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Unterbrechung antithrombotischer Behandlung (Bridging) bei kardialen Erkrankungen

Positionspapier

Bridging of Antithrombotic Therapy in Patients with Cardiovascular Disease

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Der Kardiologe Aims and scope

Zusammenfassung

Für operative oder interventionelle Prozeduren muss bei Patienten mit kardialen Erkrankungen und antithrombotischer Therapie (Antikoagulation oder Plättchenfunktionshemmer) das periprozedurale Management (Bridging) unter Berücksichtigung des thromboembolischen Risikos und der Blutungsgefahr geplant werden. Von der Dringlichkeit der Prozedur hängt es ab, ob ein sofortiger Eingriff, ein semielektiver Eingriff oder ein elektives Vorgehen indiziert ist. Dringlich indizierte Notfalleingriffe müssen ggf. unter der aktuellen antithrombotischen Therapie durchgeführt werden. Eine elektive Prozedur könnte, sofern die Antikoagulation oder Plättchenfunktionshemmung nur für einen absehbaren Zeitraum erforderlich ist, dann auf die Zeit nach einer antithrombotischen Therapie verschoben werden. Wenn möglich, sollte diese Problematik einer in näherer Zukunft erforderlichen Operation schon beim Ersteingriff mit nachfolgender Antithrombose hinsichtlich der Auswahl einer Klappenprothese oder eines Stenttyps berücksichtigt werden. Bei allen übrigen Fällen muss das thromboembolische Risiko gegen das Blutungsrisiko abgewogen werden. Während bei niedrigem thromboembolischem Risiko periprozedural die antithrombotische Therapie unterbrochen oder zumindest in sehr reduzierter Dosis durchgeführt werden kann, sind bei hohem thromboembolischem Risiko periprozedural Umstellungen der antithrombotischen Therapie unter Akzeptanz eines erhöhten Blutungsrisikos erforderlich. Berücksichtigt werden sollte, dass das vielfach angeführte Blutungsrisiko häufig nur kleinere beherrschbare Blutungen umfasst, während potenzielle thromboembolische Ereignisse zu gravierenden Krankheitszuständen führen können. Andererseits gibt es Prozeduren mit sehr hoher und schlecht beherrschbarer Blutungsgefahr, sodass in solchen Fällen eher ein mäßig erhöhtes thromboembolisches Risiko akzeptiert werden muss. Insofern ist zur optimalen Planung des periprozeduralen Gerinnungsmanagements die Kooperation der beteiligten Fachdisziplinen unabdingbar.

Abstract

In patients who need antithrombotic therapy for cardiovascular diseases (anticoagulants or antiplatelet therapy) perioperative consideration of the bridging strategy is mandatory. The risks of thromboembolism and bleeding have to be taken into account. Periprocedural management depends on the urgency of the procedure. In emergency cases the operation has to be done in spite of antithrombotic therapy. In patients who need antithrombotics only for a limited period of time, an elective procedure could be performed after the time of anticoagulation or dual antiplatelet therapy. If heart valve replacement or coronary stenting is performed in a patient with known future need of an elective procedure, devices should be preferred for implantation which need antithrombotics only for a short time post implantation. In all other cases the risk of bleeding and the risk of thromboembolism should be balanced: In patients at low risk for a thromboembolic event, cessation of effective antithrombotic therapy is reasonable. However, patients with intermediate to high risk for thromboembolic events need specific bridging treatment depending on the risk of bleeding. Continuation of antithrombotics often increases just the risk of mild to intermediate bleeding, but it prevents occurrence of life-threatening thromboembolic events. For optimal periprocedural treatment of patients on anticoagulants or antiplatelet therapy cooperation of the medical disciplines involved is mandatory.

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Interessenkonflikt

Referenten-/Beratungstätigkeit für AstraZeneca, Boehringer Ingelheim, Sanofi Aventis, MSD, Daiichi Sankyo.

Authors
  1. H.M. Hoffmeister
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  2. C. Bode
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  3. H. Darius
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  4. K. Huber
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  5. K. Rybak
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  6. S. Silber
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Hoffmeister, H., Bode, C., Darius, H. et al. Unterbrechung antithrombotischer Behandlung (Bridging) bei kardialen Erkrankungen. Kardiologe 4, 365–374 (2010). https://doi.org/10.1007/s12181-010-0294-y

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