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Aktuelle Kardiologie 2019; 8(06): 438-446
DOI: 10.1055/a-1027-6448
Kurzübersicht
Georg Thieme Verlag KG Stuttgart · New York

Herzinsuffizienz und Arrhythmien

Heart Failure and Arrhythmias
Christoph Stellbrink
Klinik für Kardiologie und Internistische Intensivmedizin, Klinikum Bielefeld
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Publication History

Publication Date:
19 December 2019 (online)

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Zusammenfassung

Die häufigsten und prognostisch bedeutsamsten Arrhythmien bei der Herzinsuffizienz sind Vorhofflimmern und ventrikuläre Arrhythmien. Pathophysiologisch liegen beiden Arrhythmien eine Aktivierung des neurohumoralen Systems im Rahmen des Remodelings, myokardiale Hypertrophie bzw. Fibrose sowie Änderungen der kardialen Erregungsleitung und der Repolarisation zugrunde. Vorhofflimmern führt zu einer Beeinträchtigung der kardialen Hämodynamik, erhöht die Mortalität und das Risiko für thromboembolische Komplikationen. Die Therapie fokussiert daher auf die Antikoagulation, den Erhalt des Sinusrhythmus bzw. eine Frequenzkontrolle, wenn ein Sinusrhythmus nicht mehr dauerhaft erhalten werden kann. Da die antiarrhythmische Therapie praktisch auf Amiodaron beschränkt ist, spielt die Katheterablation eine zunehmende Rolle, wenn ein Erhalt des Sinusrhythmus das therapeutische Ziel ist. Allerdings ist der Eingriff bei herzinsuffizienten Patienten komplex und sollte in erfahrenen Zentren durchgeführt werden. Auch für ventrikuläre Arrhythmien sind die Möglichkeiten der medikamentösen Therapie beschränkt, daher ist bei Patienten mit ausgeprägter systolischer Herzinsuffizienz oft ein implantierbarer Kardioverter-Defibrillator (ICD) indiziert. Allerdings ist die Datenlage für Patienten mit nicht ischämischer Kardiomyopathie etwas schlechter als für Patienten mit linksventrikulärer Dysfunktion nach Infarkt. Auch bei ventrikulären Tachykardien spielt die Katheterablation bei Herzinsuffizienz eine zunehmende Rolle, besonders bei ischämischen Patienten. Sie kann die Häufigkeit von ventrikulären Tachykardien und ICD-Schocks reduzieren, ein Nutzen hinsichtlich Mortalität ist allerdings nicht nachgewiesen.

Abstract

The most common and prognostically relevant arrhythmias in heart failure are atrial fibrillation and ventricular arrhythmias. Pathophysiology of both arrhythmias involves activation of the neurohumoral system in the setting of cardiac remodeling, myocardial hypertrophy and fibrosis as well as disturbances in cardiac conduction and repolarization. Atrial fibrillation leads to an impairment of cardiac hemodynamics and an increase in mortality and thromboembolic complications. Thus, therapy is focused on anticoagulation and maintenance of sinus rhythm or rate control if sinus rhythm cannot be sustained. Because antiarrhythmic drug therapy is confined mainly to amiodarone catheter ablation plays an increasingly important role for sinus rhythm maintenance in these patients. However, this procedure is especially complex in heart failure patients and should thus be reserved to experienced centers. The options for antiarrhythmic drug treatment in ventricular arrhythmias are also very limited. Thus, the implantable cardioverter-defibrillator (ICD) is often indicated in heart failure with severely reduced left ventricular function. However, the data are less unequivocal for patients with non-ischemic cardiomyopathy than for patients with postinfarct left ventricular dysfunction. Catheter ablation is also being increasingly used in the treatment of ventricular tachycardia. It can reduce the number of ventricular tachycardia episodes and ICD shocks. However, a mortality benefit has not been shown for this approach.

Was ist wichtig?

  • Vorhofflimmern und ventrikuläre Arrhythmien sind bei Herzinsuffizienz häufig und prognostisch bedeutsam. Vorhofflimmern tritt, in Abhängigkeit vom Schweregrad der Herzinsuffizienz, in 10 – 50% der Patienten auf, nicht anhaltende ventrikuläre Tachykardien (NSVT) in 30 – 60%.

  • Bei der Therapie des VHF ist die Verhinderung thromboembolischer Komplikationen durch Antikoagulanzien von zentraler Bedeutung, inzwischen ist den Nicht-Vitamin-K-Antagonisten (NOAKs) der Vorzug zu geben. Zum Erhalt des Sinusrhythmus kommen Amiodaron oder, in erfahrenen Zentren, die Katheterablation infrage. Ein Überlebensvorteil durch medikamentöse Therapie ist in Studien nicht bewiesen, zumindest in einer prospektiv-randomisierten Studie konnte eine Mortalitätssenkung durch die Katheterablation gezeigt werden.

  • Auch bei Herzinsuffizienz sollte Digitalis zur Frequenzkontrolle zurückhaltend eingesetzt werden, da in Metaanalysen Hinweise auf eine erhöhte Mortalität durch Digitalis besonders in höherer Dosierung gefunden wurden.

  • Die Primärprävention des plötzlichen Herztods durch den implantierbaren Kardioverter-Defibrillator (ICD) ist besonders bei ischämisch bedingter Herzinsuffizienz gut belegt; bei nicht ischämischer Kardiomyopathie ist ein Überlebensvorteil durch den ICD in prospektiv-randomisierten Studien nicht eindeutig belegt. Daher sollte die Indikation zur ICD-Implantation nicht nur unter Berücksichtigung der linksventrikulären Funktion allein erfolgen, sondern andere Faktoren (Alter, Komorbiditäten) verstärkt einbeziehen.

  • Die Katheterablation ventrikulärer Tachykardien ist besonders bei ischämisch bedingter Herzinsuffizienz zur Reduktion von VT und ICD-Schocks sinnvoll, eine Beeinflussung der Mortalität ist allerdings nicht nachgewiesen.

Schlüsselwörter

Herzinsuffizienz - Vorhofflimmern - ventrikuläre Arrhythmien - Antiarrhythmika - Antikoagulation - Katheterablation

Key words

heart failure - atrial fibrillation - ventricular arrhythmias - antiarrhythmic drugs - anticoagulation - catheter ablation
 

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