Kardiologie up2date 2016; 12(01): 47-59
DOI: 10.1055/s-0035-1569974
Herzinsuffizienz
© Georg Thieme Verlag KG Stuttgart · New York

Herzinsuffizienz und Vorhofflimmern

Wilhelm Haverkamp
Further Information

Publication History

Publication Date:
08 March 2016 (online)

Abstract

Heart failure and atrial fibrillation are two inter-related conditions with similar risk factors and pathophysiology. They both increase morbidity and mortality. Almost all patients need rate control, preferentially with a beta blocker. The role of rhythm control in atrial fibrillation patients with heart failure is unclear. Class I antiarrhythmic agents and dronedarone are contraindicated in patients with heart failure. Amiodarone is an option, however, a major limitation is frequent side effects. Smaller studies demonstrating that catheter ablation of atrial fibrillation may play a role have been published. However, larger studies demonstrating beneficial effects on mortality are yet not available. Antithrombotic therapy is needed in almost all patients to prevent thromboembolic complications.

Therapy of atrial fibrillation in patients with heart failure is a challenge. Therapeutic decisions should be made on an individual patient basis and implies a careful benefit-risk assessment.

Kernaussagen
  • Herzinsuffizienz und Vorhofflimmern sind beide ausgesprochen häufige Krankheitsbilder. Im Vergleich zum isolierten Auftreten sind die Morbidität und Sterblichkeit deutlich höher, wenn beide Erkrankungen gemeinsam vorliegen. Ob eine Herzinsuffizienz mit reduzierter oder erhaltener Auswurffraktion vorliegt, spielt für die Sterblichkeit keine Rolle.

  • Die Risikofaktoren und Mechanismen, die zur Manifestation einer Herzinsuffizienz und von Vorhofflimmern führen, überschneiden sich – genauso wie das auch für die Präventions- und Behandlungsmaßnahmen gilt.

  • Ein wichtiger Grundpfeiler der Behandlung von Patienten mit Vorhofflimmern bei Herzinsuffizienz ist eine adäquate Frequenzkontrolle. Hierbei steht die Gabe eines Betablockers im Vordergrund, bei unzureichender Frequenzkontrolle kann mit einem Digitalispräparat kombiniert werden.

  • Auch wenn sich Hinweise darauf ergeben, dass ein Sinusrhythmus bei Herzinsuffizienz prognostisch günstiger ist als Vorhofflimmern, ist es bisher nicht gelungen, eindeutig nachzuweisen, dass sich die Prognose mit Maßnahmen verbessert, die den Sinusrhythmus erhalten.

  • Als Antiarrhythmikum steht bei Herzinsuffizienz lediglich Amiodaron zur Verfügung. Das substanzeigene komplexe Nebenwirkungsprofil muss beachtet werden.

  • Große Hoffnungen sind mit der Katheterablation von paroxysmalem Vorhofflimmern bei Herzinsuffizienz verknüpft. Patienten, die der Methode zugeführt werden, sollten sorgfältig ausgewählt werden. Im Vordergrund steht allerdings die Behandlung der auf das Vorhofflimmern bezogenen Symptomatik. Eine Prognoseverbesserung durch Ablation konnte bislang nicht nachgewiesen werden.

  • Bei fast allen Patienten mit Vorhofflimmern bei Herzinsuffizienz besteht eine Indikation zur dauerhaften oralen Antikoagulation. Hierbei haben sich die neuen oralen Antikoagulanzien als wirksam und sicher erwiesen. Ist eine orale Antikoagulation kontraindiziert, kann ein Vorhofohrverschluss erfolgen.

 
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