperative management of antiplatelet agents in patients with coronary stents: recommendations of a French Task Force. Br J Anaesth 97: 580–582
Angiolillo DJ, Fernandez-Ortiz A, Bernardo E et al. (2006) Clopidogrel withdrawal is associated with proinflammatory and prothrombotic effects in patients with diabetes and coronary artery disease. Diabetes 55: 780–784
Antiplatelet Trialists’ Collaboration (1994) Collaborative overview of randomised trials of antiplatelet therapy–I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 308: 81–106
Antithrombotic Trialists’ Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324: 71–86
Biondi-Zoccai GG, Lotrionte M, Agostoni P et al. (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 27: 2667–2674
Burger W, Chemnitius JM, Kneissl GD, Rucker G (2005) Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med 257: 399–414
CAPRIE Steering Committee (1996) A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 348: 1329–1339
Collet JP, Himbet F, Steg PG (2000) Myocardial infarction after aspirin cessation in stable coronary artery disease patients. Int J Cardiol 76: 257–258
Collet JP, Montalescot G, Blanchet B et al. (2004) Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 110: 2361–2367
Collet J-P, Montalescot G (2006) Premature withdrawal and alternative therapies to dual oral antiplatelet therapy. Eur Heart J Suppl 8: G46–G52
Eagle KA, Berger PB, Calkins H et al. (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – executive summary a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to update the 1996 guidelines on perioperative cardiovascular evaluation for noncardiac surgery). Circulation 105: 1257–1267
Ferrari E, Benhamou M, Cerboni P, Marcel B (2005) Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 45: 456–459
Fitzgerald DJ, Catella F, Roy L, FitzGerald GA (1988) Marked platelet activation in vivo after intravenous streptokinase in patients with acute myocardial infarction. Circulation 77: 142–150
Gogarten W, Van Aken H, Büttner J et al. (2003) Rückenmarksnahe Regionalanästhesie und Thromboembolieprophylaxe/antithrombotische Medikation. Überarbeitete Empfehlungen der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Anaesthesiol Intensivmed 44: 218–230
Hamm CW (2004) Guidelines: acute coronary syndrome (ACS). 1: ACS without persistent ST segment elevations. Z Kardiol 93: 72–90
Harrington RA, Becker RC, Ezekowitz M et al. (2004) Antithrombotic therapy for coronary artery disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126: 513S–548S
Iakovou I, Schmidt T, Bonizzoni E et al. (2005) Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 293: 2126–2130
Jeremias A, Sylvia B, Bridges J et al. (2004) Stent thrombosis after successful sirolimus-eluting stent implantation. Circulation 109: 1930–1932
Kaluza GL, Joseph J, Lee JR et al. (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35: 1288–1294
Kelm M, Strauer BE (2005) Acute coronary syndrome: unstable angina and myocardial infarction. Internist 46: 265–274
Kozek-Langenecker SA (2003) Locoregional anesthesia and blood coagulation: impact of new antiplatelet drugs. Anaesthesist 52: 549–563
Lincoff AM, Califf RM, Moliterno DJ et al. (1999) Complementary clinical benefits of coronary-artery stenting and blockade of platelet glycoprotein IIb/IIIa receptors. Evaluation of platelet IIb/IIIa inhibition in stenting investigators. N Engl J Med 341: 319–327
McFadden EP, Stabile E, Regar E et al. (2004) Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 364: 1519–1521
Mitchell JA, Akarasereenont P, Thiemermann C et al. (1993) Selectivity of nonsteroidal antiinflammatory drugs as inhibitors of constitutive and inducible cyclooxygenase. Proc Natl Acad Sci U S A 90: 11693–11697
Morice MC, Serruys PW, Sousa JE et al. (2002) A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346: 1773–1780
Park SJ, Shim WH, Ho DS et al. (2003) A paclitaxel-eluting stent for the prevention of coronary restenosis. N Engl J Med 348: 1537–1545
Shuchman M (2006) Trading restenosis for thrombosis? New questions about drug-eluting stents. N Engl J Med 355: 1949–1952
Silber S, Albertsson P, Aviles FF et al. (2005) Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26: 804–847
Silber S, Böhm M, Gottwik M et al. (2006) Akutes Herzinfarktrisiko bei mangelnder Clopidogrelgabe nach koronarer Stentimplantation. Dtsch Arztebl 103: 2863–2868
The Capture Investigators (1997) Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE study. Lancet 349: 1429–1435
The EPILOG Investigators (1997) Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 336: 1689–1696
The RESTORE Investigators (1997) Effects of platelet glycoprotein IIb/IIIa blockade with tirofiban on adverse cardiac events in patients with unstable angina or acute myocardial infarction undergoing coronary angioplasty. Randomized efficacy study of tirofiban for outcomes and restenosis. Circulation 96: 1445–1453
Topol EJ, Yadav JS (2000) Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation 101: 570–580
Weisman SM, Graham DY (2002) Evaluation of the benefits and risks of low-dose aspirin in the secondary prevention of cardiovascular and cerebrovascular events. Arch Intern Med 162: 2197–2202
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
Interessenkonflikt
Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lepper, W., Kelm, M. Perioperative Therapie mit Thrombozytenaggregationshemmern. Anaesthesist 56, 592–598 (2007). https://doi.org/10.1007/s00101-007-1187-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00101-007-1187-8
Schlüsselwörter
- Thrombozytenaggregationshemmer
- Acetylsalicylsäure
- Clopidogrel
- Akutes Koronarsyndrom
- Präoperative Therapie
- Stentimplantation