Antikoagulation bei Herzinsuffizienz

Abstract

Heart failure is a complex of symptoms caused by various etiologies, basically characterized by reduced blood flow, changes in blood composition, and the activation of the endothelium. This leads to a pro-thrombotic state in many patients. Despite this clear-cut pathophysiology, the evidence for anticoagulation treatment of patients with heart failure is limited. Patients with heart failure and any form of atrial fibrillation have clearly to be treated with plasmatic anticoagulants. However, in patients with sinus rhythm, plasmatic anticoagulants were not more effective than aspirin in terms of survival. Thus, the decision whether to anticoagulate patients with heart failure should be made depending on the individual risk-to-benefit-ratio.

Kernaussagen

• Thromboembolische Komplikationen tragen zu Morbidität und Mortalität von Herzinsuffizienzpatienten bei.

• Bei Herzinsuffizienzpatienten sollte aktiv nach Indikationen für die Antikoagulation, vor allem nach paroxysmalem Vorhofflimmern, gesucht werden. Eine Risikoabschätzung für die Antikoagulation ist mit dem CHA₂DS₂VASc- und dem HASBLED-Score möglich [3].

• Wenn eine plasmatische Antikoagulation durchgeführt wird, ist eine parallele Gabe von Thrombozytenaggregationshemmern nicht sinnvoll (außer 12 Monate nach Myokardinfarkt).

• Wenn keine spezifische Indikation (KHK etc.) besteht, ist ASS bei Herzinsuffizienz nicht indiziert.

• Aktuell gibt es keine gute Datenlage dafür, alle Herzinsuffizienzpatienten mit plasmatischer Antikoagulation zu behandeln. Individuelle Antikoagulationsentscheidungen sind nach Abwägung von Thromboembolierisiko und Blutungsrisiko gemeinsam mit dem Patienten zu treffen.

• Literatur

• 1 Freudenberger RS, Schumaecker MM, Homma S. What is the appropriate approach to prevention of thromboembolism in heart failure?. Thromb Haemost 2010; 103: 489-495
• 2 Lip GYH, Piotrponikowski P, Andreotti F et al. Thromboembolism and antithrombotic therapy for heart failure in sinus rhythm. An Executive Summary of a joint Consensus Document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis. Thrombosis and Haemostasis 2012; 108: 1009-1022
• 3 Task FM et al. Developed with the special contribution of the European Heart Rhythm Association (EHRA), Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429
• 4 Task FM, Camm AJ, Lip GYH et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillationDeveloped with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-2747
• 5 Gage BF, Waterman AD, Shannon W et al. Validation of clinical classification schemes for predicting stroke: Results from the national registry of atrial fibrillation. JAMA 2001; 285: 2864-2870
• 6 Hohnloser SH, Pajitnev D, Pogue J et al. Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation in Patients Taking Oral Anticoagulation or Combined Antiplatelet Therapy: An ACTIVE W Substudy. JACC 2007; 50: 2156-2161
• 7 Connolly SJ, Ezekowitz MD, Yusuf S et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361: 1139-1151
• 8 Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med 2011; 365: 883-891
• 9 Granger CB, Alexander JH, McMurray JJV et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2011; 365: 981-992
• 10 Harper P, Young L, Merriman E. Bleeding Risk with Dabigatran in the Frail Elderly. N Engl J Med 2012; 366: 864-866
• 11 Boehringer Ingelheim Pharma GmbH & Co. KG. Rote-Hand-Brief zu Pradaxa (Dabigatranexelitat): Notwendigkeit der Überprüfung der Nierenfunktion. 2011
• 12 Wolf PA, Dawber TR, Thomas HE et al. Epidemiologic assesment of chronic atrial fibrillation and the risk of stroke: the Framingham Study. Neurology 1978; 28: 973-977
• 13 Eikelboom JW, Connolly SJ, Brueckmann M et al. Dabigatran versus Warfarin in Patients with Mechanical Heart Valves. N Engl J Med 2013; 369: 1206-1214
• 14 Lip GYH, Gibbs CR. Does heart failure confer a hypercoagulable state? Virchow's triad revisited. JACC 1999; 33: 1424-1426
• 15 Uretsky BF, Thygesen K, Armstrong PW et al. Acute Coronary Findings at Autopsy in Heart Failure Patients With Sudden Death: Results From the Assessment of Treatment With Lisinopril and Survival (ATLAS) Trial. Circ 2000; 102: 611-616
• 16 Cokkinos DV, Haralabopoulos GC, Kostis JB et al. Efficacy of antithrombotic therapy in chronic heart failure: The HELAS study. Eur J of Heart Failure 2006; 8: 428-432
• 17 Cleland JGF, Findlay I, Jafri S et al. The Warfarin/Aspirin study in heart failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure. Am Heart J 2004; 148: 157-164
• 18 Massie BM, Collins JF, Ammon SE et al. Randomized Trial of Warfarin, Aspirin, and Clopidogrel in Patients With Chronic Heart Failure: The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial. Circ 2009; 119: 1616-1624
• 19 Homma S, Thompson JLP, Pullicino PM et al. Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm. N Engl J Med 2012; 366: 1859-1869
• 20 Homma S, Thompson JLP, Sanford AR et al. Benefit of Warfarin Compared With Aspirin in Patients With Heart Failure in Sinus Rhythm: A Subgroup Analysis of WARCEF, a Randomized Controlled Trial. Circulation: Heart Failure 2013; 6: 988-997
• 21 Rengo G, Pagano G, Squizzato A et al. Oral Anticoagulation Therapy in Heart Failure Patients in Sinus Rhythm: A Systematic Review and Meta-Analysis. PLoS ONE 2013; 8: e52952
• 22 Hopper I, Skiba M, Krum H. Updated meta-analysis on antithrombotic therapy in patients with heart failure and sinus rhythm. Eur J of Heart Failure 2013; 15: 69-78
• 23 Lip GYH, Gibbs CR. Antiplatelet agents versus control or anticoagulation for heart failure in sinus rhythm: a Cochrane systematic review. QJM 2002; 95: 461-468
• 24 Oechslin E, Jenni R. Left ventricular non-compaction revisited: a distinct phenotype with genetic heterogeneity?. Eur Heart J 2011; 32: 1446-1456
• 25 Thavendiranathan P, Dahiya A, Phelan D et al. Isolated left ventricular non-compaction controversies in diagnostic criteria, adverse outcomes and management. Heart 2013; 99: 681-689