Leitlinien der Europäischen Gesellschaft für Kardiologie

Zusammenfassung

Die Europäische Gesellschaft für Kardiologie (ESC) hat im September 2010 neue Leitlinien für das Management von Vorhofflimmern (VHF) veröffentlicht. Dieses häufige Problem, das etwa ein bis zwei Millionen Menschen in Deutschland betrifft, bedarf einer optimalen Behandlung. Neue Entwicklungen, die sich in den Leitlinien wiederfinden, sind durch weitere Daten unterstützt und ergänzt worden, sodass ein „focussed update“ der ESC-Leitlinien für August 2012 erwartet wird.

Für Neurologen scheinen insbesondere die Empfehlungen der adäquaten Detektion von unterkanntem Vorhofflimmern „silent AF“ als Ursache für Schlaganfälle wichtig, zu dessen Diagnose längere EKG-Überwachung erforderlich ist, was etwa bei Patienten mit TIA/Schlaganfall relevant sein könnte. Eine Behandlung mit Antikoagulanzien wird für die Mehrzahl der Patienten mit VHF empfohlen nach Risiko-Scores. Beinahe alle Patienten mit VHF können von einer Therapie mit Vitamin-K-Antagonisten oder möglicherweise mit einem der neuen Anti-koagulanzien profitieren. Da Dabigatran und Rivaroxaben kürzlich zugelassen wurden, steht zu erwarten, dass das focussed update weitere Empfehlungen für den Einsatz dieser Substanzen geben wird. Eine frequenzregulierende Behandlung sollte der erste Schritt zur Behandlung von symptomatischem VHF sein und sollte zum Ziel eine Ruheherzfreuqenz < 100/min haben. Rhythmuserhaltende Behandlung einschließlich der Katheterablation und Antiarrhythmika wird empfohlen, wenn eine frequenzregulierende Behandlung die Symptome von VHF nicht ausreichend unterdrückt. Laufende kontrollierte Studien könnten klären, ob eine rhythmuserhaltende Behandlung, zusätzlich zu Antikoagulation und Frequenzregulierung gegeben, die häufigen Komplikationen von VHF weiter reduzieren kann. Diese Studien werden noch einige Jahre benötigen, bis sie abgeschlossen sind.

Summary

In September 2010, the European Society of Cardiology issued new guidelines for the management of atrial fibrillation. This common problem, affecting 1 to 2 million patients in Germany, is still in need of optimized therapy. Several new developments which can already be traced in that guideline have found further support by more recent data, so that a focussed update of the ESC guidelines is expected to appear in August 2012. For neurologists, adequate detection of “silent”, undiagnosed atrial fibrillation should be a main concern, and may justify intensified ECG (Holter) monitoring, e.g. in survivors of a “cryptogenic” stroke or TIA. Anticoagulant therapy is recommended for the majority of AF patients, and is guided by clinical risk scores. All but a few “lone AF” patients without concomitant cardiovascular diseases are candidates for oral anticoagulation with a vitamin K antagonist, or possibly, one of the new oral anticoagulants. As both dabigatran and rivaroxaban have recently been approved in the EU, the focussed update may give some initial guidance as to their usage. Rate control is the first approach to improve AF-related symptoms, and should aim for a resting heart rate below 100 bpm. Rhythm control therapy, including catheter ablation and antiarrhythmic drugs, is recommended when rate control therapy does not control symptoms. Ongoing trials may elucidate whether rhythm control therapy can improve outcomes such as stroke or even cardiovascular death on top of current therapy, but these will need a few years to finalise.

Schlüsselwörter

Vorhofflimmern - Antikoagulation - Diagnose - Frequenz- und Rhythmuskontrolle - Schlaganfallprävention

Keywords

Atrial fibrillation - anticoagulant therapy - diagnosis - rate control - rhythm control - stroke - stroke prevention

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