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„Kardioprotektion“ durch ACE-Hemmer bei akuter Myokardischämie und beim Infarkt?

  • Karin Przyklenk
  • R. A. Kloner

Zusammenfassung

Der Verschluß einer Koronararterie führt zu einer akuten Aktivierung des Renin-Angiotensin-Systems und zur Bildung von Angiotensin II, einem potenten Vasokonstriktor und einer positiv inotropen Substanz. Dies ließ es möglich erscheinen, daß Inhibitoren des Angiotensin Converting Enzyme (ACE-Hemmer) „kardioprotektiv“ sein könnten (das heißt, daß sie das myokardiale Trauma, die Funktionsstörung und Nekrose abmildern könnten), wenn eine akute Ischämie und ein Infarkt auftritt. Tatsächlich wurde berichtet, daß in Modellen, in denen eine permanente Koronarokklusion durchgeführt wurde, Captopril, Enalapril und Ramipril die Nekrose aufgrund des myokardialen Traumas akut limitieren können. Die Mechanismen, die für diese Kardioprotektion verantwortlich sind, sind komplex, aber zu diesen Mechanismen zählen günstige Veränderungen der myokardialen Sauerstoffversorgung/des Sauerstoffbedarfs und in einigen Fällen die Inhibition des Bradykinin-Stoffwechsels und/oder eine erhöhte Prostaglandin-Synthese. Andere Studien konnten dagegen keine Reduzierung der Infarktgröße unter einer Behandlung mit ACE-Hemmern nachweisen. Die Ergebnisse, die man in Modellen einer Koronarokklusion und -reperfusion erhielt, waren ebenfalls gemischt. In Modellen einer kurzen, transienten Ischämie, die nicht mit einer Nekrose einherging, wurde durchweg festgestellt, daß Captopril und Zofenopril die postischämische kontraktile Funktionsstörung des lebensfähigen Myokards, das allerdings ein “Stunning”-Phänomen zeigte, in den ersten Stunden nach dem Sistieren der Ischämie abmilderte. Im Gegensatz dazu wurden die Wirkungen, die Enalapril auf das Myokard mit “Stunning”-Phänomen ausübt, unterschiedlich bewertet: einige Arbeitsgruppen kamen zu positiven, andere zu negativen Ergebnissen. In Modellen einer prolongierten, Ischämie/Reperfusion, die zu einer subendokardialen Nekrose führt, wurden ähnlich divergente Resultate erzielt: einige Studien ergaben eine günstige Wirkung auf das Myokard, andere lieferten beunruhigende Hinweise auf eine offensichtliche Exazerbation der Myokardnekrose unter der Captopril- und Enalapriltherapie. Demnach bleibt die Frage, ob ACE-Hemmer bei der akuten Myokardischämie und beim Herzinfarkt „kardioprotektiv“ sind, auch nach einem Jahrzehnt intensiver Forschung ungelöst. Trotzdem werden klinische Protokolle durchgeführt, um die Wirkungen einer früh einsetzenden Therapie mit ACE-Hemmern bei Patienten mit akutem Myokardinfarkt zu bewerten.

Schlüsselwörter

Koronararterienokklusion Koronararterienreperfusion Herzinfarktgröße Kreatinkinase kontratkile Funktion des Myokards 

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Copyright information

© Springer-Verlag Berlin Heidelberg 1993

Authors and Affiliations

  • Karin Przyklenk
    • 1
  • R. A. Kloner
    • 1
  1. 1.Heart InstituteHospital of the Good Samaritan and University of Southern CaliforniaLos AngelesUSA

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