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Frequenzkontrolle versus Rhythmuskontrolle mit und ohne Herzinsuffizienz

Rate versus Rhythm Control with and without Heart Failure

Herz Kardiovaskuläre Erkrankungen volume 33, pages 568–579 (2008)Cite this article

Zusammenfassung

Vorhofflimmern und Herzinsuffizienz sind häufige Erkrankungen, die sich wechselseitig beeinflussen und bedingen können. Die Behandlung von Vorhofflimmern mit Herzinsuffizienz unterscheidet sich von der ohne Herzinsuffizienz in einer Reihe wichtiger Aspekte. Die Behandlung der Grunderkrankung und die Thromboembolieprophylaxe sind Grundbausteine der Therapie. Frequenz- und Rhythmuskontrolle stellen die beiden Behandlungsstrategien von Vorhofflimmern dar. Eine Überlegenheit der Frequenz- oder der Rhythmuskontrolle hinsichtlich der Mortalität konnte auch bei Vorliegen einer Herzinsuffizienz in der aktuellen AF-CHF-Studie (Atrial Fibrillation – Congestive Heart Failure) nicht gezeigt werden. Die Wahl der Therapiestrategie orientiert sich deshalb an der Symptomatik des Patienten mit dem Ziel, die Lebensqualität zu steigern. Entsprechend wird die Frequenzkontrolle in der Regel bei asymptomatischen oder nicht regularisierbaren Patienten mit und ohne Herzinsuffizienz verfolgt. Wenn die medikamentöse Frequenzkontrolle versagt, kann eine His-Ablation mit Schrittmachertherapie durchgeführt werden. Bei strukturell herzgesunden Patienten kommen zur Rhythmuskontrolle Klasse-I-Antiarrhythmika und bei Therapieversagen Amiodaron oder die kurative Katheterablation zum Einsatz. Die medikamentöse Rhythmuskontrolle beschränkt sich bei Vorliegen einer Herzinsuffizienz auf Amiodaron. Für die Vorhofflimmerablation bei Herzinsuffizienz liegen erste positive Daten vor, randomisierte Studien zur Bewertung dieser Therapieoption sind im Gange. Die Rhythmuskontrolle bleibt Therapieprinzip der ersten Wahl bei neu aufgetretenem und symptomatischem paroxysmalem oder persistierendem Vorhofflimmern, unabhängig vom Vorliegen einer Herzinsuffizienz.

Abstract

Atrial fibrillation and congestive heart failure are frequently associated with complex interactions. Patients with both diseases bear a sophisticated therapeutic challenge for the attending physician. The approach to treat atrial fibrillation differs for patients with and without heart failure in several aspects. Basic requirements are the treatment of the underlying diseases and prophylaxis of thromboembolic complications. Rate and rhythm control are the two main therapeutic strategies for atrial fibrillation according to the current guidelines. Large trials including the recently published AF-CHF study (Atrial Fibrillation – Congestive Heart Failure) failed to demonstrate a difference in mortality for both strategies. Thus, the therapeutic decision is mainly based on the patient’s symptoms to improve quality of life. Rate control should be applied to asymptomatic patients or if rhythm control has already failed. If β-blockers and digoxin have failed to control heart rate, His ablation with pacemaker implantation can be considered. In patients without heart disease, class I antiarrhythmic drugs and, in case of ineffectiveness, amiodarone or catheter ablation are recommended for rhythm control. First data concerning catheter ablation of atrial fibrillation in heart failure are promising and randomized studies are on the way. Rhythm control remains first-line therapy in recent-onset or highly symptomatic paroxysmal or persistent atrial fibrillation patients with and without heart failure.

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  1. Klinik für Kardiologie und internistische Intensivmedizin, Klinikum München-Bogenhausen, Städtisches Klinikum München GmbH, München, Germany

    Ellen Hoffmann

  2. Klinik für Kardiologie und internistische Intensivmedizin, Klinikum München-Bogenhausen, Städtisches Klinikum München GmbH, Englschalkinger Straße 77, 81925, München, Germany

    Florian Straube

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Straube, F., Dorwarth, U., Janko, S. et al. Frequenzkontrolle versus Rhythmuskontrolle mit und ohne Herzinsuffizienz. Herz 33, 568–579 (2008). https://doi.org/10.1007/s00059-008-3181-6

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  • DOI: https://doi.org/10.1007/s00059-008-3181-6

Schlüsselwörter:

  • Vorhofflimmern
  • Herzinsuffizienz
  • Frequenzkontrolle
  • Rhythmuskontrolle

Key Words:

  • Atrial fibrillation
  • Heart failure
  • Rate control
  • Rhythm control