Plättchenhemmung durch Thienopyridine beim akuten Koronarsyndrom – praktische Empfehlungen aufgrund der CURE-Studie

Thienopyridine platelet antagonists in acute coronary syndrome – practical recommendations based on the CURE study. The acute coronary syndrome comprises the clinical spectrum of unstable angina and myocardial infarction which may be associated with arrhythmia, heart failure, or even death. The pathophysiological background of the acute coronary syndrome is generally a coronary plaque rupture or erosion with thrombosis and subsequent subtotal or total vessel occlusion. The in-hospital management depends on the risk for associated morbidity and mortality. Clinical features (symptoms, cardiovascular risk factors, age, previous infarction or revascularisation, and Killip class) as well as troponin I/T tests and electrocardiography (ECG) are used for risk stratification. A low-risk patient (angina resolved, normal ECG and repeatedly negative troponin tests) may undergo non-invasive stress testing during the initial hospitalization to exclude myocardial ischemia. In presence of an acute coronary syndrome with ST-segment depression or T-wave inversion, clopidogrel can be given (300 mg immediately, followed by 75 mg once daily) in addition to aspirin (75–325 mg once daily), based on the results of the CURE-study. Bed rest, oxygen, anti-thrombins (heparin, low-molecular or unfractioned), nitrates, and beta-blockers remain the basic therapy of acute coronary syndromes. Statins should be initiated early as an important part of secondary prevention of atherosclerotic vascular disease. In high-risk patients such as those with a positive troponin-test or refractory angina, an invasive approach with percutaneous coronary intervention (PCI) is indicated, if indicated with the use of a GP IIb/IIIa antagonist. Clopidogrel may cause increased bleeding, if surgical revascularisation becomes required. Thus, clopidogrel should be stopped as a rule at least 5 days prior to surgery. The long-term continuation of clopidogrel (3 to 12 months) after an acute coronary syndrome is of benefit if the patient is treated conservatively and even greater when the patient undergoes a PCI. In classical myocardial infarction associated with ST-segment elevation or new left-bundle brunch block the use of clopidogrel is currently evaluated in clinical studies.