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Behandlung von Vorhofflimmern in der Intensiv- und Notfallmedizin

Treatment of atrial fibrillation in intensive care units and emergency departments

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Zusammenfassung

Hintergrund

Vorhofflimmern ist die häufigste Herzrhythmusstörung auf Notfall- und Intensivstationen und mit einer erhöhten Morbidität und Mortalität assoziiert. Diese Rhythmusstörung kann bei kritisch kranken Patienten zu hämodynamischer Instabilität und kardiogenem Schock führen. Die Mechanismen für die Entstehung von Vorhofflimmern sowie dessen Behandlung unterscheiden sich bei kritisch kranken Patienten grundlegend von denen bei Patienten im ambulanten Umfeld.

Diagnostik und Therapie

Bei neu aufgetretenem Vorhofflimmern sollen die hämodynamischen Auswirkungen beurteilt und die reversible Auslösefaktoren optimiert werden. Hämodynamisch instabile Patienten benötigen eine rasche Behandlung zur Wiederherstellung eines adäquaten Perfusionsdrucks. Die rasche Wiederherstellung des Sinusrhythmus spielt häufig eine zentrale Rolle in der hämodynamischen Stabilisierung. Die elektrische Kardioversion, wenn möglich nach Vorbehandlung mit einem Antiarrhythmikum zur Erhöhung der Erfolgschance, ist eine wichtige therapeutische Maßnahme. Bei stabilen Patienten soll initial eine Frequenzkontrolle mit einem kurzwirksamen intravenösen β-Blocker eingeleitet werden. Eine Konversion in den Sinusrhythmus kann häufig medikamentös versucht werden. Neu steht dafür Vernakalant, ein vorhofspezifischer Multikanalblocker, zur Verfügung.

Evaluation

Nach 48 h mit Vorhofflimmern sollten alle Patienten zur Vermeidung kardioembolischen Ereignisse bezüglich Indikation zur Antikoagulation evaluiert werden. Erfreulicherweise persistiert Vorhofflimmern nach Abheilung der akuten Krankheit selten.

Abstract

Background

Atrial fibrillation is the most common arrhythmia in patients hospitalized in intensive care units and emergency departments and is associated with an increased morbidity and mortality. In critically ill patients, atrial fibrillation can cause hemodynamic instability and cardiogenic shock. The mechanisms and the management of atrial fibrillation are significantly different in critically ill patients compared to outpatients.

Diagnosis and treatment

The initial management includes the evaluation of the hemodynamic consequences of new-onset atrial fibrillation and the optimization of reversible causes. In patients with hemodynamic instability the rapid restoration of an adequate perfusion pressure is the initial goal. Often, a rapid conversion in sinus rhythm is required to achieve hemodynamic stabilization. Electrical cardioversion, if possible performed after pretreatment with an antiarrhythmic drug to increase the success rate, frequently plays a central role in the conversion to sinus rhythm of hemodynamically unstable patients. Stable patients are initially treated with a short-acting intravenous β-blocker to achieve heart rate control. A conversion to sinus rhythm may be achieved pharmacologically with vernakalant, an atrial-specific multichannel blocker.

Evaluation

All patients with atrial fibrillation lasting more than 48 h should be evaluated for anticoagulation in order to reduce cardio-embolic complications. After recovering from the acute illness, atrial fibrillation persists only in a minority of patients.

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Authors and Affiliations

  1. Klinik für Kardiologie, Universitäres Herzzentrum, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz

    M. Arrigo

  2. Herzchirurgische Intensivstation, Institut für Anästhesiologie, Universitätsspital Zürich, Raemistrasse 100, 8091, Zürich, Schweiz

    M. Arrigo, D. Bettex & A. Rudiger

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  1. M. Arrigo
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  2. D. Bettex
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  3. A. Rudiger
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Correspondence to A. Rudiger.

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Interessenkonflikt

A. Rudiger gibt an, Honorare von den Firmen AOP Orphan Pharmaceuticals AG und Baxter Deutschland GmbH für Vorträge erhalten zu haben. Diese Firmen vertreiben Esmolol in Europa.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Arrigo, M., Bettex, D. & Rudiger, A. Behandlung von Vorhofflimmern in der Intensiv- und Notfallmedizin. Med Klin Intensivmed Notfmed 110, 614–620 (2015). https://doi.org/10.1007/s00063-015-0006-2

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  • DOI: https://doi.org/10.1007/s00063-015-0006-2

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