Abstract
Atrial fibrillation (AF) is characterized by insufficient coordination of atrial activity
leading to a loss of effective atrial contraction. AF can lead to different clinical
conditions, including cerebrovascular and systemic thromboembolism, decompensated
heart failure, and/or oligosymptomatic and symptomatic tachycardias. A global therapeutic
approach should target these issues, and encompass conversion of maintenance of rhythm
by means of electric cardioversion and drug and/or interventional therapies and effective
anticoagulation to prevent thromboembolism in certain risk groups. The risk for stroke
increases depending on patient age and comorbidities. Therapeutic goal consists of
safeguarding of effective anticoagulation under tolerable bleeding risk. This poses
a growing challenge in the light of complex cases and individual risk factors, as
well as the development of new antithrombotics. Treatment with vitamin K antagonists
demands a complicated patient management, is difficult to handle and susceptible for
drug interactions, nutritional influences and genetic polymorphisms. The aim of the
subsequent article is to give a current overview over treatment strategies for prophylaxis
of thromboembolism in patients with AF considering present treatments and recent development
focussing on novel thrombin inhibitors.
Kernaussagen
-
Komplikationen des Vorhofflimmerns sind zerebrovaskuläre Embolien, dekompensierte
Herzinsuffizienz, Ischämien oder oligosymptomatische und symptomatische Tachykardien.
Das Schlaganfallrisiko bei Patienten mit Vorhofflimmern hängt von begleitenden Risikofaktoren
ab und steigt mit dem Alter an.
-
Zur Vorbeugung von Thromboembolien ist bei bestimmten Risikogruppen eine effektive
antikoagulatorische Behandlung wichtig. Die Indikation zur oralen Antikoagulation
sollte man dabei anhand des individuellen Risikoprofils stellen.
-
Eine besondere Risikogruppe für thrombotische Komplikationen sind Patienten mit Vorhofflimmern
und symptomatischer KHK. Bei ihnen sollte man eine Kombination von oralen Antikoagulanzien
und antithrombozytären Substanzen nach sorgfältiger Abschätzung des Blutungsrisikos
in Erwägung ziehen.
-
Vitamin-K-Antagonisten senken das Schlaganfallrisiko erheblich, ihre variable Wirksamkeit
ist jedoch ein ernstes Problem. Sie erfordern eine komplizierte Patientenführung,
sind schwierig zu steuern und anfällig für medikamentöse Wechselwirkungen, nutritive
Einflüsse und genetische Polymorphismen.
-
Neue orale Antikoagulanzien (direkte Thrombininhibitoren und Faktor-Xa-Antagonisten)
sind derzeit in Phase-III-Studien zur Thrombembolieprophylaxe bei Vorhofflimmern in
Erprobung. Bislang sind die Ergebnisse bezüglich ihrer Effektivität und Sicherheit
im Vergleich zu den Vitamin-K-Antagonisten vielversprechend.
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Dr. med. Tobias Geisler
Medizinische Klinik III
Eberhard-Karls-Universität Tübingen
Otfried-Müller-Straße 10
72076 Tübingen
Email: tobias.geisler@email.de
