Zusammenfassung
Die absolute Arrhythmie (AF) bei
Vorhofflimmern ist eine häufige Herzrhythmusstörung. Bei Patienten
mit valvulärem (rheumatischem) Vorhofflimmern ist die orale
Antikoagulation (OAC) als Thrombembolieprophylaxe etabliert. Nun belegen
kontrollierte Studien den Wert einer OAC auch bei nichtvalvulärem
Vorhofflimmern und Thrombembolie-Risikofaktoren. Zu den »hig
risk«-Faktoren zählen z. B. arterielle Hypertonie RR syst.
> 160 mmHg, Z.n. TIA/Apoplex, Frauen > 75 Jahre, reduzierte LV-Funktion.
Vor der Entscheidung einer OAC oder einer Antiaggregation z. B. mit
Acetylsalicylsäure (ASS), hat die Abschätzung des individuellen
Thrombembolie-Risikos zu stehen (Risiko-Stratifizierung). Patienten mit
»high risk«-Faktoren müssen antikoaguliert werden. Dabei ist
ein höheres Lebensalter (< 80 Jahre) keine Kontraindikation gegen OAC.
Allerdings ist bei Patienten > 80 Jahren mit Nebenerkrankungen angesichts
einer erhöhten Blutungsrate unter OAC eher eine ASS-Medikation zu
empfehlen. Patienten < 65 Jahre ohne klinische oder echokardiographische
Risikofaktoren (reduzierte LV-Funktion FS < 25 %) können mit ASS
325 mg/Tag behandelt werden. Bei Patienten zwischen 65 und 80 Jahren ohne
Risikofaktoren muss im Einzelfall entschieden werden. Mittels vorherigher
TEE-Abklärung kann sich eine Kardioversion sicher durchführen und die
Antikoagulationsdauer verkürzen lassen.
Atrial Fibrillation and
Anticoagulation
Atrial fibrillation (AF) is a common rhythm
disturbance and a major risk factor for stroke. Oral anticoagulation (OAC) is
well established in rheumatic valvular AF. Various randomized trials strongly
support the use of OAC for the prevention of thrombembolism in patients with
nonvalvular atrial fibrillation. Using several clinical and echocardiographical
features the individual risk of the patient for embolic events has to be
determined before treatment (risk stratification). In high risk patients oral
anticoagulation is recommended. Advanced age (< 80 years) is not a
contraindication to anticoagulant therapy. But in the very elderly (> 80
years) with a great comorbidity aspirin is preferable (increased risk of major
bleedings under OAC). Aspirin is recommended in patients > 65 years without
clinical or echocardiographical risk factors (fractional shortening <
25 %) and in patients with contraindications against OAC. In patients
aged 65-80 years without other risk factors treatment has to be decided
on individual cases. The TEE-guided approach before cardioversion is feasible
and safe and may help to reduce the duration of anticoagulation before
cardioversion.
Literatur
- 1
Aboaf A P, Wolf P S.
Paroxymal
atrial fibrillation.
Arch Intern
Med.
1996;
156
362-367
- 2
Atrial fibrillation
investigators .
Risk factors for stroke and efficacy of
antithrombotic therapy in atrial fibrillation.
Arch Intern
Med.
1994;
155
468-473
- 3
Atrial fibrillation
investigators .
Risk factors for stroke and efficacy of
antithrombotic therapy in atrial fibrillation: analysis of pooled data from
five randomized controlled trials.
Arch Intern
Med.
1994;
154
1449-1457
- 4
Bethge K P, Gonska B D, Jung W, Manz M, Schöls W, Wehr M.
Vorhofflimmern:
Ein häufiges Problem der Praxis.
Dtsch Med
Wschr.
1998;
123
1525-1529
- 5
Brugada R, Roberts R.
Molecular
biology and atrial fibrillation.
Current opinion in
cardiology.
1999;
14
269-273
- 6
Chung M K.
Should
patients receive anticoagulation for paroxysmal atrial
fibrillation?.
Cleve Clin J
Med.
2000;
67
5-6
- 7
Connolly S J, Laupacis A, Gent M, Roberts R S, Cairns J A, Joyner C.
Canadian
atrial fibrillation anticoagulation study (CAFA).
J Am Coll
Cardiol.
1991;
18
349-355
- 8
Coulshed N, Epstein E J, McKendrick C S.
Systemic
embolzation in mitral valve disease.
Br Heart
J.
1970;
32
26-34
- 9
Daoud F, Bahu M.
Effect
of an irregular ventricular rhythm on cardiac output.
Am J
Cardiol.
1996;
78
1433-1436
- 10
Ezekowitz M D, Bridgers S L, James K E, Carliner N H, Colling C L, Gornick C C, Krause-Steinrauf H,
Kurtzke J F, Nazarian S M, Radford M J.
Warfarin
in the prevention of stroke associated with nonrheumatic atrial
fibrillation.
N Engl J
Med.
1992;
327
1406-1412
- 11
Falk R H.
Etiology
and complications of atrial fibrillation: Insights from pathology
studies.
Am J
Cardiol.
1998;
82
10N-17N
- 12
Fihn S D, Callahan C M, Martin D C, McDonell M B, White R H.
The
risk for and severity of bleeding complications in elderly patients treated
with warfarin.
Ann Intern
Med.
1996;
124
970-979
- 13
Frustaci A, Chimenti C, Belloci F, Morgante F, Russo M A, Maseri A.
Histologic
substrate of atrial biopsies in patients with lone atrial
fibrillation.
Circulation.
1997;
96
1180-1184
- 14
Gershlick A H.
Treating
the non-electrical risks of atrial fibrillation.
Eur Heart .
1997;
18
C19-26
- 15
Goldenberg G M, Silverstone F A, Rangu S, Leventer S L.
Outcomes
of long-term anticoagulation in frail elderly patients with atrial
fibrillation.
Clinical Drug
Investigation.
1999;
17
483-488
- 16
Grant A O.
Mechanisms
of atrial fibrillation and action of drugs used in its management.
Am
J
Cardiol.
1998;
82
43N-49N
- 17
Gullov A L, Keofoed B G, Petersen P.
Fixed
mini-dose warfarin and aspirin alone and in combination versus adjusted-dose
warfarin for stroke prevention in atrial fibrillation: Second Copenhagen Atrial
Fibrillation, Aspirin, and Anticoagulation Study (the AFASAK2
study).
Arch Intern
Med.
1998;
158
1513-1521
- 18
Hellemons B SP, Langenberg M, Lodder J, Vermeer F, Schouten H JA, Lemmens T h, van
Ree J W, Knottnerus J A.
Primary
prevention of arterial thrombembolism in non-rheumatic atrial fibrillation in
primary care: randomised controlled trial comparin two intensities of coumadin
with
aspirin.
BMJ.
1999;
319
958-964
- 19
Hylek E M, Skates S J, Sheehan M A.
An
analysis of the lowest effective intensity of prophylactic anticoagulation for
patients with non-rheumatic atrial fibrillation.
N Engl J
Med.
1996;
335
540-546
- 20
Ikeda U, Yamamoto K, Shimada K.
Biochemical
markers of coagulation activation in mitral stenosis, atrial fibrillation, and
cardiomyopathy.
Clin
Cardiol.
1997;
20
7-10
- 21
Kannel W B, Wolf P A, Benjamin E J, Levy D.
Prevalence,
incidence, prognosis and predisposing conditions for atrial fibrillation:
Population-based estimates.
Am J
Cardiol.
1998;
82
2N-9N
- 22
Klein A, Grimm R, Black I.
Cardioversion
guided by transoesophageal echocardiography: The acute pilot study. A
randomized, controlled trial.
Arch Intern
Med.
1997;
126
200-209
- 23
Landefeld C S, Beyth R J.
Anticoagulant-related
bleeding: Clinical epidemiology, prediction and prevention.
Am J
Med.
1993;
95
315-328
- 24
Laupacis A, Albers G, Dalen J, Dunn M J, Jacobson A K.
Antithrombotic
therapy in atrial
fibrillation.
Chest.
1998;
114
579S-589S
- 25
Levy S.
Classification
system of atrial fibrillation.
Curr Opin
Cardiol.
2000;
15
54-57
- 26
Lip G YH, Lowe G DO, Rumley A, Dunn F G.
Increased
markers of thrombogenesis in chronic atrial fibrillation: Effects of warfarin
treatment.
Br Heart
Jr.
1995;
73
527-533
- 27 Lüderitz B. Herzrhythmusstörungen.
Diagnostik und Therapie (5. ed.) . Springer, Berlin, Heidelberg,
New
York 1998: 371-382
- 28
Manning W J, Silverman D J, Keighley C S, Oetten P, Douglas P S.
Transoesophageal
echocardiographically facilitated early cardioversion from atrial fibrillation
using short-term anticoagulation: Final results of a prospective 4.5 year
study.
J Am Coll
Cardiol.
1995;
25
1354-1361
- 29
Moreya E, Finkelhor R S, Cebul R D.
Limitations
of transoesophageal echocardiography in the risk assessment of patients before
noncoagulated cardioversion from atrial fibrillation and flutter: An analysis
of pooled trials.
Am Heart
J.
1995;
129
71-75
- 30
Omran H, Jung W, Illien S, Lüderitz B.
Bedeutung
der transösophagealen Echokardiographie vor Kardioversion bei
Vorhofflimmern.
Dtsch
Ärztebl.
2000;
97
B672-674
- 31
Page R L, Wilkinson W E, Clair W K, McCarthy E A, Pritchett E LC.
Asymptomatic
arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and
paroxysmal supraventricular
tachycardia.
Circulation.
1994;
89
224-227
- 32
Petersen P, Boysen G, Godfredsen J, Andersen E D.
Placebo-controlled,
randomised trial of warfarin and aspirin for the prevention of thrombembolic
complications in chronic atrial fibrillation. The Copenhagen AFASAK
study.
Lancet.
1989;
1
175-179
- 33
Petersen P, Hansen J M.
Stroke
in thyreotoxicosis with atrial
fibrillation.
Stroke.
1988;
19
15-18
- 34
Presti C F, Hart R G.
Thyreotoxicosis,
atrial fibrillation and embolism, revisited.
Am Heart
J.
1989;
117
976-977
- 35
Singer D E.
Anticoagulation
to prevent stroke in atrial fibrillation and its implications for managed
care.
Am J
Cardiol.
1998;
81
53C-60C
- 36
Stroke prevention in atrial fibrillation
investigators .
Adjusted-dose warfarin versus low-intensity,
fixed-dose warfarin plus aspirin for high-risk patients with atrial
fibrillation: Stroke prevention in atrial fibrillation III randomised clinical
trial.
Lancet.
1996;
348
633-638
- 37
Stroke prevention in atrial fibrillation
investigators .
Risk factors for thromboembolism during aspirin
therapy in patients with atrial fibrillation: The Stroke prevention in atrial
fibrillation study.
J Stroke Cerebrovasc
Dis.
1995;
5
147-157
- 38
Sudlow M, Thomson R, Thwaites B, Rodgers H.
Prevalence
of atrial fibrillation and elegibility for anticoagulants in the
community.
Lancet.
1998;
352
1167-1171
- 39
The Boston Area Anticoagulation Trial for Atrial
Fibrillation Investigators (BAATAF) .
The effect of low-dose
warfarin on the risk of stroke in patients with nonrheumatic atrial
fibrillation.
N Engl J
Med.
1990;
323
1505-1511
- 40
The European Atrial Fibrillation Trial Study
Group (EAFT) .
Optimal oral anticoagulation therapy in patients
with nonrheumatic atrial fibrillation and recent cerebral ischemia.
N
Engl J
Med.
1995;
333
5-10
- 41
The SPAF III Writing
Commitee .
Patients with nonvalvular atrial fibrillation at ow risk
of stroke during treatment with aspirin.
J Am Med
Ass.
1998;
279
1273-1277
- 42
The Stroke Prevention in Atrial Fibrillation
Investigators .
Adjusted-dose warfarin plus aspirin for high-risk
patients with atrial
fibrillation.
Lancet.
1996;
348
633-638
- 43
The Stroke Prevention in Atrial Fibrillation
Investigators .
Stroke prevention in atrial fibrillation study
- final
results.
Circulation.
1991;
84
527-539
- 44
The Stroke Prevention in Atrial Fibrillation
Investigators .
Warfarin versus aspirin for prevention of
thrombembolism in atrial fibrillation: The stroke prevention in atrial
fibrillation II
study.
Lancet.
1994;
343
687-691
- 45
Wolf P A, Dawber T R, Thomas E J.
Epidemiologic
assessment of chronic atrial fibrillation and risk of stroke: The Framingham
Study.
Neurology.
1978;
28
973-977
Korrespondenz
Dr. Caspar Burkhard-Meier
Herz-Kreislauf-Klinik
Arnikaweg
57319
Bad Berleburg
Telefon: 02751/88-0
Fax: 02751/88-2407
eMail: caspmei@aol.com
