Optimale Lysestrategien bei akutem Herzinfarkt: Trotzdem perkutane Koronarintervention (PCI)?

 

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Zusammenfassung

Eine optimale Lysestrategie zeichnet sich durch eine einfache Durchführbarkeit und hohe Wirksamkeit aus. Moderne Fibrinolytika sind durch Bolusgaben möglich einfach anwendbar, aber ihre Wirksamkeit hinsichtlich der Eröffnungsrate ist jedoch begrenzt, weshalb sie im direkten Vergleich der akuten Eröffnung des Infarktgefäßes durch eine Intervention (PCI) unterlegen sind. Entscheidend für die Thrombolyse spricht ihre ubiquitäre Verfügbarkeit. Bedenkenswert ist aber, dass etwa 50 % der Patienten mit akutem Infarkt keiner kausalen Therapie zugeführt wurden, da Kontraindikationen für die Thrombolyse bestanden. Ein großer Teil dieser nichtbehandelten Patienten könnte von der Verlegung zur PCI profitieren. Die Vorteile der direkten PCI gegenüber der Thrombolyse sind nur wirksam, wenn das Gefäß interventionell innerhalb von 60 Minuten eröffnet werden kann. Bei längeren Wartezeiten oder vor einer Verlegung sollte eine Kombination von Thrombolyse und anschließender invasiver Koronardiagnostik erfolgen. Da eine routinemäßige Verlegung nach Thrombolyse nicht praktikabel ist, stellt sich die Aufgabe, im Einzelfall jene Patienten zu erkennen, die nach Thrombolyse von einer sofortigen Verlegung in ein Interventionszentrum profitieren würden. Je höher die zu erwartende Mortalität, umso häufiger wird eine Rescue-PCI einen zusätzlichen Nutzen bringen, dies gilt insbesondere für Patienten mit kardiogenem Schock. Entscheidend ist auch das frühzeitige Erkennen einer erfolglosen Thrombolyse. Dies zeigt sich an unverändert fortbestehenden Beschwerden, das wichtigste Kriterium bleibt aber das EKG. Die fehlende Rückbildung einer ST-Hebung um 50 % innerhalb 1 Stunde nach Lysebeginn ist ein Hinweis auf einen Lysemisserfolg und sollte zur Verlegung Anlass geben. Entscheidend ist, vor allem in den ersten 1 - 2 Stunden nach Symptombeginn die schnellst verfügbare kausale Infarkttherapie einzuleiten, so dass eine Kombination von prästationärer Lyse und anschließender PCI ein viel versprechendes Konzept darstellt.

Abstract

An optimal treatment strategy for thrombolysis is characterised by a simple way of administration and high efficacy. Modern fibrinolytics are now applicable as bolus injections, but their efficacy regarding vessel patency remain limited. Therefore they are inferior to the opening of an occluded infarct related artery by a percutaneous coronary intervention (PCI) in a direct comparison. However, the undisputed advantage of thrombolysis is ist ubiquitous availability. It remains a major concern that 50 % of patients with acute myocardial infarction do not receive a causal therapy because of contraindications to thrombolysis. A large proportion of these patients might have a benefit from a transfer to an interventional center for direct PCI. The advantage of direct PCI over thrombolysis will only be observed if the successful opening of the infarct related artery is achieved within a certain time from admission of about 60 minutes. With increasing delay or in case of a necessary transport from the admitting hospital without invasive facilities to an interventional center the combination of initial and immediate thrombolysis and subsequent PCI should be considered. As a routine transfer after thrombolysis in the initial admission hospital is not feasible, the decisive task is to detect those patients who might benefit most from such an immediate transfer to interventional therapy. The higher the expected mortality, the more beneficial would be a transfer and a possible rescue-PCI. This applies above all to patients with cardiogenic shock. An other group who would benefit are those with failed thrombolysis, which should be recognized as early as possible. Indicators for a failed thrombolysis are persistent symptoms, and EKG criteria of failed reperfusion. Highly sensitive is the lack of a resolution of the initial ST segment elevation of less than 50 % within one hour of the start of thrombolysis. Such an observation should indicate the transfer to an interventional center. It is crucial for the successful therapy of AMI to administer the best available causal therapy within the first 1 - 2 hours of symptom onset. A concept of prehospital thrombolysis and immediate transfer for subsequent PCI might be the most efficient therapeutic concept.

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Prof. Dr. med. Gerald S. Werner

Klinik für Innere Medizin I · Friedrich-Schiller-Universität

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Email: gerald.werner@med.uni-jena.de