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Fokussiertes Update zur dualen Plättchenhemmung

ESC-Leitlinie 2017

Focused update on dual antiplatelet treatment

ESC guidelines 2017

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Zusammenfassung

Die duale antithrombozytäre Therapie (DAPT) ist ein Eckpfeiler der Nachbehandlung interventionell versorgter Patienten sowohl nach elektiver Koronarintervention als auch nach einem akuten Koronarsyndrom (ACS; ST-Strecken-Hebungs-Infarkt, Nicht-ST-Strecken-Hebungs-Infarkt, instabile Angina pectoris). In den vergangenen Jahren wurde besonders die zusätzlich zur niedrig dosierten Acetylsalicylsäuregabe durchgeführte P2Y12-Hemmung intensiv diskutiert. Hierbei ging es nach elektiver Koronarintervention v. a. um die Dauer einer notwendigen dualen Thrombozytenhemmung, die sich mit Einführung der modernen Generation der medikamentenbeschichteten Stents deutlich verringert hat. Im Bereich des ACS stellte sich die Frage, wann anstelle von Clopidogrel eines der beiden potenteren Medikamente Prasugrel oder Ticagrelor verwendet werden sollte. Eine mögliche Verlängerung der Zeitspanne kommt bei Hochrisikopatienten nach Myokardinfarkt ins Spiel und bei Patienten nach Implantation eines bioabsorbierbaren Scaffolds. Besonderes Augenmerk gilt all jenen Patienten, die z. B. aufgrund von Vorhofflimmern antikoaguliert werden und zusätzlich eine Thrombozytenhemmung nach Stentimplantation benötigen. Im vorliegenden Artikel werden die Bewertungen des Focused Update DAPT 2017 der Europäischen Gesellschaft für Kardiologie (ESC) zusammenfassend dargestellt. V. a. widmen sich die Empfehlungen auch den Strategien zur Reduzierung eines erhöhten Blutungsrisikos aufgrund klinischer Prädiktoren.

Abstract

Dual antiplatelet treatment (DAPT) is a cornerstone of maintenance medication of patients following elective percutaneous coronary interventions or an acute coronary syndrome (ACS), e. g. ST elevation myocardial infarction, non-ST elevation myocardial infarction and unstable angina. In recent years the inclusion of P2Y12 inhibition in addition to low-dose acetylsalicylic acid has been intensively debated. Following the introduction of the modern generation of drug-eluting stents for elective coronary interventions, the duration of the necessary DAPT has been clearly reduced. In patients with ACS the question arises when treatment with one of the more potent P2Y12 inhibitors, such as prasugrel and ticagrelor should be used instead of clopidogrel. A potential extension of DAPT beyond 12 months can be considered in high-risk patients after implantation of bioresorbable vascular scaffolds and following myocardial infarction. A special focus is on those patients who have already been treated with oral anticoagulants for stroke prevention in atrial fibrillation and require additional platelet inhibition following coronary stenting. This article summarizes and assesses the major recommendations given in the Focused Update DAPT 2017 of the European Society of Cardiology (ESC). In particular the recommendations address strategies to reduce an increased risk of bleeding based on clinical predictors.

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  1. Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30659, Hannover, Deutschland

    A. Schäfer & J. Bauersachs

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  1. A. Schäfer
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  2. J. Bauersachs
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Correspondence to A. Schäfer.

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A. Schäfer hat für folgende Firmen Vorträge gehalten oder diese beraten: Daiichi-Sankyo, BMS/Pfizer, Boehringer Ingelheim, Bayer. J. Bauersachs hat für folgende Firmen Vorträge gehalten oder diese beraten: Daiichi-Sankyo, BMS/Pfizer, Boehringer Ingelheim, Bayer, AstraZeneca.

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

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Schäfer, A., Bauersachs, J. Fokussiertes Update zur dualen Plättchenhemmung. Herz 42, 739–745 (2017). https://doi.org/10.1007/s00059-017-4634-6

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