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Hamostaseologie 2000; 20(01): 59-64
DOI: 10.1055/s-0037-1619458
Original article
Schattauer GmbH

Akuter Myokardinfarkt – Thrombolyse versus interventionelle Therapie

Myocardial Infarction – Thrombolysis versus Interventional Therapy
A. van de Loo
1   Medizinische Universitätsklinik Freiburg, Abteilung Kardiologie und Angiologie
,
T. Klaus
1   Medizinische Universitätsklinik Freiburg, Abteilung Kardiologie und Angiologie
,
Ch. Bode
1   Medizinische Universitätsklinik Freiburg, Abteilung Kardiologie und Angiologie
› Author Affiliations
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Publication History

Publication Date:
22 December 2017 (online)

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Zusammenfassung

Die frühe, vollständige und anhaltende Rekanalisation des Infarktgefäßes ist das entscheidende therapeutische Ziel in der Behandlung des akuten Myokardinfarkts. Durch die Einführung der intravenösen Thrombolysetherapie ist die Letalität signifikant gesunken. In prospektiven Studien sind die Thrombolytika Streptokinase und rt-PA umfassend geprüft. Ihr Differentialeinsatz in der Akuttherapie ist heute genau definiert. Das Wissen um die Bedeutung der Thrombozytenaggregation in der Thrombogenese führte zur Untersuchung von Kombinationen moderner GPIIb/IIIa-Inhibitoren mit Plasminogen-Aktivatoren. Als wirksame Alternative zur Thrombolyse hat sich in den letzten Jahren die akute, kathetertechnische Ballondilatation etabliert. In Kombination mit einer Thrombozyteninhibition mit dem monoklonalen Antikörper Abciximab und einer Stentimplantation können exzellente Ergebnisse erzielt werden. Nachteil dieses Vorgehens ist der höhere wirtschaftliche Aufwand sowie die Beschränkung auf entsprechend ausgestattete Zentren. Zukünftige Strategien werden darauf hinzielen, thrombolytische Therapien so zu entwickeln, daß sie sich im Einzelfall optimal durch mechanische Rekanalisationsverfahren ergänzen lassen. Patienten, die besonders von einem solchen kooperativen Konzept zwischen Krankenhäusern der Regelversorgung, Notärzten und interventionell aktiven Zentren profitieren, müssen identifiziert werden.

Summary

The dominant goal of therapy in acute myocardial infarction is to achieve early, complete and persistent patency of the infarct related coronary artery. As the occluding thrombus was identified to cause 90% of myocardial infarctions intravenous thrombolytic therapy was developed. Infarct related mortality decreased significantly. Among various substances that have been developed Streptokinase and recombinant tissue Plasminogen Activator are well established. Increasing knowledge about the importance of platelet aggregation during the process of thrombus formation and dissolution led to concepts combining Plasminogen activators and Glycoprotein IIb/IIIa – Inhibitors as thrombolytic agents. Primary balloon angioplasty with or without stent implantation and pharmacological platelet inhibition has emerged as a convincing alternative concept to achieve patent coronary arteries after myocardial infarction. However its obvious advantages (known coronary anatomy, immediate complete interventional therapy) are restricted to some well equipped centers. Currently therapeutic strategies are under investigation that allow immediate thrombolytic therapy in peripheral hospitals and support interventional treatment in case of failure of the thrombolytic approach. Patients that specially profit from cooperative mangement between emergency teams, primary care hospitals and interventional centers will be identified.

Stichwörter

Herzinfarkt - Koronarangioplastie - Thrombolyse

Keywords

Myocardial infarction - coronary angioplasty - thrombolysis
 

  • Literatur

  • 1 1999 Update. ACC/AHA Guidelines for the mangement of Patients With Acute Myocardial Infarction: Executive Summary and Recommendations. Circulation 1999; 100: 1016-30.
    CrossrefPubMedGoogle Scholar
  • 2 A clinical trial comparing primary angioplasty with tissue plasminogen activator for acute myocardial infarction. The Global Use of Strategies To Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators. N Engl J Med 1997; 336: 1621-8.
    CrossrefPubMedGoogle Scholar
  • 3 American College of Cardiology/American Heart Association Task Force on assessment of diagnostic and therapeutic cardiovascular procedures. ACC/AHA guidelines for the early management of patients with acute myocardial infarction. Circulation 1990; 82: 664-707.
    CrossrefPubMedGoogle Scholar
  • 4 American College of Cardiology/American Heart Association. Guidelines for the management of patients with acute myocardial infarction. J Am Coll Cardiol 1996; 28: 11328-428.
    PubMedGoogle Scholar
  • 5 Antman E M, Giuglan R P, Gibson C M. et al. Abciximab facilitates the rate and extent of thrombolysis: results of the Thrombolysis in myocardial infarction (TIMI) 14 Trial. Circulation 1999; 99: 2720-32.
    CrossrefPubMedGoogle Scholar
  • 6 Antoniucci D, Santoro GM, Bolognese L. et al. A clinical trial comparing primary stenting of the infarct-related artery with optimal primary angioplasty for acute myocardial infarction: results from the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRE-SCO) trial. J Am Coll Cardiol 1998; 31: 1234-9.
    CrossrefPubMedGoogle Scholar
  • 7 Arnout J, Simoons M, De Bono D. et al. Correlation between level of heparinization and patency of the infarct-related coronary artery treatment of acute myocardial infarction with alteplase (rt-PA). J Am Coll Cardiol 1992; 20: 513-9.
    CrossrefPubMedGoogle Scholar
  • 8 Azar R R, McKay R G, Thompson P D. et al. Abciximab in Primary Coronary Angioplasty for Acute Myocardial Infarction Improves Short- and Medium Term Outcomes. J Am Coll Cardiol 1996; 32: 1996-2002.
    PubMedGoogle Scholar
  • 9 Bode C, Smalling RW, Berg G. et al. Randomized comparison of coronary thrombolysis achieved with double-bolus reteplase (recombinant plasminogen activator) and front-loaded, accelerated alteplase (recombinant tissue plasminogen activator) in patients with acute myocardial infarction. The RAPID II Investigators. Circulation 1996; 94: 891-8.
    CrossrefPubMedGoogle Scholar
  • 10 Boersma E, Maas A C P, Deckers J W. et al. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348: 771-5.
    CrossrefPubMedGoogle Scholar
  • 11 Brener S J, Barr L A, Burchenal J. et al. A randomized Plazebo controlled trial of abciximab with primary angioplasty for acute MI: the RAPPORT Trial. Circulation 1998; 98: 734-41.
    CrossrefPubMedGoogle Scholar
  • 12 De Wood M A, Fisher M J. Direkt PTCA versus intravenous rtPA in acute myocardial infarction. Circulation 1989; 80: II-418.
    PubMedGoogle Scholar
  • 13 DeWood M A, Spores J, Notske R. et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infraction. N Engl J Med 1980; 303: 897-901.
    CrossrefPubMedGoogle Scholar
  • 14 Elizaga J, Garcia E J, Delcan J L. et al. Primary coronary angioplasty versus systemic thrombolysis in acute anterior myocardial infarction: in-hospital results from prospective randomized trial. Circulation 1993; 88: I-411.
    PubMedGoogle Scholar
  • 15 Every N R, Parsons L S, Hlatky M. et al. A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. N Engl J Med 1996; 335: 1253-60.
    CrossrefPubMedGoogle Scholar
  • 16 Fibrinolytic Therapy Trialists Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more then 1000 patients. Lancet 1994; 343: 311-22.
    PubMedGoogle Scholar
  • 17 Franzosi M G, Santoro E, De Vita C. et al. Ten year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction. Results of the Gruppo Italiano per lo Studio della Sopravivenza nell‘ Infarto-1 (GISSI) study. Circulation 1998; 98: 2659-65.
    CrossrefPubMedGoogle Scholar
  • 18 Freed M, Grines C, Safian D R. The New Manual of Interventional Cardiology. Michigan: Physicians Press Birmingham; 1996
    Google Scholar
  • 19 French J K, Williams B F, Hart H H. Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction. BMJ 1996; 312: 1637-41.
    CrossrefPubMedGoogle Scholar
  • 20 Gibbons R J, Holmes D R, Reeder G S. et al. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993; 328: 685-91.
    CrossrefPubMedGoogle Scholar
  • 21 Grines C L, Browne K F, Marco J. et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993; 328: 673-9.
    CrossrefPubMedGoogle Scholar
  • 22 Gruppo Italiano per lo Studio dello Streptochinasi nel‘ Infarto Miocardio (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; 1: 397-401.
    PubMedGoogle Scholar
  • 23 Gulba D C, Tanswell P, Dechend R. et al. Sixty-minute alteplase protocol: a new accelerated recombinant tissue-type plasminogen activator regimen for thrombolysis in acute myocardial infarction. J Am Coll Cardiol 1997; 30: 1611-7.
    CrossrefPubMedGoogle Scholar
  • 24 Herrick J B. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015-20.
    PubMedGoogle Scholar
  • 25 Hsia J, Kleiman N, Aguirre F. et al. Heparin-induced prolongation of partial thromboplastin time after thrombolysis: relation to coronary artery patency. J Am Coll Cardiol 1992; 20: 31-5.
    CrossrefPubMedGoogle Scholar
  • 26 ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; III: 349-60.
    PubMedGoogle Scholar
  • 27 Karnash S L, Granger C B, White H D. et al. Treating menstruating women with thrombolytic therapy: insights from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) Trial. The GUSTO-I Investigators. J Am Coll Cardiol 1995; 26: 1651-6.
    CrossrefPubMedGoogle Scholar
  • 28 Lefkovits J, Ivanhoe R J, Califf R M. et al. Effects of platelet glycoprotein IIb/IIIa receptor blockade by a chimeric monoclonal antibody (abciximab) on acute and sixmonth outcomes after percutaneous transluminal coronary angioplasty for acute myocardial infarction. Am J Cardiol 1996; 77: 1045-51.
    CrossrefPubMedGoogle Scholar
  • 29 Michels K B, Yusuf S. Does PTCA in acute myocardial infarction affect mortality and reinfarction rates? A quantitative overview (meta-analysis) of the randomized clinical trials. Circulation 1995; 91: 476-85.
    CrossrefPubMedGoogle Scholar
  • 30 Neches R B, Goldfarb A M. Thrombolytic therapy after cardiopulmonary resuscitation in acute myocardial infarction. Am J Cardiol 1993; 71: 258.
    CrossrefPubMedGoogle Scholar
  • 31 Neuhaus K L, Feuerer W, Jeep-Tebbe S. et al. Improved thrombolysis with a modified dose regimen of recombinant tissue-type plasminogen activator. J Am Coll Cardiol 1989; 14: 1566-9.
    CrossrefPubMedGoogle Scholar
  • 32 Neumann F J, Blasini R, Schmitt C, Alt E, Dirschinger J, Gawaz M, Kastrati A, Schömig A. Effect of Glycoprotein IIb/IIIa Receptor Blockade on Recovery of Coronary Blood Flow and Left Ventricular Function after The Placement of Coronary Artery Stents in Acute Myocardial Infarction. Circulation 1998; 98: 2695-701.
    CrossrefPubMedGoogle Scholar
  • 33 O’Neill W, Timmis C G, Bourdillon P D. et al. A prospective randomized trial of intracoronary streptokinase versus coronary angioplasty for acute Myocardial infarction. N Engl J Med 1986; 314: 812-8.
    CrossrefPubMedGoogle Scholar
  • 34 Purvis J A, McNeill A J, Siddiqui R A. et al. Efficacy of 100 mg of double bolus alteplase in achieving complete perfusion in the treatment of acute myocardial infarction. J Am Coll Cardiol 1994; 23: 6-10.
    CrossrefPubMedGoogle Scholar
  • 35 Raitt M H, Maynard C, Wagner G S. et al. Relation between symptom duration before thrombolytic therapy and final myocardial infarct size. Circulation 1996; 93: 48-53.
    CrossrefPubMedGoogle Scholar
  • 36 Ribeiro E E, Silva L A, Carneiro R. et al. Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction. J Am Coll Cardiol 1993; 22: 376-80.
    CrossrefPubMedGoogle Scholar
  • 37 Rodriguez A, Bernadi V, Fernandez M. et al. In-hospital and late results of coronary stents versus conventional balloon angioplasty in acute myocardial infarction (GRAMI trial). Am J Cardiol 1998; 81: 1286-91.
    CrossrefPubMedGoogle Scholar
  • 38 Rodriguez A, Bernadi V, Fernandez M. et al. Primary stent implantation is superior to balloon angioplasty in acute myocardial infarction: the results of the Japanese PASTA (Primary Angioplasty versus Stent Implantation in Acute Myocardial Infarction) trial (abstract). J Am Coll Cardiol 1997; 29 (Suppl. A): 390A.
    CrossrefPubMedGoogle Scholar
  • 39 Ross A M. New plasminogen activators: A clinical review. Clin Cardiol 1999; 22: 165-71.
    CrossrefPubMedGoogle Scholar
  • 40 Scholz K H, Tebbe U, Herrman C. et al. Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction. Am J Cardiol 1992; 69: 724-8.
    CrossrefPubMedGoogle Scholar
  • 41 Schuster H P. Präklinische Lyse bei akutem Myokardinfarkt:Aktuelle Situation. Intensivmed 1994; 31: 233-6.
    PubMedGoogle Scholar
  • 42 Smalling R W. Molecular biology of plasminogen activators: What are the clinical implications of drug design?. Am J Cardiol 1996; 78 (Suppl. 12A): 2-7.
    PubMedGoogle Scholar
  • 43 Stone G W, Brodie B R, Griffin J J. et al. Improved short term outcomes of primary stenting compared to primary angioplasty in acute myocardial infarction. Circulation 1997; 96 (Suppl. I): 594.
    PubMedGoogle Scholar
  • 44 Stone G W, Brodie B R, Griffin J J. et al. Prospective multi-center study of the safety and feasibility of primary stenting in acute myocardial infarction: in-hospital and 30-day results of the PAMI stent pilot trial. Primary Angioplasty in Myocardial Infarction Stent Pilot Trial Investigators. J Am Coll Cardiol 1998; 31: 23-30.
    CrossrefPubMedGoogle Scholar
  • 45 Suryapranata H, van’t Hof A W, Hoorntje J C. et al. Randomized comparison of coronary stenting with balloon angioplasty in selected patients with acute myocardial infarction. Circulation 1998; 97: 2502-5.
    CrossrefPubMedGoogle Scholar
  • 46 The GUSTO III Investigators. A comparison of reteplase with alteplase for acute myocardial infarction. N Engl J Med 1997; 337: 1118-23.
    CrossrefPubMedGoogle Scholar
  • 47 The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 703-9.
    CrossrefPubMedGoogle Scholar
  • 48 The International Study Group. In-hospital mortality and clinical course of 20891 patients with suspected acute myocardial infarction randomised between alteplase and streptokinase with or without heparin. Lancet 1990; 336: 71-5.
    CrossrefPubMedGoogle Scholar
  • 49 The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Acute myocardial infarction: pre-hospital and in-hospital management. Eur Heart J 1996; 17: 43-63.
    PubMedGoogle Scholar
  • 50 Tiefenbrunn A J, Sobel B E. Thrombolysis and myocardial infarction. Fibrinolysis 1991; 5: 1-15.
    PubMedGoogle Scholar
  • 51 Weaver W D, Simes R J, Betriu A. et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative view. JAMA 1997; 278: 2093-8.
    CrossrefPubMedGoogle Scholar
  • 52 White H D, Van De Werf F J. Thrombolysis for acute myocardial infarction. Circulation 1998; 97: 1632-46.
    CrossrefPubMedGoogle Scholar
  • 53 Zijlstra F, DeBoer M J, Hoorntje J C A. et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993; 328: 680-4.
    CrossrefPubMedGoogle Scholar