Herzinsuffizienz und Vorhofflimmern

Abstract

Both, heart failure and atrial fibrillation, are very common clinical features, which might simply co-exist, but more often cause or at least modify each other. Acutely, lowering heart rate with digoxin and betablockers or calcium antagonists will alleviate symptoms. Improvement of left ventricular function might occur and point to a causal role of the arrhythmia. Treatment of any underlying heart disease might, in turn, exert positive effects on atrial fibrillation, but frequently, arrhythmia-specific long-term therapy is required. Based on currently available data, rate and rhythm control have to be considered as alternative therapeutic strategies, with the goal being symptom relief and exercise capacity. In most cases, rate control can be easily achieved with betablockers or calcium antagonists, but not all patients tolerate rate control. On the other hand, not too many patients experience long-lasting rhythm control on antiarrhythmic agents, but might suffer from serious adverse events. Dronedarone supplements the therapeutic spectrum, but does certainly not revolutionize antiarrhythmic drug therapy. Even in heart failure patients, catheter ablation of atrial fibrillation represents an option, but success rates of about 60 – 70 % have to be weighed against the hazards of the procedure(s) and the risk of complications. Heart failure in atrial fibrillation is a risk factor for thromboembolic complications, and, thus, most patients need to be put on vitamin-K-antagonists. In the near future, direct thrombin inhibitors like dabigatran might emerge as a more convenient and efficient mode of anticoagulation.

Kernaussagen

• Vorhofflimmern als Folge oder auch als Ursache einer Herzinsuffizienz ist häufig und bedarf einer entsprechenden Therapie, die sich sowohl spezifisch auf die Herzrhythmusstörung als auch auf eine etwaige Grunderkrankung richtet.

• Belegtes Primärziel der rhythmusspezifischen Therapie ist die Verbesserung der Leistungsfähigkeit und die Beseitigung von Symptomen, diesbezüglich sind Frequenz- und Rhythmuskontrolle als alternative Therapiestrategien anzusehen.

• Die pharmakologische Frequenzkontrolle gelingt häufig, wird aber nicht immer toleriert. Nur ausnahmsweise muss auf eine AV-Knoten-Ablation zurückgegriffen werden.

• Eine dauerhafte pharmakologische Rhythmuskontrolle wird eher selten erreicht, Dronedaron erweitert das Therapiespektrum, ohne es zu revolutionieren. Die Katheterablation ist in der Stufentherapie des Vorhofflimmerns weiter nach vorne gerückt, Aufwand, Komplikations- und bislang suboptimale Erfolgsraten stehen einer Einstufung als Primärstrategie entgegen.

• Nachdem bei Vorhofflimmern die Herzinsuffizienz bereits als ein eigenständiger Risikofaktor für Thromboembolien gilt, ist in aller Regel eine Antikoagulation mit Vitamin-K-Antagonisten erforderlich. Hier steht mit den direkten Thrombinantagonisten, namentlich Dabigatran, wahrscheinlich bald eine Alternative zur Verfügung.

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