Niedermolekulare Heparine zur Thromboseprophylaxe nach ischämischem Schlaganfall

 

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Zusammenfassung

Patienten in der akuten Phase nach ischämischem Insult haben eine erhöhte Inzidenz von Beinvenenthrombosen und Lungenembolien, die die Genesung verzögern und zu einer erhöhten Morbidität und Mortalität dieser Patienten beitragen. Lungenembolien sind eine wichtige Todesursache von Patienten nach ischämischem Schlaganfall. Während die Plättchenhemmung mit z. B. Azetylsalizylsäure (ASS) heute zur Standardtherapie der frühen Rezidivprophylaxe beim Schlaganfall gehört, wird die Dauer und die Dosierung sowie die Substanz (unfraktioniertes versus niedermolekulares Heparin) nicht aber die Notwendigkeit einer Antikoagulation zur Thromboembolieprophylaxe kontrovers diskutiert. Plazebo- oder ASS-kontrollierte Studien mit Heparinen - überwiegend in PTT-wirksamer Dosis - zeigten eine Reduktion früher Reinfarkte. Allerdings ging dieser positive Effekt zulasten einer erhöhten zerebralen Blutungsrate, sodass keine allgemeine Empfehlung für eine PTT-wirksame Heparinisierung ausgesprochen werden konnte. Alle Studien mit niedrigen oder hohen Heparindosen zeigten aber eine Reduktion des Risikos von tiefen Beinvenenthrombosen. Neuere Vergleichsstudien von niedermolekularen Heparinen (Enoxaparin, Certoparin) mit unfraktionierten Heparinen zeigten in den letzten Jahren die Bedeutung einer frühzeitigen Antikoagulation innerhalb der ersten 48 Stunden nach Insult. Deren Anwendung ist mit einer Senkung thromboembolischer Ereignisse bei gleichzeitig unverändertem Blutungsrisiko gegenüber unfraktioniertem Heparin verbunden. Darüber hinaus ist die Anwendung niedermolekularer Heparine mit einer vereinfachten Handhabung ein praktisch gut umsetzbares Therapieprinzip. Die Prophylaxe thromboembolischer Komplikationen mit niedermolekularen Heparinen wird somit bei Patienten nach ischämischem Schlaganfall empfohlen.

Abstract

Patients in the acute phase after ischaemic insult have an increased incidence of venous thrombosis in the leg and pulmonary embolism which delay recovery and contribute to a higher morbidity and mortality for these patients. Pulmonary embolism is an important cause of death in patients after ischaemic stroke. Although platelet inhibition with, e. g., acetylsalicylic acid (ASA), constitutes the standard therapy for prophylaxis against early recurrence in stroke patients, the duration and doses as well as the substances (unfractionated versus low molecular heparin), but not the necessity for anticoagulation as prophylaxis against thromboemolism, are currently a subject of controversy. Placebo- or ASA-controlled studies with heparins, mainly in PTT-effective doses, were often not clinically unambiguous in practice and showed a reduction of early reinfarctions at the cost of cerebral haemorrhage. However, all studies with low or high doses of heparin showed a reduced risk for deep vein thrombosis of the legs. New comparative studies of low-molecular heparins (Enoxaparin, Certoparin) with unfractionated have shown in recent years the significance of early anticoagulation within the first 48 hours after the insult. Their use is associated with a reduction of thromboembolic events with a concomitant unchanged risk of haemorrhage in comparison with unfractionated heparin. Furthermore, the administration of low-molecular heparins with their simple use constitutes a practical and easily applicable therapeutic principle. It can be recommended as a prophylaxis against thromboembolic complications in these patients.

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Prof. Dr. Hans-Christoph Diener

Universitätsklinik Essen, Klinik für Neurologie

Hufelandstr. 55

45147 Essen

Email: hans.diener@uni-duisburg-essen.de