Langzeit-Antikoagulation bei Patienten mit Vorhofflimmern

Vorhofflimmern (VHF) ist die häufigste anhaltende atriale Rhythmusstörung. Mit einer Häufigkeit von unter 1 % in der Allgemeinbevölkerung bis 55 Jahre, von 4-6 % bei über 60-Jährigen und von 9-16 % bei über 80-Jährigen steigt die Häufigkeit mit dem Lebensalter an [10]. Eine relevante Komplikation des VHF ist im Vergleich zu Patienten im Sinusrhythmus das häufigere Auftreten arterieller Thromboembolien, die sich in ca. 90 % als ischämische zerebrale Insulte manifestieren. Das individuelle Risiko für einen Schlaganfall schwankt erheblich, wobei wesentliche Risikofaktoren ein höheres Lebensalter und (kardiale) Begleiterkrankungen sind.

Literatur

• 1 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
• 2 Albers G W, Diener H C, Frison L. et al. SPORTIF Executive Steering Committee for the SPORTIF V Investigators (2005) . Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial.  JAMA. 293 690-698
• 3 Atrial F ibrillation 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 Atrial Fibrillation Investigators . Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1,066 patients from three clinical trials.  Arch Intern Med. 1998;  158 1316-1320
• 5 Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators . 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
• 6 EAFT (European Atrial Fibrillation Trial) Study Group . Secondary prevention in non-rheumatic atrial fibrillation after transient ischemic attack or minor stroke.  Lancet. 1993;  342 1255-1262
• 7 Ezekowitz M D, Bridgers S L, James K E. et al . Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation: Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators.  N Engl J Med. 1992;  327 1406-1412
• 8 Fihn S D, Callahan C M, Martin D C. et al, for the National Consortium of Anticoagulation Clinics . The risk for and severity of bleeding complications in elderly patients treated with warfarin.  Ann Intern Med. 1996;  124 970-979
• 9 Fuster V, Ryden L E. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation.  JACC. 2001;  38 1231-1266
• 10 Go A S, Hylek E M, Phillips K A. et al . Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.  JAMA. 2001;  285 2370-2375
• 11 Go A S, Hylek E M, Chang Y. et al . Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice?.  JAMA. 2003;  290 2685-2692
• 12 Gullov A L, Koefoed B G, Petersen P. et al . Fixed minidose 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 AFASAK-2 study).  Arch Intern Med. 1998;  158 1513-1521
• 13 Hart R G, Benavente O, McBride R. et al . Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.  Ann Intern Med. 1999;  131 492-501
• 14 Hart R G, Pearce L A, McBride R. et al . Factors associated with ischemic stroke during Aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials: Stroke Prevention in Atrial Fibrillation (SPAF) Investigators.  Stroke. 1999;  30 1223-1229
• 15 Hellemons B SP, Lanbenberg M, Lodder J. et al . Primary prevention of arterial thromboembolism in non-rheumatic atrial fibrillation in primary care: randomised controlled trial comparing two intensities of coumarin with Aspirin.  BMJ. 1999;  319 958-964
• 16 Hylek E M, Skates S J, Sheehan M A. et al . An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation.  N Engl J Med. 1996;  335 540-546
• 17 Hylek E M, Go A S, Chang Y. et al . Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation.  N Engl J Med. 2003;  349 1019-1026
• 18 Lewalter T, Luderitz B. Vorhofflimmern - interventionelle Differenzialtherapie unter besonderer Berücksichtigung des Lebensalters.  Dtsch Med Wochenschr. 2005;  130 721-725
• 19 Menendez-Jandula B, Souto J C, Oliver A. et al . Comparing Self-Management of Oral Anticoagulant Therapy with Clinic Management.  Ann Intern Med. 2005;  142 1-10
• 20 Patten M, Meinertz T. Medikamentöse antiarrhythmische Therapie - aktuelle Aspekte.  Dtsch Med Wochenschr. 2005;  130 1325-1329
• 21 Petersen P, Boysen G, Godtfredsen J. et al . Placebo-controlled, randomised trial of warfarin and Aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: the Copenhagen AFASAK study.  Lancet. 1989;  1 175-178
• 22 Rockson S G, Albers G W. Comparing the guidelines: anticoagulation therapy to optimize stroke prevention in patients with atrial fibrillation.  J Am Coll Cardiol. 2004;  43 929-935
• 23 Singer D E, Albers G W, Dalen J E. et al . Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.  Chest. 2004;  126 (Suppl 3) 429S-456S
• 24 SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators . Patients with nonvalvular atrial fibrillation at low risk of stroke during treatment with Aspirin: Stroke Prevention in Atrial Fibrillation III study.  JAMA. 1998;  279 1273-1277
• 25 Stellbrink C, Nixdorff U, Hofmann T. et al . ACE (Anticoagulation in Cardioversion using Enoxaparin) Study Group Safety and efficacy of enoxaparin compared with unfractionated heparin and oral anticoagulants for prevention of thromboembolic complications in cardioversion of nonvalvular atrial fibrillation: the Anticoagulation in Cardioversion using Enoxaparin (ACE) trial.  Circulation. 2004;  109 997-1003
• 26 Stroke Prevention in Atrial Fibrillation Investigators . Warfarin versus Aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study.  Lancet. 1994;  343 687-691
• 27 Stroke Prevention in Atrial Fibrillation Investigators . Risk factors for thromboembolism during Aspirin therapy in patients with atrial fibrillation: the Stroke Prevention in Atrial Defibrillation Study.  J Stroke Cerebrovasc Dis. 1995;  5 147-157
• 28 Völler H, Glatz J, Taborski U. et al . Self-Management of oral Anticoagulation in nonvalvular Atrial Fibrillation (SMAAF study).  Z Kardiol. 2005;  94 182-186
• 29 Voss R, Grebe M. Perioperative/peri-interventionelle Antikoagulation.  Dtsch Med Wochenschr. 2005;  130 2209-2212
• 30 van Walraven C, Hart R G, Wells G A. et al . A clinical prediction rule to identify patients with atrial fibrillation and a low risk for stroke while taking aspirin.  Arch Intern Med. 2003;  163 936-943
• 31 Gang B F, Waterman A D, Shannon W, Boechler M, Rich M W, Radford M J. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.  JAMA. 2001;  285 (22) 2864-2870
• 32 Wang T J, Massaro J M, Levy D, Vasan R S, Wolf P A, D’Agostino R B, Larson M G, Kannel W B, Benjamin E J. A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study.   JAMA. 2003;  290 (8) 1049-1056