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Perioperativer Umgang mit Thrombozytenaggregationshemmern

The use of platelet aggregation inhibitors in the perioperative period

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Zusammenfassung

Pro Jahr werden in Deutschland ca. 16 Mio. operative Eingriffe durchgeführt. Eine nicht unerhebliche Anzahl an Patienten nehmen Thrombozytenaggregationshemmer als Primär- oder Sekundärprophylaxe ein, um das Risiko kardiovaskulärer Ereignisse zu reduzieren. Besonders in der perioperativen Phase ist diese Risikoreduktion relevant, da perioperative Myokardinfarkte in bis zu 6,2 % der Operationen festgestellt wurden. Andererseits wird aufgrund des mutmaßlich erhöhten Blutungsrisikos die Einnahme der Thrombozytenaggregationshemmer perioperativ häufig pausiert. Im klinischen Alltag ist der operativ tätige Arzt mit der Frage konfrontiert, ob diese Medikation perioperativ fortgeführt werden kann oder pausiert werden sollte und wenn ja, mit welchem Risiko. Ist die Indikation zur Acetylsalicylsäure(ASS)-Therapie die Primärprophylaxe, so kann die Einnahme perioperativ pausiert werden, wohingegen ASS, welches im Rahmen der Sekundärprophylaxe eingenommen wird, nur bei Operationen in engen Räumen pausiert werden sollte. Wichtig ist es, beim Absetzen auf einen ausreichenden Abstand zur Operation und dem „ASS-withdrawal-Syndrom“ mit erhöhter Koagulationsneigung zu achten. Des Weiteren ist der perioperative Umgang mit einer dualen Plättchenaggregationshemmung, die nach Koronarstentimplantation notwendig ist, zu beachten. Aufgrund des erhöhten Risikos einer In-Stent-Thrombose wird die duale Plättchenaggregationshemmung ungerne pausiert. Kann eine Operation nicht verschoben werden, so muss im Notfall unter der dualen Plättchenaggregationshemmung operiert werden. Ist jedoch das operative Blutungsrisiko hoch und das Risiko einer In-Stent-Thrombose vergleichsweise gering, so sollte der P2Y12-Inhibitor (z. B. Clopidogrel) pausiert und die Operation unter ASS-Monotherapie durchgeführt werden.

Abstract

Every year 16 million operations are performed in Germany. Many patients take platelet aggregation inhibitors as a primary or secondary prevention to reduce the risk of cardiovascular events. Especially during the perioperative period, this risk reduction is relevant due to an increased risk for cardiac events (in approximately 6.2% of operations). As a result of a presumed increased risk of bleeding, platelet aggregation inhibitors are often paused perioperatively. Thus, doctors must decide on a risk-adapted basis whether the medication can be continued perioperatively and, if so, with what risks. If acetylsalicylic acid (ASA) treatment is solely used as primary prevention it can be paused during the perioperative period, whereas ASA treatment for secondary prevention should only be paused for operations within narrow confines. When pausing ASA, a sufficient time interval should be maintained before the operation. Furthermore, the ASA withdrawal syndrome with an increased predisposition for clotting is an important phenomenon to be considered. Additionally, the perioperative handling of dual platelet aggregation inhibition needed after coronary stent implantation should be addressed. Due to an increased risk for in-stent thrombosis, dual platelet aggregation inhibition is only reluctantly paused. Emergency surgery must, if not otherwise possible, be carried out even if the dual platelet aggregation inhibition is not paused; however, if the risk for intraoperative bleeding is too high and the risk of an in-stent thrombosis is lower in comparison, P2Y12 inhibitors (e.g. clopidogrel) should be paused and the operation carried out solely with ASA therapy.

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Authors and Affiliations

  1. Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberduerrbacherstr. 6, 97080, Würzburg, Deutschland

    J. Wagner, J. F. Lock, U. A. Dietz, S. Lichthardt, N. Matthes, K. Krajinovic, C.-T. Germer &  A. Wiegering

  2. Klinik für Innere Medizin II, Universitätsklinikum Würzburg, Würzburg, Deutschland

    V. Luber & S. Knop

  3. Comprehensive Cancer Centre Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland

    C.-T. Germer & S. Knop

  4. Institut für Biochemie und Molekularbiologie, Universität Würzburg, Würzburg, Deutschland

    A. Wiegering

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J. Wagner, J.F. Lock, V. Luber, U.A. Dietz, S. Lichthardt, N. Matthes, K. Krajinovic, C.‑T. Germer, S. Knop und A. Wiegering geben an, dass kein Interessenkonflikt besteht.

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Wagner, J., Lock, J.F., Luber, V. et al. Perioperativer Umgang mit Thrombozytenaggregationshemmern. Chirurg 89, 90–94 (2018). https://doi.org/10.1007/s00104-017-0525-x

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