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Schlaganfallprophylaxe bei Vorhofflimmern

Wann, wie und bei wem?

Stroke prophylaxis in atrial fibrillation

When, how and for whom?

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Zusammenfassung

Eine moderne Schlaganfallprophylaxe bei Patienten mit Vorhofflimmern (VHF) erfolgt stets individualisiert und berücksichtigt das Schlaganfallrisiko, das Blutungsrisiko und den Patientenwunsch. Die Abschätzung des Risikos für kardioembolische Ereignisse gelingt weiterhin anhand des CHA2DS2-VASc-Scores. Die jüngste Leitlinie empfiehlt, die Aufnahme einer oralen Antikoagulation (OAK) ab einem CHA2DS2-VASc-Score von 1 Punkt bei Männern und 2 Punkten bei Frauen zu erwägen. Risikofaktoren für eine Blutung unter einer blutverdünnenden Therapie sollten systematisch erfasst und frühzeitig behandelt werden. Das medikamentöse Therapiespektrum umfasst neben den seit Jahrzehnten etablierten Vitamin-K-Antagonisten neue, direkte orale Antikoagulanzien. Für Patienten mit einem relevanten Schlaganfallrisiko, jedoch einer Kontraindikation für eine OAK, z. B. aufgrund eines hohen, nicht korrigierbaren Blutungsrisikos, stellt der interventionelle Verschluss des linken Vorhofohrs eine Therapiealternative dar. Dieser Artikel bietet eine Übersicht zu Indikationen und Kontraindikationen einer modernen Schlaganfallprophylaxe und diskutiert das Vorgehen in häufigen klinischen Szenarien, wie z. B. die Behandlung von Patienten nach einem Koronarsyndrom, einer koronaren Stentintervention oder einer Katheterablation von VHF.

Abstract

In patients suffering from atrial fibrillation (AF), modern antithrombotic therapy and anticoagulation strategies should be individualized based on shared decision making including patient preferences and the absolute and relative risks of stroke and bleeding. Estimation of the individual risk for stroke is still based on the CHA2DS2-VASc score. Based on the most recent guidelines for the management of AF, oral anticoagulation therapy should be considered for men with a CHA2DS2-VASc score ≥1 and women with a score ≥2, balancing the expected stroke reduction, risk of bleeding and patient preference. Both vitamin K antagonists and novel oral anticoagulants (NOAC) are effective for the prevention of stroke in AF. In AF patients treated with NOAC, kidney function should be regularly monitored to refine risk estimation and to enable dose adaptation. As an alternative to oral anticoagulation therapy, left atrial appendage occlusion may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment. This article provides a review of the indications and contraindications of modern stroke prophylaxis and discusses the approach to frequent clinical scenarios, such as treatment of patients with an acute coronary syndrome, coronary stent intervention or catheter ablation of AF.

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Authors and Affiliations

  1. Abteilung für Kardiologie, Asklepios Klinik St. Georg, Hamburg, Deutschland

    T. Maurer &  C. Sohns

  2. Elektrophysiologie Bremen, Senator Weßling Straße 1, 28277, Bremen, Deutschland

    C. Sohns

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  1. T. Maurer
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Correspondence to C. Sohns.

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T. Maurer und C. Sohns geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Maurer, T., Sohns, C. Schlaganfallprophylaxe bei Vorhofflimmern. Herz 42, 373–379 (2017). https://doi.org/10.1007/s00059-017-4568-z

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