Antikoagulation mit Vitamin-K-Antagonisten bei nicht-valvulärem Vorhofflimmern – Standortbestimmung 2012

Nach Zulassung des ersten direkten Thrombinantagonisten Dabigatran und des ersten Faktor Xa-Inhibitors Rivaroxaban zur Thromboembolieprophylaxe bei nicht-valvulärem Vorhofflimmern haben die Vitamin-K-Antagonisten (VKA) ihr Alleinstellungsmerkmal als orale Antikoagulantien verloren. Inwieweit sich die neuen Substanzen im primär zugelassenen Indikationsbereich und darüber hinaus durchsetzen, werden die Ergebnisse weiterer Zulassungsstudien, die klinischen Erfahrungen mit den neuen Substanzen und deren Akzeptanz angesichts der hohen Tagestherapiekosten zeigen.

With the introduction of dabigatran and rivaroxaban into routine clinical practice, the vitamin K antagonists (VKA) lost their unique position as oral anticoagulants hitherto for the indication of non-valvular atrial fibrillation. The new oral anticoagulants however have been tested against warfarin (Coumadin^®) only, while in Germany nearly exclusively phenprocoumon (Marcumar^®, Falithrom^®) is used. Phenprocoumon significantly differs in a variety of pharmacological features from the warfarin-type VKA.

The extensive widening of indications for the long-term use of oral anticoagulants based on score systems providing a selectivity as low as 20 % is critically discussed and an algorithm given for the differential use of VKA vs. the new oral anticoagulants focusing on first ever vs. already established therapy, effectiveness of VKA, underlying etiology of atrial fibrillation (e. g. ”lone“ , ”valvular“, and/or ”rheumatic“ atrial fibrillation) and potential contraindications for the use of either anticoagulants.

Key words

vitamin K antagonists - phenprocoumon - dabigatran - rivaroxaban - atrial fibrillation - stability of oral anticoagulation - left atrial appendage closure

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