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Antikoagulation bei Vorhofflimmern

Anticoagulation with atrial fibrillation

  • BEITRAG ZUM THEMENSCHWERPUNKT
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Summary

Atrial fibrillation is associated with a relevant risk for ischemic stroke: Observational studies suggest that one in four to five strokes is due to atrial fibrillation. Depending on the risk profile of an individual patient, the yearly risk for a stroke is between 2% and 14%. Continuous oral anticoagulation is indicated if atrial fibrillation is accompanied by at least one additional risk factor for thromboembolic complications. This recommendation is supported by several large randomized trials. Due to their low therapeutic range, vitamin K antagonists (phenprocoumon, warfarin, and others), the most commonly used oral anticoagulants, require regular anticoagulation monitoring. If well-controlled (international normalized ratio 2–3, in elderly patients preferably 2–2.5), oral anticoagulation prevents more than half of ischemic strokes related to atrial fibrillation, while bleeding complications are rare. In the follow-up of low risk patients (CHADS2-Score 0), oral anticoagulation becomes necessary when risk factors for thromboembolic complications develop. If a stroke occurs during oral anticoagulation and an INR>2 in a patient with atrial fibrillation, other causes than thromboembolic events should be considered. New anticoagulants—especially direct thrombin antagonists—are currently evaluated in clinical trials and may in the future facilitate anticoagulation in patients with atrial fibrillation.

Zusammenfassung

Wenn Vorhofflimmern und mindestens ein weiterer Risikofaktor für thrombembolische Komplikationen vorliegt, ist eine dauerhafte orale Antikoagulation indiziert, um Schlaganfälle zu verhindern. Diese erfolgt in aller Regel mit Vitamin-K-Antagonisten, deren Wirkung regelmäßig durch die Messung der INR kontrolliert werden muss. Durch eine sorgfältig kontrollierte Einstellung des INR-Wertes zwischen 2–3 (bei älteren Patienten vorzugsweise zwischen 2–2,5) überwiegt der Nutzen (Verhinderung von Schlaganfällen) eindeutig die Gefahr von schweren Blutungskomplikationen. In der Praxis sollte darauf geachtet werden, ob Niedrigrisikopatienten (CHADS2-Score von 0) im Verlauf der Zeit Begleiterkrankungen entwickeln, die ihr Thromboembolierisiko erhöhen und eine orale Antikoagulation notwendig machen. Tritt ein Schlaganfall bei einer oralen Antikoagulation mit einer INR>2 auf, so sollte bei Vorhofflimmer-Patienten auch an andere Ursachen des Schlaganfalls gedacht werden. In der klinischen Erprobung befinden sich neue oral verfügbare Antikoagulantien, insbesondere direkte Thrombin-Inhibitoren.

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Literatur

  1. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE (2001) Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Jama 285:2370–2375

    Article  PubMed  CAS  Google Scholar 

  2. Kirchhof P, Eckardt L, Loh P, Weber K, Fischer RJ, Seidl KH, Böcker D, Breithardt G, Haverkamp W, Borggrefe M (2002) Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomised trial. Lancet 360:1275–1279

    Article  PubMed  Google Scholar 

  3. Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK et al (2005) Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 352:1861–1872

    Article  PubMed  CAS  Google Scholar 

  4. Hsu LF, Jais P, Sanders P, Garrigue S, Hocini M, Sacher F, Takahashi Y, Rotter M, Pasquie JL, Scavee C et al (2004) Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 351:2373–2383

    Article  PubMed  CAS  Google Scholar 

  5. Pappone C, Rosanio S, Augello G, Gallus G, Vicedomini G, Mazzone P, Gulletta S, Gugliotta F, Pappone A, Santinelli V et al (2003) Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol 42:185–197

    Article  PubMed  Google Scholar 

  6. Oral H, Pappone C, Chugh A, Good E, Bogun F, Pelosi F Jr, Bates ER, Lehmann MH, Vicedomini G, Augello G et al (2006) Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl J Med 354:934–941

    Article  PubMed  CAS  Google Scholar 

  7. Cox JL (2004) Cardiac surgery for arrhythmias. Pacing Clin Electrophysiol 27:266–282

    Article  PubMed  Google Scholar 

  8. Israel CW, Gronefeld G, Ehrlich JR, Li YG, Hohnloser SH (2004) Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol 43:47–52

    Article  PubMed  Google Scholar 

  9. Fetsch T, Bauer P, Engberding R, Koch HP, Lukl J, Meinertz T, Oeff M, Seipel L, Trappe HJ, Treese N et al (2004) Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial. Eur Heart J 25:1385–1394

    Article  PubMed  Google Scholar 

  10. AFFIRM, Investigators (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 347:1825–1833

    Article  Google Scholar 

  11. Van Gelder I, Hagens VE, Bosker HA, Kingma H, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermanns AJM, Tijssen JGP et al (2002) A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med 347:1834–1840

    Article  PubMed  Google Scholar 

  12. Sherman DG, Kim SG, Boop BS, Corley SD, Dimarco JP, Hart RG, Haywood LJ, Hoyte K, Kaufman ES, Kim MH et al (2005) Occurrence and characteristics of stroke events in the Atrial Fibrillation Follow-up Investigation of Sinus Rhythm Management (AFFIRM) study. Arch Intern Med 165:1185–1191

    Article  PubMed  Google Scholar 

  13. Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G (1996) Stroke recurrence in patients with patent foramen ovale: the Lausanne Study. Lausanne Stroke with Paradoxal Embolism Study Group. Neurology 46:1301–1305

    PubMed  CAS  Google Scholar 

  14. Jorgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS (1996) Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke 27:1765–1769

    PubMed  CAS  Google Scholar 

  15. Conway DS, Pearce LA, Chin BS, Hart RG Lip GY (2003) Prognostic value of plasma von Willebrand factor and soluble P-selectin as indices of endothelial damage and platelet activation in 994 patients with nonvalvular atrial fibrillation. Circulation 107:3141–3145

    Article  PubMed  CAS  Google Scholar 

  16. Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22:983–988

    PubMed  CAS  Google Scholar 

  17. Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy, D (1998) Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98:946–952

    PubMed  CAS  Google Scholar 

  18. Hart RG, Benavente O, McBride R, Pearce LA (1999) Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 131:492–501

    PubMed  CAS  Google Scholar 

  19. Hylek EM, Skates SJ, Sheehan MA, Singer DE (1996) An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med 335:540–546

    Article  PubMed  CAS  Google Scholar 

  20. Hylek EM, Go AS, Chang Y, Jensvold NG, Henault LE, Selby JV, Singer DE (2003) Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 349:1019–1026

    Article  PubMed  CAS  Google Scholar 

  21. Rockson SG, Albers GW (2004) Comparing the guidelines: anticoagulation therapy to optimize stroke prevention in patients with atrial fibrillation. J Am Coll Cardiol 43:929–935

    Article  PubMed  Google Scholar 

  22. Taylor FC, Cohen H, Ebrahim S (2001) Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation. Bmj 322:321–326

    Article  PubMed  CAS  Google Scholar 

  23. Hohnloser, SH, Connolly SJ (2003) Combined antiplatelet therapy in atrial fibrillation: review of the literature and future avenues. J Cardiovasc Electrophysiol 14:S60–S63

    Article  PubMed  Google Scholar 

  24. Olsson SB (2003) Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet 362:1691–1698

    Article  PubMed  CAS  Google Scholar 

  25. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. Jama 285:2864–2870

    Article  PubMed  CAS  Google Scholar 

  26. Man-Son-Hing M, Laupacis A (2003) Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians’ fears often unfounded. Arch Intern Med 163:1580–1586

    Article  PubMed  Google Scholar 

  27. Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S (2004) Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126:287S–S310S

    Article  PubMed  CAS  Google Scholar 

  28. Gurm HS, Bhatt DL (2005) Thrombin, an ideal target for pharmacological inhibition: a review of direct thrombin inhibitors. Am Heart J 149:S43–S53

    Article  PubMed  CAS  Google Scholar 

  29. Albers GW (2004) Stroke prevention in atrial fibrillation: pooled analysis of SPORTIF III and V trials. Am J Manag Care 10:S462–S469; discussion S469–S473

    PubMed  Google Scholar 

  30. Albers GW, Diener HC, Frison L, Grind M, Nevinson M, Partridge S, Halperin JL, Horrow J, Olsson SB, Petersen P et al (2005) Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. Jama 293:690–698

    Article  PubMed  Google Scholar 

  31. Ostermayer SH, Reisman M, Kramer PH, Matthews RV, Gray WA, Block PC, Omran H, Bartorelli AL, Della Bella P, Di Mario C et al (2005) Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials. J Am Coll Cardiol 46:9–14

    Article  PubMed  Google Scholar 

  32. Lown B, Perlroth M, Kaidbey S, Abe T, Harken DE (1963) Cardioversion of atrial firbrillation. A report on the treatment of 65 episodes in 59 patients. N Engl J Med 269:325–331

    Article  PubMed  CAS  Google Scholar 

  33. Bjerkelund CJ, Orning OM (1969) The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation. Am J Cardiol 23:208–216

    Article  PubMed  CAS  Google Scholar 

  34. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S et al (2001) ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to develop guidelines for the management of patients with atrial fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J 22:1852–1923

    Article  PubMed  CAS  Google Scholar 

  35. Weigner MJ, Thomas LR, Patel U, Schwartz JG, Burger AJ, Douglas PS, Silverman DI, Manning WJ (2001) Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: short-term safety and impact on maintenance of sinus rhythm at 1 year. Am J Med 110:694–702

    Article  PubMed  CAS  Google Scholar 

  36. Nabavi DG, Allroggen A, Reinecke H, Kemeny V, Droste DW, Breithardt G, Ringelstein EB (2001) Absence of circulating microemboli in patients with atrial fibrillation undergoing electric cardioversion. Cerebrovasc Dis 11:95–99

    Article  PubMed  CAS  Google Scholar 

  37. Nattel S, Opie LH (2006) Controversies in atrial fibrillation. Lancet 367:262–272

    Article  PubMed  Google Scholar 

  38. http://en.sanofi-aventis.com/press/ppc_2647.asp, Zugriff am 18. 3. 2006

  39. http://www.cardiosource.com/pops/trialSum.asp?trialID=1397, Zugriff am 18. 3. 2006

  40. http://www.cardiosource.com/rapidnewssummaries/index.asp? EID=22&DoW=Tues&SumID=157, Zugriff am 18. 3. 2006

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Authors and Affiliations

  1. Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie, Kompetenznetz Vorhofflimmern, Universitätsklinikum Münster, Albert-Schweitzer-Straße 33, 48149, Münster, Germany

    S. Zellerhoff &  P. Kirchhof

  2. Klinik für Kardiologie und Pulmonologie, Universitätsklinikum Magdeburg, Magdeburg

    A. Goette

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  1. S. Zellerhoff
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  2. A. Goette
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  3. P. Kirchhof
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Correspondence to P. Kirchhof.

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Unterstützt vom Kompetenznetz Vorhofflimmern

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Zellerhoff, S., Goette, A. & Kirchhof, P. Antikoagulation bei Vorhofflimmern. Herzschr. Elektrophys. 17, 89–94 (2006). https://doi.org/10.1007/s00399-006-0515-z

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  • DOI: https://doi.org/10.1007/s00399-006-0515-z

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