Der Klinikarzt 2017; 46(05): 236-240
DOI: 10.1055/s-0043-109481
Serie
© Georg Thieme Verlag Stuttgart · New York

Antikoagulation bei Risikopatienten

Ältere Patienten und Patienten mit NiereninsuffizienzAnticoagulation therapy in patients at risk - older patients and patients with renal failure
Ralf Zahn
1   Herzzentrum, Kardiologie, Klinikum der Stadt Ludwigshafen
,
Thomas Kleemann
1   Herzzentrum, Kardiologie, Klinikum der Stadt Ludwigshafen
,
Nicolas Werner
1   Herzzentrum, Kardiologie, Klinikum der Stadt Ludwigshafen
,
Uwe Zeymer
1   Herzzentrum, Kardiologie, Klinikum der Stadt Ludwigshafen
› Author Affiliations
Further Information

Publication History

Publication Date:
23 May 2017 (online)

Bei Patienten mit Vorhofflimmern und einem CHA2DS2-VASc-Score ≥ 2 sind zur antithrombotischen Therapie die neueren oralen Antikoagulanzien (NOAK) Mittel der ersten Wahl. Ältere Patienten und Patienten mit Niereninsuffizienz stellen ein Risikokollektiv dar, das im Alltag seltener als möglich mit einer antithrombotischen Therapie versorgt wird. Bei älteren Patienten wird oft die Gefahr einer antithrombotischen Therapie überschätzt. Die NOAK sind gerade bei älteren Menschen effektiv und im Alltag leichter zu handhaben als Vitamin-K-Antagonisten. Bei Niereninsuffizienz muss sehr auf die Zulassungsbestimmungen der einzelnen NOAK geachtet und im Grenzbereich häufiger eine Kontrolle der Nierenfunktionswerte durchgeführt werden. Jedoch scheint es unter den NOAK zu einer langsameren Progredienz der Niereninsuffizienz zu kommen im Vergleich zu den Vitamin-K-Antagonisten. Bei Dialysepatienten ist die Datenlage nicht eindeutig, sodass zurzeit keine eindeutigen Empfehlungen zu einer antithrombotischen Therapie gegeben werden können.

In patients with atrial fibrillation and an elevated CHA2DS2-VASc score the new oral anticoagulants (NOAC) are the method of choice for antithrombotic therapy. Older patients and patients with renal failure are a risk population, which in clinical practice is treated less often with recommended antithrombotic therapy. In older patients, the risk of an antithrombotic therapy is often judged too high. NOAC are especially in older patients highly effective and easier to handle than Vitamin K antagonists. In patients with renal failure, one must obey the different admissions of the different NOAC and to control the renal function in shorter intervals. NOAC seem to be associated with a slower progression of renal insufficiency compared to Vitamin K antagonists. In patients on haemodialysis there are no clear recommendations on antithrombotic therapy due to insufficient data.

 
  • Literatur

  • 1 Camm AJ, Lip GY, De Caterina R et al 2012; focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719-2747
  • 2 Kirchhof P, Benussi S, Kotecha D et al 2016; ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18: 1609-1678
  • 3 Ruff CT, Giugliano RP, Braunwald E et al Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383: 955-962
  • 4 Kirchhof P, Ammentorp B, Darius H et al Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events - European Registry in Atrial Fibrillation (PREFER in AF). Europace 2014; 16: 6-14
  • 5 Kirchhof P, Schmalowsky J, Pittrow D et al Management of patients with atrial fibrillation by primary-care physicians in Germany: 1-year results of the ATRIUM registry. Clin Cardiol 2014; 37: 277-284
  • 6 Man-Son-Hing M, Nichol G, Lau A et al Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677-685
  • 7 Bahri O, Roca F, Lechani T et al Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: comparisons of resident characteristics and physician attitude. J Am Geriatr Soc 2015; 63: 71-76
  • 8 Gallagher AM, Rietbrock S, Plumb J et al Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?. J Thromb Haemost 2008; 6: 1500-1506
  • 9 January CT, Wann LS, Alpert JS et al 2014; AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130: 2071-2104
  • 10 Connolly SJ, Ezekowitz MD, Yusuf S et al Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151
  • 11 Patel MR, Mahaffey KW, Garg J et al Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-891
  • 12 Granger CB, Alexander JH, McMurray JJ et al Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981-992
  • 13 Giugliano RP, Ruff CT, Braunwald E et al Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369: 2093-2104
  • 14 Heidbuchel H, Verhamme P, Alings M et al Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17: 1467-1507
  • 15 Reinecke H, Brand E, Mesters R et al Dilemmas in the management of atrial fibrillation in chronic kidney disease. J Am Soc Nephrol 2009; 20: 705-711
  • 16 Bonde AN, Lip GY, Kamper AL et al Net clinical benefit of antithrombotic therapy in patients with atrial fibrillation and chronic kidney disease: a nationwide observational cohort study. J Am Coll Cardiol 2014; 64: 2471-2482
  • 17 Chan KE, Lazarus JM, Thadhani R et al Warfarin use associates with increased risk for stroke in hemodialysis patients with atrial fibrillation. J Am Soc Nephrol 2009; 20: 2223-2233
  • 18 Wizemann V, Tong L, Satayathum S et al Atrial fibrillation in hemodialysis patients: clinical features and associations with anticoagulant therapy. Kidney Int 2010; 77: 1098-1106
  • 19 Shah M, Avgil Tsadok M, Jackevicius CA et al Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis. Circulation 2014; 129: 1196-1203
  • 20 Li J, Wang L, Hu J et al Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis. Nutr Metab Cardiovasc Dis 2015; 25: 706-713
  • 21 Qamar A, Bhatt DL. Stroke prevention in atrial fibrillation in patients with chronic kidney disease. Circulation 2016; 133: 1512-1515
  • 22 Bohm M, Ezekowitz MD, Connolly SJ et al Changes in renal function in patients with atrial fibrillation: an analysis from the RE-LY trial. J Am Coll Cardiol 2015; 65: 2481-2493
  • 23 Murshed M, Schinke T, McKee MD et al Extracellular matrix mineralization is regulated locally; different roles of two gla-containing proteins. J Cell Biol 2004; 165: 625-630
  • 24 Holmes Jr DR, Kar S, Price MJ et al Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014; 64: 1-12
  • 25 Holmes DR, Reddy VY, Turi ZG et al Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374: 534-542
  • 26 Reddy VY, Mobius-Winkler S, Miller MA et al Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol 2013; 61: 2551-2556