Therapie des Vorhofflimmerns: Rhythmuskontrolle oder Frequenzkorrektur?

Zusammenfassung

Für Patienten mit persistierendem oder rezidivierendem Vorhofflimmern gibt es zwei unterschiedliche Therapieansätze: Wiederherstellung und Erhalt des Sinusrhythmus oder Stabilisierung der Herzfrequenz im Normbereich bei weiterbestehendem Vorhofflimmern. Aus pathophysiologischer Sicht erscheint das Terminieren der Arrhythmie für die Leistungsfähigkeit, Lebensqualität und Prognose des Betroffenen günstiger zu sein als die alleinige Korrektur der zu schnellen Kammerfrequenz. Doch fünf prospektiv und multizentrisch durchgeführte Vergleiche der beiden Strategien ergaben keinen Vorteil für den rhythmuskontrollierenden Therapieansatz.

Summary

There are two different strategies for treating patients with chronic or recurrent atrial fibrillation (AF): restitution and maintenance of sinus rhythm or ventricular rate stabilization within the normal range with persisting AF. Considered from a pathophysiological perspective termination of the AF would seem to be superior to control of only the rapid ventricular rate regarding exercise capacity, quality of life and prognosis. But five prospective multi-center trials comparing the two strategies have shown no advantage of reconversion to and maintenance of sinus rhythm in most patients.

Literatur

• 1 Wolf P A, Mitchell J B, Baker C S, Kannel W B, D’Agostino R B. Impact of atrial fibrillation on mortality, stroke, and medical costs.  Arch Intern Med. 1998;  158 229-234
• 2 Hohnloser S H, Kuck K H, Lilienthal J. Rhythm or rate control in atrial fibrillation - Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial.  Lancet. 2000;  356 1789-1794
• 3 Wyse D G, Waldo A L, DiMarco J P. et al.; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators . A comparison of rate control and rhythm control in patients with atrial fibrillation.  New Engl J Med. 2002;  347 1825-1833
• 4 Van Gelder I C, Hagens V E, Bosker H A. et al.; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group . A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation.  New Engl J Med. 2002;  347 1834-1840
• 5 Carlsson J, Miketic S, Windeler J. et al.; STAF Investigators . Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study.  J Am Coll Cardiol. 2003;  41 1690-1696
• 6 Opolski G, Torbicki A, Kosior D A. et al.; Investigators of the Polish How to Treat Chronic Atrial Fibrillation Study . Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study.  Chest. 2004;  126 476-486
• 7 Fuster V, Ryden L E, Asinger R W. et al.; American College of Cardiology; American Heart Association; European Society of Cardiology; North American Society of Pacing and Electrophysiology . ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation.  Eur Heart J. 2001;  1852-1923
• 8 Fetsch T, Bauer P, Engberding R. et al.; Prevention of Atrial Fibrillation after Cardioversion Investigators . Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial.  Eur Heart J. 2004;  25 1385-1394
• 9 Corley S D, Epstein A E, DiMarco J P. et al.; AFFIRM Investigators . Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study.  Circulation. 2004;  109 1509-1513
• 10 AFFIRM First Antiarrhythmic Drug Substudy Investigators . Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug.  J Am Coll Cardiol. 2003;  42 20-29
• 11 Roy D, Talajic M, Dorian P. et al . Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators.  Engl J Med. 2000;  342 913-920
• 12 Flaker G C, Blackshear J L, McBride R, Kronmal R A, Halperin J L, Hart R G. Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators.  J Am Coll Cardiol. 1992;  20 527-532
• 13 Steinberg J S, Sadaniantz A, Kron J. et al . Analysis of cause-specific mortality in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.  Circulation. 2004;  109 1973-1980
• 14 Chung M K, Shemanski L, Sherman D G. et al.; AFFIRM Investigators . Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy.  J Am Coll Cardiol. 2005;  46 1891-1899