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Der Klinikarzt 2016; 45(06): 291-299
DOI: 10.1055/s-0042-108397
Schwerpunkt
© Georg Thieme Verlag Stuttgart · New York

Der Patient mit neu aufgetretenem Vorhofflimmern auf der Intensivstation

Was tun?The patient with new-onset atrial fibrillation in the ICU – What to do?
Tobias Willich
1   Medizinische Klinik II, St. Vincenz Krankenhaus Paderborn, Paderborn
,
Andreas Goette
1   Medizinische Klinik II, St. Vincenz Krankenhaus Paderborn, Paderborn
› Institutsangaben
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Publikationsdatum:
29. Juni 2016 (online)

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Vorhofflimmern (VHF) ist die häufigste neu auftretende Rhythmusstörung auf der Intensivstation und ist mit einer erhöhten Mortalität assoziiert. Die Schwere der zugrundeliegenden Erkrankung, eine systemische Inflammation (SIRS) und Sepsis sowie das Alter sind die größten Risikofaktoren. Nach herzchirurgischen oder thoraxchirurgischen Operationen tritt VHF ebenfalls gehäuft auf. Neben der Initialtherapie unterscheidet man in der Behandlung eine antithrombotische, frequenzkontrollierende und rhythmuserhaltende Therapie. Bei der Initialtherapie steht die Wiederherstellung eines suffizienten Kreislaufes und die Optimierung und Behandlung beeinflussbarer Auslöser im Vordergrund. Bei hämodynamischer Instabilität wird eine dringende elektrische Kardioversion empfohlen, ebenso bei Patienten mit VHF und Präexzitation bei Wolff-Parkinson-White-Syndrom. Bei hämodynamischer Stabilität kann auch eine pharmakologische Kardioversion durchgeführt werden. Bei der Wahl des antiarrhythmischen Medikaments bei kritisch kranken Patienten kommt aufgrund der jeweiligen Kontraindikationen bis auf Ausnahmen nur Amiodaron in Betracht. Bei erhöhtem Risiko für thrombembolische Komplikationen ist eine Antikoagulation notwendig. Eine Risikoabschätzung erfolgt dabei am einfachsten über den CHADS2-Score.

Atrial fibrillation (AF) is the most common new onset arrhythmia in the ICU and is associated with increased mortality. The severity of the underlying disease, systemic inflammation (SIRS) and sepsis and age are the biggest risk factors. After cardiac surgery or thoracic surgical operations VHF also occurs frequently. In addition to the initial treatment, there is antithrombotic therapy, rate und rhythm management.

First step in the initial treatment is the restoration of a sufficient circuit and optimization or treatment of modifiable risk factors. Urgent direct current cardioversion is recommended for patients with AF when haemodynamic instability is present, also in patients with AF and pre-excitation in Wolff-Parkinson-White syndrome. Pharmacological cardioversion may be considered in patients with AF when haemodynamic stability is present. When choosing the antiarrhythmic agent in critically ill patients due to the specific contraindications only amiodarone is considered with exceptions. In patients with increased risk of thrombo-embolism events anticoagulation is recommended. The simplest risk assessment scheme is the CHADS2-Score.

Key words

Atrial fibrillation - cardioversion - rhythm control - rate control - anticoagulation
 

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