Vorhofflimmern – Aktuelle Leitlinien – Therapie in der Praxis und Indikation zur Elektrophysiologie

Vorhofflimmern ist eine der wesentlichen Ursachen für Morbidität und Mortalität vor allem im höheren Lebensalter. Bei den meisten Patienten ist an erster Stelle die Frage der Antikoagulation zu klären. Aus grundsätzlichen Überlegungen heraus wäre es wünschenswert, den Sinusrhythmus zu erhalten bzw. wieder herzustellen. Medikamente sind jedoch leider zum Erhalt des Sinusrhythmus wenig effektiv. Deutlich wirkungsvoller ist die Katheterablation des Vorhofflimmerns. Die Komplexität und die Risiken des Verfahrens erlauben jedoch keinen breiten Einsatz, zumal wesentliche Fragen – wie zum Beispiel die nach der Antikoagulation nach Katheterablation bei Risikopatienten – noch nicht beantwortet sind.

Atrial fibrillation is one of the essential causes of morbidity and mortality especially in patients of advanced age. In most of the patients it is of primary importance to clarify first of all the problem of anticoagulation. Fundamentally, it would be desirable to maintain or re-establish the sinus rhythm. Unfortunately, however, drugs are not very effective in maintaining the sinus rhythm. Catheter ablation of the atrial fibrillation is definitely more effective. This is however a complicated and risky procedure, so that it cannot be done on a large scale, the more so since essential questions are still unanswered, such as anticoagulation after catheter ablation in risk patients.

atrial fibrillation - anticoagulation - rate control - rhythm control - sinus rhythm - catheter ablation

Literatur

• 1 Benjamin EJ, Wolf PA, D'Agostino RB. et al. . Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.  Circulation. 1998;  98 946-952
• 2 Kannel WB, Abbott RD, Savage DD. et al. . Epidemiologic features of chronic atrial fibrillation: The Framingham study.  N Engl J Med. 1982;  306 1018-1022
• 3 Lloyd-Jones DM, Wang TJ, Leip EP. et al. . Lifetime risk for development of atrial fibrillation. The Framingham Heart Study.  Circulation. 2004;  110 1042-1046
• 4 Miyasaka Y, Barnes ME, Gersh BJ. et al. . Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.  Circulation. 2006;  114 119-125
• 5 Stewart S, MacIntyre K, MacLeod MM. et al. . Trends in hospital activity, morbidity and case fatality related to atrial fibrillation in Scotland, 1986–1996.  Eur Heart J. 2001;  22 693-701
• 6 Wang TJ, Parise H, Levy D. et al. . Obesity and the risk of new-onset atrial fibrillation.  JAMA. 2004;  24 2471-2477
• 7 Wolf PA, Abbott RD, Kannel WB.. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.  Stroke. 1991;  22 983-988
• 8 Scherf D, Blumenfeld S, Gurbuzer B. et al. . Effect of hypercapnia on aconitine-induced atrial fibrillation and on ventricular fibrillation caused by focal cooling of the rapidly beating ventricles of the dog.  Am Heart J. 1958;  55 733-738
• 9 Haissaguerre M, Jais P, Shah DC. et al. . Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.  N Engl J Med. 1998;  339 659-666
• 10 Moe GK, Abildskov JA.. Atrial fibrillation as a self-sustaining arrhythmia independent of focal discharge.  Am Heart J. 1959;  58 59-70
• 11 Wijffels MCEF, Kirchhof CJHJ, Dorland R. et al. . Atrial fibrillation begets atrial fibrillation: a study in awake chronically instrumented goats.  Circulation. 1995;  92 1954-1968
• 12 Nattel S.. New ideas about atrial fibrillation 50 years on.  Nature. 2002;  415 219-226
• 13 Bosch RF, Zeng X, Grammer JB. et al. . Ionic mechanisms of electrical remodeling in human atrial fibrillation.  Cardiovasc Res. 1999;  44 121-131
• 14 Fuster V, Ryden LE, Cannom DS. et al. . ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society.  Circulation. 2006;  114
• 15 Healey JS, Baranchuk A, Crystal E. et al. . Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis.  J Am Coll Cardiol. 2005;  45 1832-1839
• 16 L'Allier PL, Ducharme A, Keller PF. et al. . Angiotensin-converting enzyme inhibition in hypertensive patients is associated with a reduction in the occurrence of atrial fibrillation.  J Am Coll Cardiol. 2004;  44 159-164
• 17 Siu CW, Lau CP, Tse HF.. Prevention of atrial fibrillation recurrence by statin therapy in patients with lone atrial fibrillation after successful cardioversion.  Am J Cardiol. 2003;  9 1343-1345
• 18 Young-Xu Y, Jabbour S, Goldberg R. et al. . Usefulness of statin drugs in protecting against atrial fibrillation in patients with coronary artery disease.  Am J Cardiol. 2003;  92 1379-1383
• 19 Psaty BM, Manolio TA, Kuller LH. et al. . Incidence of and risk factors for atrial fibrillation in older adults.  Circulation. 1997;  96 2455-2461
• 20 Kühlkamp V, Bosch RF, Mewis C. et al. . Use of beta-blockers in atrial fibrillation.  Am J Cardiovasc Drugs. 2002;  2 37-42
• 21 Salem DN, Stein PD, Al-Ahmad A. et al. . Antithrombotic therapy in valvular heart disease – native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126
• 22 Brass LM, Krumholz HM, Scinto JM. et al. . Warfarin use among patients with atrial fibrillation.  Stroke. 1997;  28 2382-2389
• 23 Cohen N, Almoznino-Sarafian D, Alon I. et al. . Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission.  Stroke. 2000;  31 1217-1222
• 24 Kalra L, Yu G, Perez I. et al. . Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness.  BMJ. 2000;  320 1236-1239
• 25 Mant J, Hobbs R, Fletcher K. et al. . Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial.  Lancet. 2007;  370 493-503
• 26 Benavente O, Hart R, Koudstaal P. et al. .Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev 2000
• 27 Hart RG, Halperin JL, McBride R. et al. . Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses.  Arch Neurol. 2000;  57 326-332
• 28 Hart RG, Benavente O, McBride R. et al. . Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.  Ann Intern Med. 1999;  131 492-501
• 29 Go AS, Hylek EM, Chang Y. et al. . Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice?.  JAMA. 2003;  290 2685-2692
• 30 Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group [see comments].  Lancet. 1993;  342 1255-1262
• 31 Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators.  Ann Intern Med. 1992;  116 1-5
• 32 Moulton AW, Singer DE, Haas JS.. Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study.  Am J Med. 1991;  91 156-161
• 33 Boysen G, Nyboe J, Appleyard M. et al. . Stroke incidence and risk factors for stroke in Copenhagen, Denmark.  Stroke. 1988;  19 1345-1353
• 34 Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with aspirin: Stroke Prevention in Atrial Fibrillation III Study. The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators.  JAMA. 1998;  279 1273-1277
• 35 Pengo V, Legnani C, Noventa F. et al. . Oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and risk of bleeding. A Multicenter Inception Cohort Study.  Thromb Haemost. 2001;  85 418-422
• 36 Howard PA, Ellerbeck EF, Engelman KK. et al. . Warfarin for stroke prevention in octogenarians with atrial fibrillation.  Am J Geriatr Cardiol. 2001;  10 139-144
• 37 Gorter JW.. Major bleeding during anticoagulation after cerebral ischemia: patterns and risk factors. Stroke Prevention In Reversible Ischemia Trial (SPIRIT). European Atrial Fibrillation Trial (EAFT) study groups.  Neurology. 1999;  53 1319-1327
• 38 Hylek EM, Skates SJ, Sheehan MA. et al. . An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation.  N Engl J Med. 1996;  335 540-546
• 39 Shireman TI, Howard PA, Kresowik TF. et al. . Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients.  Stroke. 2004;  35 2362-2367
• 40 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
• 41 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
• 42 Hohnloser SH, Kuck KH, Lilienthal J.. Rhythm or rate control in atrial fibrillation – Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial.  Lancet. 2000;  356 1789-1794
• 43 Wyse DG, Waldo AL, DiMarco JP, Domanski MJ. et al. . A comparison of rate control and rhythm control in patients with atrial fibrillation.  N Engl J Med. 2002;  347 1825-1833
• 44 Van Gelder IC, Hagens VE, Bosker HA. et al. . A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation.  N Engl J Med. 2002;  347 1834-1840
• 45 Carlsson J, Miketic S, Windeler J. et al. . 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
• 46 Opolski G, Torbicki A, Kosior DA. et al. . 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
• 47 Steinberg JS, 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
• 48 Pritchett EL, Page RL, Connolly SJ. et al. . Antiarrhythmic effects of azimilide in atrial fibrillation: efficacy and dose-response. Azimilide Supraventricular Arrhythmia Program 3 (SVA-3) Investigators.  J Am Coll Cardiol. 2000;  36 794-802
• 49 Singh BN, Connolly SJ, Crijns HJGM. et al. . Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter.  N Engl J Med. 2007;  357 987-999
• 50 Rawles JM.. What is meant by a „controlled“ ventricular rate in atrial fibrillation?.  Br Heart J. 1990;  63 157-161
• 51 Atwood JE, Sullivan MJ, Forbes SM. et al. . Effect of beta-adrenergic blockade on exercise performance in patiens with chronic atrial fibrillation.  J Am Coll Cardiol. 1987;  10 314-320
• 52 Farshi R, Kistner D, Sarma JS. et al. . Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens.  J Am Coll Cardiol. 1999;  33 304-310
• 53 DiBianco R, Morganroth J, Freitag JA. et al. . Effects of nadolol on the spontaneous and exercise-provoked heart rate of patients with chronic atrial fibrillation receiving stable dosages of digoxin.  Am Heart J. 1984;  108 1121-1127
• 54 Koh KK, Kwon KS, Park HB. et al. . Efficacy and safety of digoxin alone and in combination with low-dose diltiazem or betaxolol to control ventricular rate in chronic atrial fibrillation.  Am J Cardiol. 1995;  75 88-90
• 55 Lundström T, Ryden L.. Ventricular rate control and exercise performance in chronic atrial fibrillation: Effects of diltiazem and verapamil.  J Am Coll Cardiol. 1990;  16 86-90
• 56 Lewis R, Lakhani M, Moreland TA. et al. . A comparison of verapamil and digoxin in the treatment of atrial fibrillation.  Eur Heart J. 1987;  8 148-153
• 57 Atwood JE, Myers JN, Sullivan MJ. et al. . Diltiazem and exercise performance in patients with chronic atrial fibrillation.  Chest. 1988;  9 20-25
• 58 Hnatkova K, Murgatroyd FD, Poloniecki J. et al. . Mid- and long-term similarity of ventricular response to paroxysmal atrial fibrillation: digoxin versus placebo.  Pacing Clin Electrophysiol. 1998;  21 1735-1740
• 59 Brignole M, Menozzi C, Gianfranchi L. et al. . Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with heart failure and chronic atrial fibrillation: a randomized, controlled study.  Circulation. 1998;  98 953-960
• 60 Wood MA, Brown-Mahoney C, Kay GN. et al. . Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis.  Circulation. 2000;  101 1138-1144
• 61 Doshi RN, Daoud EG, Fellows C. et al. . Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (The PAVE Study).  J Cardiovasc Electrophysiol. 2005;  16 1160-1165
• 62 Preliminary report: Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction.  N Engl J Med. 1989;  321 406-412
• 63 Waldo AL, Camm AJ, de H Ryuter. et al. . Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction.  Lancet. 1996;  348 7-12
• 64 Coplen SE, Antman EM, Berlin JA. et al. . Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials.  Circulation. 1990;  82 1106-1116
• 65 Flaker GC, Blackshear JL, McBride R. et al. . Antiarrhythmic drug therapy and cardiac mortality in atrial fibrillation.  J Am Coll Cardiol. 1992;  20 527-532
• 66 Kühlkamp V, Schirdewan A, Stangl K. et al. . Use of Metoprolol CR/XL to maintain sinus rhythm after conversion from persistent atrial fibrillation. A randomized double blind placebo controlled study.  J Am Coll Cardiol. 2000;  36 139-146
• 67 Plewan A, Lehman G, Ndrepepa G. et al. . Maintenance of sinus rhythm after cardioversion of atrial fibrillation: sotalol vs. bisoprolol.  Eur Heart J. 2001;  22 1504-1510
• 68 Graboys TB, Podrid PJ, Lown B.. Efficacy of amiodarone for refractory supraventricular tachyarrhythmias.  Am Heart J. 1983;  106 870-876
• 69 Fetsch T, Breithardt G, Engberding R. et al. . Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial.  Eur Heart J. 2004;  25 1385-1394
• 70 Patten M, Maas R, Bauer P. et al. . Suppression of paroxysmal atrial tachyarrhythmias – results of the SOPAT trial.  Eur Heart J. 2004;  25 1395-1404
• 71 A randomized, placebo-controlled trial of propafenone in the prophylaxis of paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation. UK Propafenone PSVT Study Group.  Circulation. 1995;  92 2550-2557
• 72 Fetsch T, Bauer P, Engberding R. et al. . Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial.  Eur Heart J. 2004;  25 1385-1394
• 73 Pritchett ELC, Wilkinson WE.. Mortality in patients treated with flecainide and encainide for supraventricular arrhythmias.  Am J Cardiol. 1991;  67 976-980
• 74 Alboni P, Botto GL, Baldi N. et al. . Outpatient treatment of recent onset atrial fibrillation with the „Pill-in-the-Pocket“ approach.  N Engl J Med. 2004;  351 2384-2391
• 75 Pappone C, Rosanio S, Augello G. et al. . Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study.  J Am Coll Cardiol. 2003;  42 185-197
• 76 Oral H, Chugh A, Ozaydin M. et al. . Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation.  Circulation. 2006;  114 759-765
• 77 Agnelli G, Gallus A, Goldhaber SZ. et al. . Treatment of proximal deep-vein thrombosis with the oral direct factor Xa inhibitor rivaroxaban (BAY 59–7939): The ODIXa-DVT (Oral Direct Factor Xa Inhibitor BAY 59–7939 in Patients With Acute Symptomatic Deep-Vein Thrombosis) Study.  Circulation. 2007;  116 180-187
• 78 Pappone C, Augello G, Sala S. et al. . A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: The APAF Study.  J Am Coll Cardiol. 2006;  48 2340-2347
• 79 Oral H, Pappone C, Chugh A. et al. . Circumferential pulmonary-vein ablation for chronic atrial fibrillation.  N Engl J Med. 2006;  354 934-941
• 80 Wazni OM, Marrouche NF, Martin DO. et al. . Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial.  JAMA. 2005;  293 2634-2640
• 81 Haissaguerre M, Shah DC, Jais P. et al. . Electrophysiological breakthroughs from the left atrium to the pulmonary veins.  Circulation. 2000;  102 2463-2465
• 82 Pappone C, Rosanio S, Oreto G. et al. . Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation.  Circulation. 2000;  102 2619-2628
• 83 Ouyang F, Bansch D, Ernst S. et al. . Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-lasso technique in paroxysmal atrial fibrillation.  Circulation. 2004;  110 2090-2096
• 84 Nademanee K, McKenzie J, Kosar E. et al. . A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate.  J Am Coll Cardiol. 2004;  43 2054-2056
• 85 Haissaguerre M, Jais P, Shah DC. et al. . Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation.  J Cardiovasc Electrophysiol. 1996;  7 1132-1144
• 86 Pappone C, Santinelli V, Manguso F. et al. . Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation.  Circulation. 2004;  109 327-334
• 87 Scherlag BJ, Yamanashi W, Patel U. et al. . Autonomically induced conversion of pulmonary vein focal firing into atrial fibrillation.  J Am Coll Cardiol. 2005;  45 1878-1886
• 88 Scherlag BJ, Po S.. The intrinsic cardiac nervous system and atrial fibrillation.  Curr Opin Cardiol. 2006;  21 51-54
• 89 Hocini M, Sanders P, Jais P. et al. . Techniques for curative treatment of atrial fibrillation.  J Cardiovasc Electrophysiol. 2004;  15 1467-1471
• 90 Cappato R, Calkins H, Chen SA. et al. . Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.  Circulation. 2005;  111 1100-1105
• 91 Keane D, Reddy V, Ruskin J.. Emerging concepts on catheter ablation of atrial fibrillation from the Tenth Annual Boston Atrial Fibrillation Symposium.  J Cardiovasc Electrophysiol. 2005;  16 1025-1028
• 92 Raviele A, Themistoclakis S, Rossillo A. et al. . Iatrogenic postatrial fibrillation ablation left atrial tachycardia/flutter: how to prevent and treat it?.  J Cardiovasc Electrophysiol. 2005;  16 298-301
• 93 Ernst S, Schluter M, Ouyang F. et al. . Modification of the substrate for maintenance of idiopathic human atrial fibrillation: efficacy of radiofrequency ablation using nonfluoroscopic catheter guidance.  Circulation. 1999;  100 2085-2092
• 94 O'Neill MD, Jais P, Takahashi Y. et al. . The stepwise ablation approach for chronic atrial fibrillation – evidence for a cumulative effect.  J Intervent Cardiac Electrophysiol. 2006;  16 153-167
• 95 Oral H, Knight BP, Ozaydin M. et al. . Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation.  J Am Coll Cardiol. 2002;  40 100-104
• 96 Hsu LF, Jais P, Sanders P. et al. . Catheter ablation for atrial fibrillation in congestive heart failure.  N Engl J Med. 2004;  351 2373-2383
• 97 Perisinakis K, Damilakis J, Theocharopoulos N. et al. . Accurate assessment of patient effective radiation dose and associated detriment risk from radiofrequency catheter ablation procedures.  Circulation. 2001;  104 58-62
• 98 Einstein AJ, Henzlova MJ, Rajagopalan S.. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography.  JAMA. 2007;  298 317-323
• 99 Pappone C, Oral H, Santinelli V. et al. . Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation.  Circulation. 2004;  109 2724-2726
• 100 Cummings JE, Schweikert RA, Saliba WI. et al. . Brief communication: atrial-esophageal fistulas after radiofrequency ablation.  Ann Intern Med. 2006;  144 572-574

1 C = Congestive Heart Failure (Herzinsuffizienz); H = Hypertonie, arterieller Bluthochdruck; A = Alter; D = Diabetes mellitus; S = Schlaganfall

2 Atrial Fibrillation Follow-up Investigation of Rhythm Management

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