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Diabetespatienten mit kardiovaskulärer Erkrankung

Fokus Thrombozytenaggregationshemmung

Diabetic patients with cardiovascular disease

Focus on antiplatelet therapy

  • CME
  • Published:
Der Diabetologe Aims and scope

Zusammenfassung

Bei Diabetespatienten liegen eine erhöhte thrombozytäre Aktivierung sowie ein prokoagulatorischer Zustand vor, weshalb sie für kardiovaskuläre Ereignisse besonders gefährdet sind. Eine primärprophylaktische plättchenhemmende Therapie ohne Vorliegen von Gefäßerkrankungen ist nicht indiziert. Nach Gefäßinterventionen, v. a. bei vorherigem Myokardinfarkt, ist eine intensive antithrombozytäre Therapie indiziert. Dabei kommen zusätzlich zu ASS (Azetylsalizylsäure) Prasugrel bzw. Ticagrelor oder bei Gegenanzeigen gegen letztere nach individueller Risikoabwägung Clopidogrel in Kombination mit Vorapaxar bzw. Cilostazol zum Einsatz. Nach Myokardinfarkt kann die Therapie über die empfohlenen 12 Monate hinaus prolongiert werden. Eine individuelle Risikoeinschätzung mit Einbeziehung des Blutungsrisikos ist bei Diabetespatienten essentiell. Bei Vorhofflimmern ist das Thrombembolierisiko erhöht, sodass die orale Antikoagulation zur Schlaganfallprävention eine besondere Rolle spielt. Neue Antikoagulanzien haben bei Patienten mit Diabetes vergleichbare Effekte wie bei Nicht-Diabetikern.

Abstract

Due to elevated platelet activation and procoagulatoric state, diabetic patients are at particular risk for ischemic cardiovascular events. Primary prophylactic antiplatelet treatment in patients without cardiovascular disease is not indicated. After cardiovascular interventions, especially after myocardial infarction, an intensified antiplatelet regime is warranted. In addition to aspirin, ticagrelor or prasugrel can be used, while a further possibility is triple antiplatelet treatment with aspirin, clopidogrel and vorapaxar or cilostazol after careful risk assessment. After myocardial infarction, prolonged therapy (more than 12 months) can be considered. An individual assessment of bleeding risk is necessary in particular in diabetics. In atrial fibrillation, the thromboembolic risk is elevated; thus, oral anticoagulation is of particular importance for stroke prevention. New direct anticoagulants have comparable effects in patients with diabetes compared to non-diabetics.

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Authors and Affiliations

  1. Medizinische Klinik III, Abteilung für Kardiologie und Kreislauferkrankungen, Deutsches Herzkompetenzzentrum, Klinikum der Eberhard-Karls-Universität, Otfried-Müller-Straße 10, 72076, Tübingen, Deutschland

    M. Droppa &  T. Geisler

  2. Hämostaseologie, Klinikum der Universität München, Ziemssenstr. 1, 80336, München, Deutschland

    M. Spannagl

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  1. M. Droppa
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Interessenkonflikt

M. Droppa gibt an, dass kein Interessenkonflikt besteht.

M. Spannagl hat Vortragshonorare der Firmen Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Pfizer/BMS, AstraZeneca, Aspen Pharma erhalten.

T. Geisler hat Vortrags- und Beraterhonorare von AstraZeneca, Daiichi Sankyo, Eli Lilly, Pfizer/BMS, Boehringer Ingelheim, Bayer Healthcare und MSD sowie Forschungsunterstützung von Daiichy Sankyo, Pfizer/BMS erhalten.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Redaktion

R. Landgraf, München

CME-Fragebogen

CME-Fragebogen

Bei Patienten mit Diabetes mellitus ist …

die Thrombozytenfunktion im Vergleich zu Gesunden unverändert.

die Thrombozytenaggregation gesteigert.

die Thrombozytenaktivierung gemindert.

die Thrombozytenfunktion nur bei Patienten mit koronarer Herzerkrankung gesteigert.

die Thrombozytenfunktion nur bei Patienten mit koronarer Herzerkrankung gemindert.

Warum ist die Thrombogenität bei Diabetespatienten im Vergleich zu Gesunden erhöht?

Die Aktivitäten des plasmatischen Gerinnungs- und des Fibrinolysesystems sind erhöht.

Die Aktivitäten des plasmatischen Gerinnungs- und Fibrinolysesystems sind erniedrigt.

Die Aktivität des plasmatischen Gerinnungssystems ist erhöht, die Aktivität des Fibrinolysesystems ist erniedrigt.

Die Aktivität des plasmatischen Gerinnungssystems ist erniedrigt, die Aktivität des Fibrinolysesystems ist erhöht.

Wegen des erhöhten Spiegels an glykiertem Hämoglobin

Ein 57-jähriger Diabetespatient mit bekannter koronarer 3-Gefäß-Erkrankung mit Zustand nach wiederholten Stentimplantationen sollte wegen instabiler Angina pectoris erneut mit PCI behandelt werden. Zur Thrombozytenfunktionshemmung soll er zur Gabe von ASS und Clopidogrel noch eine dritte Substanz erhalten. Welche ist hier laut aktueller Studienlage am ehesten empfohlen?

Cilostazol

Abciximab

Dabigatran

Prasugrel

Ticagrelor

Die primärprophylaktische ASS-Gabe bei Diabetespatienten …

ist indiziert, um kardiovaskulären Ereignissen vorzubeugen.

ist nicht indiziert, wenn keine Gefäßerkrankung vorliegt.

ist nicht mit erhöhtem Blutungsrisiko assoziiert.

ist bei allen Patienten ab dem 60. Lebensjahr indiziert.

erniedrigt die Mortalität.

Die sekundärprophylaktische ASS-Gabe bei Patienten mit Diabetes mellitus und Gefäßerkrankungen…

ist mit der Erniedrigung der kardiovaskulären ischämischen Ereignisse assoziiert.

darf wegen deutlich erhöhtem Blutungsrisiko nur ausgewählten Diabetespatienten verschrieben werden.

ist kontraindiziert.

sollte mit einer Dosierung von 300–325 mg täglich durchgeführt werden.

wird nur für Patienten mit aggregometrisch nachgewiesener erhöhter Thrombozytenaktivität empfohlen.

Patienten mit Diabetes mellitus und Gefäßerkrankungen weisen eine im Vergleich zu Patienten ohne Diabetes mellitus verminderte Thrombozytenhemmung durch Clopidogrel auf. Dies ist bedingt durch …

verminderte Ausgangsaggregation.

verstärkte Absorption aufgrund diabetischer Gastropathie.

gestörte Signaltransduktion über den P2Y12-Rezeptor.

Interaktion mit erniedrigtem Fibrinogenspiegel.

erhöhte Konzentration des aktiven Metaboliten.

Die neuen P2Y12-Rezeptor-Antagonisten Prasugrel und Ticagrelor …

haben eine dem Clopidogrel vergleichbare antithrombozytäre Wirkung.

sind bei Patienten mit akutem Koronarsyndrom dem Clopidogrel vorzuziehen.

sind bei Patienten mit stabiler Angina pectoris indiziert.

werden in der Primärprophylaxe der Patienten mit Diabetes eingesetzt.

werden zusammen mit oralen Antikoagulanzien eingesetzt.

Vorapaxar und Cilostazol …

gehören zu den neuen direkten Antikoagulanzien.

darf man aufgrund erhöhtem Blutungsrisiko nicht zusätzlich zu ASS und Clopidogrel verordnen.

erniedrigen ischämische kardiovaskuläre Ereignisse bei Diabetespatienten signifikant, wenn sie zusätzlich zu ASS und Clopidogrel gegeben werden.

sind bei Diabetespatienten in Kombination mit ASS und Clopidogrel wirkungsvoller als eine Therapie mit ASS und neuen P2Y12-Rezeptor-Antagonisten.

können die Thrombozytenhemmung, die durch ASS und Clopidogrel erreicht wurde, nicht weiter verbessern.

Für die antithrombozytäre Behandlung der Patienten mit Diabetes gilt:

Diese unterscheidet sich prinzipiell nicht von Patienten ohne Diabetes.

Da die Patienten eine erhöhte Thrombozytenaktivität aufweisen, ist eine intensivierte antithrombozytäre Therapie sinnvoll.

Aufgrund erhöhter Thrombozytenaktivität sollte mit erhöhter ASS-Dosis behandelt werden.

Die neuen P2Y12-Rezeptor-Antagonisten sind wegen des erhöhten Blutungsrisikos kontraindiziert.

Während der PCI sollten GPIIb/IIIa-Inhibitoren verwendet werden.

Neue direkte Antikoagulanzien …

sind bei Patienten mit Diabetes mellitus kontraindiziert.

weisen bei Patienten mit Diabetes eine wesentlich stärkere Wirkung als Vitamin-K-Antagonisten auf.

haben bei Patienten mit Diabetes einen vergleichbaren antikoagulatorischen Effekt wie Vitamin-K-Antagonisten.

können bei Patienten mit Vorhofflimmern und Diabetes thrombembolische Ereignisse nicht ausreichend verhindern.

sind bei Patienten mit Diabetes mit erhöhtem Blutungsrisiko im Vergleich zur Vitamin-K-Antagonisten verbunden.

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Droppa, M., Spannagl, M. & Geisler, T. Diabetespatienten mit kardiovaskulärer Erkrankung. Diabetologe 12, 49–68 (2016). https://doi.org/10.1007/s11428-015-0059-0

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