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Antithrombotische Therapie bei akutem Myokardinfarkt

Antithrombotic therapy of acute myocardial infarction

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Zusammenfassung

Die gerinnungshemmende Therapie stellt einen essenziellen Pfeiler der Behandlung des akuten Myokardinfarkts dar. Zeitgleich mit der Diagnosestellung wird durch Risikostratifizierung die Intensität der gerinnungshemmenden Medikation und der Zeitpunkt der Koronarintervention geplant. Alle Patienten mit Myokardinfarkt erhalten eine Therapie mit Acetylsalicylsäure und Clopidogrel. Patienten mit einem ST-Streckenhebungsinfarkt und Hochrisikopatienten mit einem Nicht-ST-Streckenhebungsinfarkt, die direkt einer invasiven Therapie zugeführt werden, erhalten zusätzlich Heparin (evtl. Enoxaparin) und periinterventionell einen Glykoprotein-IIb/IIIa-Inhibitor. Der direkte Thrombinantagonist Bivalirudin könnte sich hier zu einer Alternative entwickeln. Patienten mit niedrigem Risiko, die für eine dringliche elektive Koronarintervention vorgesehen sind, scheinen aufgrund des günstigen Risikoprofils von der Gabe des Faktor-Xa-Inhibitors Fondaparinux zu profitieren. Dann ist die periinterventionelle Gabe von unfraktioniertem Heparin erforderlich.

Abstract

Inhibition of blood coagulation is an essential cornerstone of the therapy of acute myocardial infarction. Risk stratification represents a valuable tool to adjust the intensity of anticoagulation and timing of invasive therapy according to patient risk. All patients presenting with myocardial infarction should be treated with aspirin and clopidogrel. Patients with ST-segment elevation myocardial infarction and high-risk patients with myocardial infarction without ST-segment elevation who undergo invasive therapy should be treated immediately with unfractionated heparin (alternatively enoxaparin) and a glycoprotein (GP) IIb/IIIa antagonist in the catheter laboratory. The direct thrombin antagonist bivalirudin may emerge as an attractive alternative in these patients. In low-risk patients who undergo delayed urgent elective interventional therapy the factor Xa antagonist fondaparinux may be advantageous because of its low bleeding rate. In these patients administration of unfractionated heparin is necessary for percutaneous coronary intervention.

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Abb. 1

Abbreviations

aPTT:

Aktivierte partielle Thromboplastinzeit

ASS:

Acetylsalicylsäure

LMWH:

„low molecular weight heparin“; niedermolekulares Heparin

NSTEMI:

„non-ST elevation myocardial infarction“; Nicht-ST-Streckenhebungsinfarkt

PCI:

Perkutane Koronarintervention

STEMI:

„ST elevation myocardial infarction“; ST-Streckenhebungsinfarkt

UFH:

Unfraktioniertes Heparin

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Interessenkonflikt

Die Autoren weisen auf folgende Beziehungen hin:

Prof. Dr. C. Bode ist im Advisory Board von Bayer Health Vital, Sanofi Aventis, Egyptian Society of Cardiology, GlaxoSmithKline, Critical Care Europe (Lilly France), Lilly Germany, Medical Review Co (Japan), Schering Corporation USA, Essex Pharma, CV Therapeutics Europe Ltd., Schering Corporation USA, MSD Sharp & Dohme (Haar), Meda Pharma (Homburg) sowie im Steering Committee der Heinz Nixdorf-Recall Study tätig.

PD Dr. M. Moser erhielt Vortragshonorare von Sanofi Aventis und GlaxoSmithKline.

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  1. Innere Medizin III (Kardiologie), Universitätsklinik Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland

    M. Moser & C. Bode

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  1. M. Moser
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Correspondence to M. Moser.

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Moser, M., Bode, C. Antithrombotische Therapie bei akutem Myokardinfarkt. Internist 49, 1031–1037 (2008). https://doi.org/10.1007/s00108-008-2074-3

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