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Hamostaseologie 2018; 38(04): 240-246
DOI: 10.1055/s-0038-1673412
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Anticoagulation in Atherosclerotic Disease

Samer Al Said
1   Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Christoph Bode
1   Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
,
Daniel Duerschmied
1   Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
› Author Affiliations
Further Information

Publication History

28 April 2018

13 August 2018

Publication Date:
17 October 2018 (online)

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Abstract

The prevention of atherothrombotic events is an essential therapeutic goal in the treatment of patients with arteriosclerotic diseases. After plaque rupture, a rapidly growing thrombus can lead to acute vascular occlusion and thus heart attack, stroke or limb ischaemia. The acute therapy combines anticoagulation and platelet inhibition. However, the only available therapy so far in the primary and secondary prevention of stable patients is the platelet inhibitors aspirin and clopidogrel. Despite the use of antiplatelet therapies, including aspirin and P2Y12-receptor antagonists, some patients with artery disease continue to experience recurrent cardiovascular ischaemic events due to excessive thrombin generation beyond the acute period. As a result, studies have tested non-vitamin K antagonist oral anticoagulants (NOACs), specifically the factor Xa inhibitors, either alone or in combination with antiplatelet therapy, in the management of arterial disease. For the first time, the COMPASS study investigated low-dose anticoagulation in stable coronary heart disease or peripheral arterial disease. The addition of 2 × 2.5 mg rivaroxaban to long-term aspirin therapy not only prevented cardiovascular death, myocardial infarction and stroke, but even reduced all-cause mortality by a relative 18% after a mean follow-up of 23 months. This benefit came at the expense of more gastrointestinal bleeding, which might be reduced by the addition of a proton pump inhibitor (investigations are ongoing). Interestingly, however, there was no increase in fatal or intracranial haemorrhages. Therefore, a new standard therapy for high-risk patients with atherosclerotic disease may become available in the near future.

Zusammenfassung

Die Verhinderung atherothrombotischer Ereignisse ist ein wesentliches therapeutisches Ziel bei der Behandlung von Patienten mit arteriosklerotischen Erkrankungen. Ein schnell wachsender Thrombus kann nach Plaqueruptur zu akutem Gefäßverschluss und damit zu Herzinfarkt, Schlaganfall oder Ischämie der Extremitäten führen. Die Akuttherapie kombiniert Antikoagulation und Thrombozytenhemmung. Die bislang einzige verfügbare Therapie in der Primär- und Sekundärprävention stabiler Patienten sind jedoch die Thrombozytenaggregationshemmer Aspirin und Clopidogrel. Trotz der Verwendung von Thrombozytenaggregationshemmern, einschließlich Aspirin und P2Y12-Rezeptorantagonisten, leiden einige Patienten mit Arterienerkrankungen weiterhin unter kardiovaskulären ischämischen Ereignissen, die auf eine übermäßige Thrombinbildung nach der akuten Phase zurückzuführen sind. Als ein Ergebnis haben Studien Nicht-Vitamin-K-Antagonist-orale Antikoagulantien (NOAKs) getestet, insbesondere die Faktor-Xa-Inhibitoren, entweder allein oder in Kombination mit einer Antiplättchen-Therapie bei der Behandlung von arteriellen Erkrankungen. Die COMPASS-Studie untersuchte erstmals die niedrig dosierte Antikoagulation bei stabiler koronarer Herzkrankheit oder peripherer arterieller Verschlusskrankheit. Die Zugabe von 2 × 2,5 mg Rivaroxaban zur Langzeit-Aspirintherapie verhinderte nicht nur kardiovaskulären Tod, Myokardinfarkt und Schlaganfall, sondern reduzierte sogar die Gesamtmortalität um 18% nach einer mittleren Nachbeobachtungszeit von 23 Monaten. Dieser Vorteil ging auf Kosten von mehr gastrointestinalen Blutungen, die durch die Zugabe eines Protonenpumpenhemmers reduziert werden könnten (Untersuchungen laufen noch). Interessanterweise gab es jedoch keine Zunahme von tödlichen oder intrakraniellen Blutungen. Daher könnte in naher Zukunft eine neue Standardtherapie für Hochrisikopatienten mit atherosklerotischer Erkrankung verfügbar werden.

Keywords

atherosclerosis - clinical trials - direct antithrombin agents - coronary artery disease - non-vitamin K antagonist oral anticoagulants - peripheral arterial disease

Schlüsselwörter

Arteriosklerose - Klinische Studien - Direkte Antithrombinmittel - Koronare Herzkrankheit - Nicht-Vitamin-K-Antagonist-orale Antikoagulantien (NOAKs) - Periphere arterielle Erkrankung
 

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