Antikoagulation bei Vorhofflimmern

Zusammenfassung

Die absolute Arrhythmie (AF) bei Vorhofflimmern ist eine häufige Herzrhythmusstörung. Bei Patienten mit valvulärem (rheumatischem) Vorhofflimmern ist die orale Antikoagulation (OAC) als Thrombembolieprophylaxe etabliert. Nun belegen kontrollierte Studien den Wert einer OAC auch bei nichtvalvulärem Vorhofflimmern und Thrombembolie-Risikofaktoren. Zu den »hig risk«-Faktoren zählen z. B. arterielle Hypertonie RR syst. > 160 mmHg, Z.n. TIA/Apoplex, Frauen > 75 Jahre, reduzierte LV-Funktion. Vor der Entscheidung einer OAC oder einer Antiaggregation z. B. mit Acetylsalicylsäure (ASS), hat die Abschätzung des individuellen Thrombembolie-Risikos zu stehen (Risiko-Stratifizierung). Patienten mit »high risk«-Faktoren müssen antikoaguliert werden. Dabei ist ein höheres Lebensalter (< 80 Jahre) keine Kontraindikation gegen OAC. Allerdings ist bei Patienten > 80 Jahren mit Nebenerkrankungen angesichts einer erhöhten Blutungsrate unter OAC eher eine ASS-Medikation zu empfehlen. Patienten < 65 Jahre ohne klinische oder echokardiographische Risikofaktoren (reduzierte LV-Funktion FS < 25 %) können mit ASS 325 mg/Tag behandelt werden. Bei Patienten zwischen 65 und 80 Jahren ohne Risikofaktoren muss im Einzelfall entschieden werden. Mittels vorherigher TEE-Abklärung kann sich eine Kardioversion sicher durchführen und die Antikoagulationsdauer verkürzen lassen.

Atrial Fibrillation and Anticoagulation

Atrial fibrillation (AF) is a common rhythm disturbance and a major risk factor for stroke. Oral anticoagulation (OAC) is well established in rheumatic valvular AF. Various randomized trials strongly support the use of OAC for the prevention of thrombembolism in patients with nonvalvular atrial fibrillation. Using several clinical and echocardiographical features the individual risk of the patient for embolic events has to be determined before treatment (risk stratification). In high risk patients oral anticoagulation is recommended. Advanced age (< 80 years) is not a contraindication to anticoagulant therapy. But in the very elderly (> 80 years) with a great comorbidity aspirin is preferable (increased risk of major bleedings under OAC). Aspirin is recommended in patients > 65 years without clinical or echocardiographical risk factors (fractional shortening < 25 %) and in patients with contraindications against OAC. In patients aged 65-80 years without other risk factors treatment has to be decided on individual cases. The TEE-guided approach before cardioversion is feasible and safe and may help to reduce the duration of anticoagulation before cardioversion.

Literatur

• 1 Aboaf A P, Wolf P S. Paroxymal atrial fibrillation.  Arch Intern Med. 1996;  156 362-367
• 2 Atrial fibrillation investigators . Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation.  Arch Intern Med. 1994;  155 468-473
• 3 Atrial fibrillation investigators . 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
• 4 Bethge K P, Gonska B D, Jung W, Manz M, Schöls W, Wehr M. Vorhofflimmern: Ein häufiges Problem der Praxis.  Dtsch Med Wschr. 1998;  123 1525-1529
• 5 Brugada R, Roberts R. Molecular biology and atrial fibrillation.  Current opinion in cardiology. 1999;  14 269-273
• 6 Chung M K. Should patients receive anticoagulation for paroxysmal atrial fibrillation?.  Cleve Clin J Med. 2000;  67 5-6
• 7 Connolly S J, Laupacis A, Gent M, Roberts R S, Cairns J A, Joyner C. Canadian atrial fibrillation anticoagulation study (CAFA).  J Am Coll Cardiol. 1991;  18 349-355
• 8 Coulshed N, Epstein E J, McKendrick C S. Systemic embolzation in mitral valve disease.  Br Heart J. 1970;  32 26-34
• 9 Daoud F, Bahu M. Effect of an irregular ventricular rhythm on cardiac output.  Am J Cardiol. 1996;  78 1433-1436
• 10 Ezekowitz M D, Bridgers S L, James K E, Carliner N H, Colling C L, Gornick C C, Krause-Steinrauf H, Kurtzke J F, Nazarian S M, Radford M J. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation.  N Engl J Med. 1992;  327 1406-1412
• 11 Falk R H. Etiology and complications of atrial fibrillation: Insights from pathology studies.  Am J Cardiol. 1998;  82 10N-17N
• 12 Fihn S D, Callahan C M, Martin D C, McDonell M B, White R H. The risk for and severity of bleeding complications in elderly patients treated with warfarin.  Ann Intern Med. 1996;  124 970-979
• 13 Frustaci A, Chimenti C, Belloci F, Morgante F, Russo M A, Maseri A. Histologic substrate of atrial biopsies in patients with lone atrial fibrillation.  Circulation. 1997;  96 1180-1184
• 14 Gershlick A H. Treating the non-electrical risks of atrial fibrillation.  Eur Heart . 1997;  18 C19-26
• 15 Goldenberg G M, Silverstone F A, Rangu S, Leventer S L. Outcomes of long-term anticoagulation in frail elderly patients with atrial fibrillation.  Clinical Drug Investigation. 1999;  17 483-488
• 16 Grant A O. Mechanisms of atrial fibrillation and action of drugs used in its management.  Am J Cardiol. 1998;  82 43N-49N
• 17 Gullov A L, Keofoed B G, Petersen P. Fixed mini-dose warfarin and aspirin alone and in combination versus adjusted-dose warfarin for stroke prevention in atrial fibrillation: Second Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study (the AFASAK2 study).  Arch Intern Med. 1998;  158 1513-1521
• 18 Hellemons B SP, Langenberg M, Lodder J, Vermeer F, Schouten H JA, Lemmens T h, van Ree J W, Knottnerus J A. Primary prevention of arterial thrombembolism in non-rheumatic atrial fibrillation in primary care: randomised controlled trial comparin two intensities of coumadin with aspirin.  BMJ. 1999;  319 958-964
• 19 Hylek E M, Skates S J, Sheehan M A. An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with non-rheumatic atrial fibrillation.  N Engl J Med. 1996;  335 540-546
• 20 Ikeda U, Yamamoto K, Shimada K. Biochemical markers of coagulation activation in mitral stenosis, atrial fibrillation, and cardiomyopathy.  Clin Cardiol. 1997;  20 7-10
• 21 Kannel W B, Wolf P A, Benjamin E J, Levy D. Prevalence, incidence, prognosis and predisposing conditions for atrial fibrillation: Population-based estimates.  Am J Cardiol. 1998;  82 2N-9N
• 22 Klein A, Grimm R, Black I. Cardioversion guided by transoesophageal echocardiography: The acute pilot study. A randomized, controlled trial.  Arch Intern Med. 1997;  126 200-209
• 23 Landefeld C S, Beyth R J. Anticoagulant-related bleeding: Clinical epidemiology, prediction and prevention.  Am J Med. 1993;  95 315-328
• 24 Laupacis A, Albers G, Dalen J, Dunn M J, Jacobson A K. Antithrombotic therapy in atrial fibrillation.  Chest. 1998;  114 579S-589S
• 25 Levy S. Classification system of atrial fibrillation.  Curr Opin Cardiol. 2000;  15 54-57
• 26 Lip G YH, Lowe G DO, Rumley A, Dunn F G. Increased markers of thrombogenesis in chronic atrial fibrillation: Effects of warfarin treatment.  Br Heart Jr. 1995;  73 527-533
• 27 Lüderitz B. Herzrhythmusstörungen. Diagnostik und Therapie (5. ed.) . Springer, Berlin, Heidelberg, New York 1998: 371-382
• 28 Manning W J, Silverman D J, Keighley C S, Oetten P, Douglas P S. Transoesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: Final results of a prospective 4.5 year study.  J Am Coll Cardiol. 1995;  25 1354-1361
• 29 Moreya E, Finkelhor R S, Cebul R D. Limitations of transoesophageal echocardiography in the risk assessment of patients before noncoagulated cardioversion from atrial fibrillation and flutter: An analysis of pooled trials.  Am Heart J. 1995;  129 71-75
• 30 Omran H, Jung W, Illien S, Lüderitz B. Bedeutung der transösophagealen Echokardiographie vor Kardioversion bei Vorhofflimmern.  Dtsch Ärztebl. 2000;  97 B672-674
• 31 Page R L, Wilkinson W E, Clair W K, McCarthy E A, Pritchett E LC. Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia.  Circulation. 1994;  89 224-227
• 32 Petersen P, Boysen G, Godfredsen J, Andersen E D. Placebo-controlled, randomised trial of warfarin and aspirin for the prevention of thrombembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study.  Lancet. 1989;  1 175-179
• 33 Petersen P, Hansen J M. Stroke in thyreotoxicosis with atrial fibrillation.  Stroke. 1988;  19 15-18
• 34 Presti C F, Hart R G. Thyreotoxicosis, atrial fibrillation and embolism, revisited.  Am Heart J. 1989;  117 976-977
• 35 Singer D E. Anticoagulation to prevent stroke in atrial fibrillation and its implications for managed care.  Am J Cardiol. 1998;  81 53C-60C
• 36 Stroke prevention in atrial fibrillation investigators . Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke prevention in atrial fibrillation III randomised clinical trial.  Lancet. 1996;  348 633-638
• 37 Stroke prevention in atrial fibrillation investigators . Risk factors for thromboembolism during aspirin therapy in patients with atrial fibrillation: The Stroke prevention in atrial fibrillation study.  J Stroke Cerebrovasc Dis. 1995;  5 147-157
• 38 Sudlow M, Thomson R, Thwaites B, Rodgers H. Prevalence of atrial fibrillation and elegibility for anticoagulants in the community.  Lancet. 1998;  352 1167-1171
• 39 The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators (BAATAF) . The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation.  N Engl J Med. 1990;  323 1505-1511
• 40 The European Atrial Fibrillation Trial Study Group (EAFT) . Optimal oral anticoagulation therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia.  N Engl J Med. 1995;  333 5-10
• 41 The SPAF III Writing Commitee . Patients with nonvalvular atrial fibrillation at ow risk of stroke during treatment with aspirin.  J Am Med Ass. 1998;  279 1273-1277
• 42 The Stroke Prevention in Atrial Fibrillation Investigators . Adjusted-dose warfarin plus aspirin for high-risk patients with atrial fibrillation.  Lancet. 1996;  348 633-638
• 43 The Stroke Prevention in Atrial Fibrillation Investigators . Stroke prevention in atrial fibrillation study - final results.  Circulation. 1991;  84 527-539
• 44 The Stroke Prevention in Atrial Fibrillation Investigators . Warfarin versus aspirin for prevention of thrombembolism in atrial fibrillation: The stroke prevention in atrial fibrillation II study.  Lancet. 1994;  343 687-691
• 45 Wolf P A, Dawber T R, Thomas E J. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: The Framingham Study.  Neurology. 1978;  28 973-977

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