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Therapie des Vorhofflimmern beim kritisch Kranken

Therapy of atrial fibrillation in the critically ill

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Zusammenfassung

Vorhofflimmern (VHF) ist die häufigste Rhythmusstörung auf der Intensivstation und ist mit einer erhöhten Mortalität assoziiert. Es werden fünf verschiedene Formen des VHF unterteilt: erstdiagnostiziertes, paroxysmales, persistierendes, lang-anhaltend persistierendes und permanentes VHF. Neben der Initialtherapie unterscheidet man in der Behandlung eine antithrombotische, frequenzkontrollierende und rhythmuserhaltende Therapie. Die Behandlung von Komorbiditäten ist Teil des Therapiekonzeptes. Bei erhöhtem Risiko für thrombembolische Komplikationen ist eine Antikoagulation notwendig. Eine Risikoabschätzung erfolgt dabei am einfachsten über den CHADS2-Score. Initial steht in der Behandlung die Frequenzkontrolle im Vordergrund. Bei hämodynamischer Instabilität wird eine dringende elektrische Kardioversion empfohlen, ebenso bei VHF und Präexzitation bei Wolff-Parkinson-White-Syndrom. Bei hämodynamischer Stabilität kann auch eine pharmakologische Kardioversion durchgeführt werden. Für kritisch Kranke kommt als Antiarrhythmikum aufgrund der jeweiligen Kontraindikationen bis auf Ausnahmen nur Amiodaron in Betracht.

Abstract

Atrial fibrillation (AF) is the most common form of arrhythmia in the intensive care unit (ICU) and is associated with increased mortality. A total of five types of AF can be distinguished: initially diagnosed, paroxysmal, persistent, long-standing persistent and permanent AF. In addition to the initial treatment, antithrombotic therapy, rate and rhythm management can be used. The treatment of comorbidities is part of the patient management and for patients with increased risk of thromboembolic events anticoagulation is recommended. The simplest risk assessment scheme is the CHADS score. In the acute setting rate control is important. Direct current cardioversion is urgently recommended for patients with AF when hemodynamic instability is present even in patients with AF and pre-excitation in Wolff-Parkinson-White syndrome. Pharmacological cardioversion may be considered in patients with AF when hemodynamic stability is present. When choosing the antiarrhythmic agent for critically ill patients only amiodarone can be considered with some exceptions due to the specific contraindications.

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  1. Medizinische Klinik II, St. Vincenz Krankenhaus Paderborn, Am Busdorf 2, 33098, Paderborn, Deutschland

    T. Willich,  M. Hammwöhner &  A. Goette

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  1. T. Willich
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  2. M. Hammwöhner
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  3. A. Goette
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Willich, T., Hammwöhner, M. & Goette, A. Therapie des Vorhofflimmern beim kritisch Kranken. Med Klin Intensivmed Notfmed 107, 368–376 (2012). https://doi.org/10.1007/s00063-012-0082-5

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