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Kommentare zu den Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Diagnostik und Therapie von Patienten mit ST-Streckenhebungsinfarkt (STEMI)

Commentary on the guidelines of the European Society of Cardiology (ESC) regarding the diagnosis and treatment of patients with ST-segment elevation myocardial infarction (STEMI)

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Zusammenfassung

Die möglichst unverzügliche Wiedereröffnung des verschlossenen Infarktgefäßes steht nach wie vor im Mittelpunkt der Behandlung von Patienten mit STEMI. Die möglichst rasche prähospitale klinische und EKG-Diagnose eines STEMI ist für die Optimierung des Zeitablaufs zwischen Symptom- und Reperfusionsbeginn unerlässlich. Dies wird am besten durch die Etablierung eines Netzwerkes von Kliniken mit und ohne PCI-Bereitschaft erreicht, die durch ein effizientes Rettungswagensystem verknüpft sind. Kliniken mit PCI-Bereitschaft müssen diese durchgehend (24 h/7 Tage) vorweisen. Die beste Reperfusionsstrategie ist die durch ein erfahrenes Team durchgeführte primäre PCI mit Stentimplantation. Die primäre PCI sollte so rasch wie möglich, aber spätestens noch innerhalb von 2 h nach der EKG-Diagnose (sog. „medizinischer Erstkontakt“) durchgeführt werden. Bei Patienten mit großem Infarkt ist diese Zeitspanne mit maximal 90 min kürzer. Alle Patienten sollten grundsätzlich möglichst sofort Acetylsalicylsäure (i.v. oder zum Kauen), eine Bolusdosis eines Thienopyridinderivates sowie eines der folgenden Antikoagulanzien erhalten: bei geplanter primärer PCI: vorzugsweise Bivalirudin oder (unfraktioniertes) Heparin; nach Einleitung einer Fibrinolyse (wenn keine PCI innerhalb von 2 h möglich ist): Enoxaparin oder Heparin. Die routinemäßige i.v.-Verabreichung eines β-Blockers ist nicht indiziert. Auch bei einer erfolgreichen Thrombolyse soll der Transport in eine PCI-Klinik möglichst rasch erfolgen, um 3–24 h nach Lysebeginn eine invasive Koronarangiographie in PCI-Bereitschaft durchzuführen. Neuere Untersuchungen weisen darauf hin, dass (sofern keine Kontraindikationen vorliegen) bei Patienten mit STEMI das Clopidogrel durch Prasugrel ersetzt werden kann.

Abstract

Very early reperfusion of the occluded infarct artery is the mainstay in the treatment of an acute myocardial infarction with persistent ST-segment elevation (STEMI). Pre-hospital (ambulance) clinical and ECG diagnosis is critical for reducing the time delays between onset of symptoms and start of reperfusion. This can best be achieved by establishing a network of non-PCI-capable and PCI-capable (24 h/7 days) hospitals connected by an efficient ambulance service. Primary PCI with stenting, when performed by an experienced team within the recommended time, is the best reperfusion treatment to save lives. Primary PCI should be performed within 120 min after ECG diagnosis (first medical contact) in all patients and within 90 min in patients presenting within 2 h and with a large infarct. In the absence of contraindications, all patients should receive aspirin, a thienopyridine and one of the following anticoagulants as soon as possible: bivalirudin or heparin, if primary PCI is planned; enoxaparin or heparin, if a fibrin-specific lytic agent is given. Routine i.v. administration of a beta-blocker is not indicated. Even after successful fibrinolysis, transfer to a PCI-capable hospital for coronary angiography, ideally between 3 and 24 h after start of fibrinolytic therapy, is indicated. Recent studies have shown that (if no contraindications exist), in patients with STEMI, clopidogrel may be replaced by prasugrel.

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  1. Kardiologische Praxis und Praxisklinik, Akademische Lehrpraxis der Ludwig-Maximilians-Universität, Am Isarkanal 36, 81379, München, Deutschland

    S. Silber F.A.C.C., F.E.S.C., M. Borggrefe, G. Hasenfuß, V. Falk, A. Kastrati, M. Weis & C.W. Hamm

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  1. S. Silber F.A.C.C., F.E.S.C.
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  2. M. Borggrefe
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  3. G. Hasenfuß
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  4. V. Falk
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  5. A. Kastrati
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  6. M. Weis
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  7. C.W. Hamm
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Correspondence to S. Silber F.A.C.C., F.E.S.C..

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Silber, S., Borggrefe, M., Hasenfuß, G. et al. Kommentare zu den Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zur Diagnostik und Therapie von Patienten mit ST-Streckenhebungsinfarkt (STEMI). Kardiologe 4, 84–92 (2010). https://doi.org/10.1007/s12181-009-0246-6

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