Summary
Within the last few years, marked progress has been made in the prevention of thromboembolic events in patients with mechanical heart valves. Thus, therapy has become more effective and is associated with less risk. This includes a number of developments like the introduction of the internationalized, normalized ratio (INR) for determination of the intensity of anticoagulation, the concept of a risk factor-adjusted, prosthesis specific, individualized indication for and intensity of anticoagulation and the possibility for self-determination of anticoagulation intensity by the patient. Prospective, randomized studies on the effect of different intensities of anticoagulation allowed definitions of individualized anticoagulation target levels and were the basis for guidelines on clinical management of anticoagulation. In spite of this progress, thromboembolic complications and anticoagulation associated bleedings are still the most frequent complications after valve replacement. The guidelines published by the professional societies on anticoagulation should be followed more closely in daily clinical practice. The management of oral anticoagulant treatment can be improved by following the concept of a risk factor-adjusted indication for and intensity of oral anticoagulant treatment as well as the use of the INR for monitoring the intensity of anticoagulation. Intensive education of the patient, implementation of self-testing by suitable patients and increasing the frequency of testing can further contribute to improvement.
Zusammenfassung
In den letzten Jahren sind in der Prävention thrombembolischer Ereignisse bei Patienten mit Herzklappenprothesen deutliche Fortschritte gemacht worden, sodass die Therapie effektiver und mit geringerem Risiko durchgeführt werden kann. Hier sind Entwicklungen zu nennen, wie die Einführung der internationalen normalisierten Ratio (INR) für die Intensitätsmessung der Antikoagulation, das Konzept der risikoadjustierten, prothesenspezifischen, individuellen Indikation und die Intensität der Antikoagulation sowie die Möglichkeit zur Selbstbestimmung der Antikoagulation durch den Patienten. Die Durchführung von prospektiven, randomisierten Studien, die den Effekt unterschiedlicher Antikoagulationsintensitäten untersuchten und eine individualisierte Antikoagulation erlauben, bildete die Grundlage für die Erstellung von Richtlinien für die praktische Durchführung der Antikoagulation. Trotz dieser Fortschritte stellen thrombembolische Komplikationen und antikoagulanzienassoziierte Blutungen die häufigsten Komplikationen nach Herzklappenersatz dar. Die in den Richtlinien der Fachgesellschaften festgesetzten Empfehlungen zur Antikoagulation sollten in der täglichen klinischen Praxis breitere Anwendung finden. Die Qualität der Antikoagulation in der Praxis kann durch die Berücksichtigung des Konzepts der risikofaktorenadjustierten Indikation und Intensität der Antikoagulation deutlich verbessert werden, ebenso auch durch die Benutzung des INR-Werts zur Bestimmung der Antikoagulationsintensität. Die intensive Schulung des Patienten und die Möglichkeit zur Bestimmung der Intensität der Antikoagulation durch geeignete Patienten sowie die Erhöhung der Bestimmungsfrequenz sind geeignete Maßnahmen, die Therapie mit Antikoagulanzien zu verbessern.
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Gohlke-Bärwolf, C. Aktuelle Empfehlungen zur Thrombembolieprophylaxe bei Herzklappenprothesen. Z Kardiol 90 (Suppl 6), 112–117 (2001). https://doi.org/10.1007/s003920170018
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DOI: https://doi.org/10.1007/s003920170018