Antikoagulation und antithrombotische Therapie bei Herzerkrankungen Christian Sticherling Kardiologie Dimitrios Tsakiris Hämatologie
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
Akutes Koronarsyndrom (ACS) Anticoagulants Antiplatelets
Plättchenaktivierung Thrombin Plättchen GPIIb/IIIa Fibrinogen Plättchenaggregation
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]
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
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 )
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%
NOAC: Wirksamkeit
NOAC: Dosierung bei Niereninsuffizienz CrCl ml/min Rivaroxaban (Xarelto) 1x20mg/d Dabigatran (Pradaxa) 2x150mg/d Apixaban (Eliquis) 2x5mg/d 30-49 1x15mg/d 2x110mg/d [2x2.5mg/d bei Kreatinin >133] 15-29 Mit Vorsicht KONTRAINDIKATION Mit Vorsicht <15 KONTRAINDIKATION KONTRAINDIKATION KONTRAINDIKATION ESC guidelines on AF, focused update 2012
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