Antikoagulation und antithrombotische Therapie bei Herzerkrankungen

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1 Antikoagulation und antithrombotische Therapie bei Herzerkrankungen Christian Sticherling Kardiologie Dimitrios Tsakiris Hämatologie

2 Einsatz der Antikoagulation und antithrombotischen Therapie in der Kardiologie 1. Akutes Koronarsyndrom 2. Nach Stent- Implantation (BMS vs. DES) 3. Vorhofflimmern/- flattern 4. Herzinsuffizienz, eingeschränkte LVEF 5. Kunstklappen

3 Akutes Koronarsyndrom (ACS) Anticoagulants Antiplatelets

4

5 Plättchenaktivierung Thrombin Plättchen GPIIb/IIIa Fibrinogen Plättchenaggregation

6 Thrombozytenaggregationshemmung 2013 Alte Substanzen Aspirin Ticlopidin Dipyridamol NSAR Prostacyclin-Analoga NO Neuere Substanzen Thienopyridinderivate u.a. Clopidogrel (Plavix ) Prasugrel (Efient ) Ticagrelor (Brilique ) GPIIb/IIIa-Blocker Abciximab (ReoPro ) Tirofiban (Aggrastat ) Eptifibatid (Integrilin ) Noch nicht auf dem CH- Markt [Cangrelor(ARC69931]

7 Vorhofflimmern CHA 2 DS 2 -VASc Score a Vascular disease: Prior MI, peripheral arterial disease, aortic plaque ESC Guidelines: Camm AJ et al. Eur Heart J, 2010

8 Antikoagulation 2013 Alte Substanzen Heparin Unfraktioniertes Heparin (Liquemin ) Niedermolekulare Heparine Vitamin K - Antagonisten Marcoumar Sintrom Neuere Substanzen Direkte Thrombininhibtoren Bivalirudin (Angiox ) Argatroban (Argatra ) Dabigatran (Pradaxa ) Indirekte Faktor Xa- Inhibitoren Fondaparinux (Arixtra ) Direkte Faktor Xa- Inhibitoren Rivaroxaban (Xarelto ) Apixaban (Eliquis ) Edoxaban (Lixiana )

9 NOAC: Eigenschaften Warfarin/Marc oumar Rivaroxaban (Xarelto) Dabigatran (Pradaxa) Apixaban (Eliquis) Dose adjustment INR dependent CrCl Age, CrCl Age, CrCl, weight Onset of action 36-72h 2-4h 0.5-2h 1-3h Half-life 20/60h 9-13h 12-14h 8-15h Interactions CYP 3A4 CYP 3A4 P-gp inhibitors P-gp inhibitors CYP 3A4 Renal elimination 92% (inactive) 33% 80% 40%

10 NOAC: Wirksamkeit

11 NOAC: Dosierung bei Niereninsuffizienz CrCl ml/min Rivaroxaban (Xarelto) 1x20mg/d Dabigatran (Pradaxa) 2x150mg/d Apixaban (Eliquis) 2x5mg/d x15mg/d 2x110mg/d [2x2.5mg/d bei Kreatinin >133] Mit Vorsicht KONTRAINDIKATION Mit Vorsicht <15 KONTRAINDIKATION KONTRAINDIKATION KONTRAINDIKATION ESC guidelines on AF, focused update 2012

12 Literatur 1. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006;48:e Cannon CP, Harrington RA, James S, et al. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet;375: Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361: Montalescot G, Wiviott SD, Braunwald E, et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 2009;373: Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007;28: Gasparyan AY, et al. The role of Aspirin in cardiovascular prevention: Implications of Asprin resistance. J Am Coll Cardiol 2008; 51: Guyer KE. The present state of aspirin and clopidogrel resistance. Hämostaseologie 2009; 29: Fontana P, Reny JL. Clopidogrel en pratique : indications, résistance et tests biologiques chez les patients avec affections vasculaires. Rev Med Suisse 2008;4: Cattaneo M. Resistance to antiplatelet drugs : Molecular mechanisms and laboratory detection. J Thromb Haemost 2007;5: Camm A, Lip GYH. De Caterina et al focused update of the ESC guidelines for the management of atrial fibrillation. Eur Heart J 2012; 33: Steg PG, James SK, Atar D et al, ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:

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