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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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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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