Rhythmusmanagement bei Vorhofflimmern

ZUSAMMENFASSUNG

Vorhofflimmern ist die häufigste Herzrhythmusstörung und ist mit einem erhöhten Risiko für Mortalität, Herzinsuffizienz, Schlaganfälle und Demenz assoziiert. Das therapeutische Management des Vorhofflimmerns hat sich in den letzten Jahren in vielfältiger Hinsicht entscheidend verändert. Die frühzeitige Diagnostik und die Einleitung einer gezielten und individualisierten Therapie spielen hierbei eine große Rolle. Die konsequente Behandlung von Risikofaktoren und Begleiterkrankungen sowie die Prävention thrombembolischer Komplikationen rücken in den Vordergrund. Zudem weisen neuste Studienergebnisse auf eine Prognoseverbesserung durch eine frühe Rhythmuskontrolle hin, welche durch antiarrhythmische Medikation oder eine Katheterablation erreicht werden kann. Im folgenden Artikel wird das Therapiemanagement des Vorhofflimmerns mit Fokus auf rhythmuserhaltende Strategien im Kontext der aktuellen Literatur beleuchtet.

ABSTRACT

Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with an increased risk of mortality, heart failure, stroke and dementia. Within the last couple of years, management of AF has decisively changed. In this regard, early detection and establishment of an individualized arrhythmia management guided by integrated pathways play a central role. Assessment and consequent treatment of risk factors and comorbidities as well as stroke prevention are essential elements of current guidelines. Additionally, recent studies indicate that early rhythm control of AF may have prognostic impact. Rhythm control can either be gained by antiarrhythmic drug treatment or performance of catheter ablation. In the following article, the therapeutic management of AF with focus on rhythm control strategies will be discussed in context with the current literature.

Schlüsselwörter

Vorhofflimmern - Schlaganfallprophylaxe - orale Antikoagulation - Katheterablation

Key words

Atrial fibrillation - stroke prophylaxis - oral anticoagulation - catheter ablation

Publication History

Article published online:
07 June 2022

• Literatur

• 1 Hindricks G, Potpara T, Serbia C. et al 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the EuropeanAssociation of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020 0 1-126
• 2 Staerk L, Wang B, Preis SR. et al Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. BMJ 2018; 361: k1453
• 3 Wynn GJ, Todd DM, Webber M. et al The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification. Europace 2014; 16: 965-72
• 4 Pistoia F, Sacco S, Tiseo C. et al The Epidemiology of Atrial Fibrillation and Stroke. Cardiol Clin 2016; 34 (02) 255-68
• 5 Benjamin EJ, Muntner P, Alonso A. et al Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139 (10) e56-528
• 6 Dagres N, Chao T, Fenelon G. et al European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society [APHRS]/Latin American Heart Rhythm Society (LAHRS) expert consensus on arrhythmias and cognitive function: what is the best practice?. Heart Rhythm 2018; 15 (06) e37-60
• 7 Calkins H, Hindricks G, Cappato R. et al 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14 (10) e275-444
• 8 Willems S, Gunawardene MA, Eickholt C. et al Medical, Interventional, and Surgical Treatment Strategies for Atrial Fibrillation. Dtsch Arztebl Int 2022 Jan; arztebl.m2021.0303
• 9 Ruff CT, Giugliano RP, Braunwald E. et al Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383 9921 955-62
• 10 Tijssen JGP, Ph D, Alings AM. et al Lenient versus Strict Rate Control in Patients with Atrial fibrillation. N Engl J Med 2010; 362: 1363-73
• 11 Andrade JG, Wells GA, Deyell MW. et al Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation. N Engl J Med 2021; 384 (04) 305-15
• 12 Wazni OM, Dandamudi G, Sood N. et al Cryoballoon Ablation as Initial Therapy for Atrial Fibrillation. N Engl J Med 2020; 384 (04) 316-24
• 13 Kuniss M, Pavlovic N, Velagic V. et al Cryoballoon ablation vs. antiarrhythmic drugs : first-line therapy for patients with paroxysmal atrial fibrillation. Europace 2021; 23: 1033-41
• 14 Gunawardene MA, Hartmann J, Jularic M. et al Therapeutic management of nonvalvular atrial fibrillation. Herz 2020; 45 (06) 603-16
• 15 Abed HS, Wittert GA, Leong DP. et al Effect of Weight Reduction and Cardiometabolic Risk Factor Management on Symptom Burden and Severity in Patients With Atrial Fibrillation A Randomized Clinical Trial. JAMA 2013; 310 (19) 2050-60
• 16 Blum S, Aeschbacher S, Meyre P. et al Incidence and Predictors of Atrial Fibrillation Progression. J Am Hear Assoc 2019: e012554
• 17 Rienstra M, Hobbelt AH, Alings M. et al Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation: Results of the RACE 3 trial. Eur Heart J 2018; 39 (32) 2987-96
• 18 Pathak RK, Middeldorp ME, Meredith M. et al Long-term effect of goal-directed weight management in an atrial fibrillation cohort: A long-term follow-up study [LEGACY]. J Am Coll Cardiol 2015; 65 (20) 2159-69
• 19 Haïssaguerre M, Jaïs P, Shah DC. et al Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339 (10) 659-66
• 20 Verma A, Jiang CY, Betts TR. et al STAR AF II Investigators. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015; 372: 1812-22
• 21 Di Biase L, Mohanty P, Mohanty S. et al Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial. Circulation 2016; 133: 1637-44
• 22 Packer DL, Mark DB, Robb RA. et al Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA 2019; 321: 1261-1274
• 23 Kuck KH, Lebedev DS, Mikhaylov EN. et al Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST). Europace 2021; 23: 362-369
• 24 Steinberg BA, Hellkamp AS, Lokhnygina Y. et al Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial. Eur Heart J 2015; 36: 288-96
• 25 Friberg L, Tabrizi F, Englund A. Catheter ablation for atrial fibrillation is associated with lower incidence of stroke and death: data from Swedish health registries. Eur Heart J 2016; 37 (31) 2478-87
• 26 Kalman JM, Sanders P, Rosso R. et al Should We Perform Catheter Ablation for Asymptomatic Atrial Fibrillation?. Circulation 2017; 136: 490-499
• 27 Marrouche NF, Brachmann J, Andresen D. et al Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378: 417-427
• 28 Packer DL, Piccini JP, Monahan KH. et al Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial. Circulation 2021; 143: 1377-1390
• 29 Kirchhof P, Camm AJ, Goette A. et al Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med 2020; 383: 1305-1316
• 30 Metzner A, Suling A, Brandes A. et al Anticoagulation, therapy of concomitant conditions, and early rhythm control therapy: a detailed analysis of treatment patterns in the EAST – AFNET 4 trial. Europace 2021 Sep 2: euab200
• 31 Rillig A, Magnussen C, Ozga AK. et al Early Rhythm Control Therapy in Patients With Atrial Fibrillation and Heart Failure. Circulation 2021; 144: 845-858
• 32 Willems S, Borof K, Brandes A. et al Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial. Eur Heart J 2021; Aug 27: ehab593