Skip to main content
SpringerLink
Log in

Schlaganfall und Vorhofflimmern

Stroke and atrial fibrillation

  • Schwerpunkt
  • Published:
Herzschrittmachertherapie + Elektrophysiologie Aims and scope Submit manuscript

Zusammenfassung

Schlaganfälle sind zu etwa 80% ischämischer und zu 20% hämorrhagischer Natur. Die häufigste Ursache für eine zerebrale Ischämie ist ein kardioembolischer Verschluss einer Hirnarterie bei Patienten mit Vorhofflimmern (VHF). Dieser Artikel stellt die wichtigsten Gesichtspunkte bei der Therapie von Patienten mit Schlaganfall und VHF auf der Grundlage der aktuellen Leitlinien der Deutschen Gesellschaft für Neurologie (DGN) und der Europäischen Schlaganfallorganisation (ESO) vor: Bei Patienten mit VHF wird eine orale Antikoagulation mit einer Ziel-INR von 2,0–3,0 empfohlen. Nach TIA oder leichtem ischämischem Insult und VHF kann die orale Antikoagulation innerhalb der ersten Woche begonnen werden. Die Kombination von ASS und Clopidogrel ist einer oralen Antikoagulation unterlegen.

Abstract

Approximately 80% of all strokes are ischemic, the remaining being hemorrhagic. The major reason for cerebral ischemia is occlusion of a cerebral artery by a cardiac thrombus in a patient with atrial fibrillation. This article focuses on the therapeutic management of patients with cerebral ischemia due to atrial fibrillation and is based on the guidelines of the German Society of Neurology and the European Stroke Organization: Patients with cerebral ischemia and atrial fibrillation require oral anticoagulation with an INR of 2.0–3.0. After a TIA (transient ischemic attack) or minor ischemic stroke, anticoagulation can be initiated within the first week after the stroke. Combination therapy of aspirin and clopidogrel is less effective than oral anticoagulation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Akins PT, Feldman HA, Zoble RG et al (2007) Secondary stroke prevention with ximelagatran versus warfarin in patients with atrial fibrillation: pooled analysis of SPORTIF III and V clinical trials. Stroke 38:874–880

    Article  CAS  PubMed  Google Scholar 

  2. Bath PM, Lindenstrom E, Boysen G et al (2001) Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial. Lancet 358:702–710

    Article  CAS  PubMed  Google Scholar 

  3. Berge E, Abdelnoor M, Nakstad PH et al (2000) Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. haest study group. heparin in acute embolic stroke trial. Lancet 355:1205–1210

    Article  CAS  PubMed  Google Scholar 

  4. Christensen H, Fogh Christensen A, Boysen GG (2005) Abnormalities on ECG and telemetry predict stroke outcome at 3 months. J Neurol Sci 234:99–103

    Article  PubMed  Google Scholar 

  5. Connolly S, Pogue J, Hart R et al (2006) Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 367:1903–1912

    Article  CAS  PubMed  Google Scholar 

  6. de Bruijn SF, Agema WR, Lammers GJ et al (2006) Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. Stroke 37:2531–2534

    Article  Google Scholar 

  7. Diener HC, Ringelstein EB, von Kummer R et al (2001) Treatment of acute ischemic stroke with the low-molecular-weight heparin certoparin: results of the TOPAS trial. Therapy of patients with acute stroke (TOPAS) investigators. Stroke 32:22–29

    CAS  PubMed  Google Scholar 

  8. Douen AG, Pageau N, Medic S (2008) Serial electrocardiographic assessments significantly improve detection of atrial fibrillation 2.6-fold in patients with acute stroke. Stroke 39:480–482

    Article  PubMed  Google Scholar 

  9. EAFT Group (1993) Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 342:1255–1262

    Google Scholar 

  10. Ferro JM (2003) Cardioembolic stroke: an update. Lancet Neurol 2:177–188

    Article  PubMed  Google Scholar 

  11. Ferro JM (2004) Patterns of ischaemic cerebral diseases. J Neurol 251:1–10

    Article  PubMed  Google Scholar 

  12. Fuster V, Ryden LE, Cannom DS et al (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation [full text: 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 (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society]. Europace 8(9):651–745

    Article  PubMed  Google Scholar 

  13. Gage BF, Waterman AD, Shannon W et al (2001) Validation of clinical classification schemes for predicting stroke results from the national registry of atrial fibrillation. J Am Med Assoc 285:2864–2870

    Article  CAS  Google Scholar 

  14. Grau AJ, Weimar C, Buggle F et al (2001) Risk factors, outcome and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 32:2559–2566

    Article  CAS  PubMed  Google Scholar 

  15. Gubitz G, Sandercock P, Counsell C (2004) Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev:CD000024

    Google Scholar 

  16. Gunalp M, Atalar E, Coskun F et al (2006) Holter monitoring for 24 hours in patients with thrombo-embolic stroke and sinus rhythm diagnosed in the emergency department. Adv Ther 23:854–860

    Article  PubMed  Google Scholar 

  17. Hardman SMC, Cowie MR (1999) Anticoagulation in heart disease. Br Med J 318:238–244

    CAS  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  19. Hylek EM, Evans-Molina C, Shea C et al (2007) Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 115:2689–2696

    Article  CAS  PubMed  Google Scholar 

  20. International Stroke Trial Collaborative Group (1997) The International Stroke Trial (IST): a rando-mised trial if aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute is-chaemic stroke. Lancet 349:1569–1581

    Article  Google Scholar 

  21. Kapral MK, Silver FL (1999) Preventive health care, 1999 update: 2. Echocardiography for the detection of a cardiac source of embolus in patients with stroke. Canadian task force on preventive health care. CMAJ 161:989–996

    CAS  PubMed  Google Scholar 

  22. Kay R, Wong KS, Yu YL et al (1995) Low-molecular-weight heparin for the treatment of acute ischemic stroke. N Engl J Med 333:1588–1593

    Article  CAS  PubMed  Google Scholar 

  23. Khaw KT (1996) Epidemiology of stroke. J Neurol Neurosurg Psychiatry 61:333–338

    Article  CAS  PubMed  Google Scholar 

  24. Lerakis S, Nicholson WJ (2005) Part I: use of echocardiography in the evaluation of patients with suspected cardioembolic stroke. Am J Med Sci 329:310–316

    Article  PubMed  Google Scholar 

  25. Liao J, Khalid Z, Scallan C et al (2007) Noninvasive cardiac monitoring for detecting paroxysmal atrial fibrillation or flutter after acute ischemic stroke: a systematic review. Stroke 38:2935–2940

    Article  PubMed  Google Scholar 

  26. Lovett J, Coull A, Rothwell P (2004) Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. J Neurol 62:569–573

    CAS  Google Scholar 

  27. Mant J, Hobbs F, Fletcher K et al (2007) Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 370:493–503

    Article  CAS  PubMed  Google Scholar 

  28. Nieuwlaat R, Capucci A, Camm AJ et al (2005) Atrial fibrillation management: a prospective survey in ESC member countries: the Euro heart survey on atrial fibrillation. Eur Heart J 26:2422–2434

    Article  PubMed  Google Scholar 

  29. Paciaroni M, Agnelli G, Micheli S et al (2007) Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke 38:423–430

    Article  CAS  PubMed  Google Scholar 

  30. Rash A, Downes T, Portner R et al (2007) A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing 36:151–156

    Article  PubMed  Google Scholar 

  31. Saxena R, Koudstaal PJ (2004) Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Stroke 35:1782–1783

    Article  Google Scholar 

  32. Schellinger PD, Ringleb P, Hacke W (2008) Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der europäischen Schlaganfallorganisation, Teil 2. Nervenarzt 79:1180–1201

    Article  CAS  PubMed  Google Scholar 

  33. Singer DE, Albers GW, Dalen JE et al (2004) Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126(Suppl 3):429S–456S

    Article  CAS  PubMed  Google Scholar 

  34. Tatschl C, Stollberger C, Matz K et al (2006) Insular involvement is associated with QT prolongation: ECG abnormalities in patients with acute stroke. Cerebrovasc Dis 21:47–53

    Article  PubMed  Google Scholar 

  35. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators (2000) Low molecular weight heparinoid, ORG 10172 (danaparoid) and outcome after acute ischemic stroke: a randomized controlled trial. JAMA 279:1265–1272

    Google Scholar 

  36. Wong KS, Chen C, Ng PW et al (2007) Low-mo-lecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a ran-domised study. Lancet Neurol 6:407–413

    Article  CAS  PubMed  Google Scholar 

  37. Zabalgoitia M, Halperin JL, Pearce LA et al (1998) Transesophageal echocardiographic correlates of clinical risk of thromboembolism in non-valvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol 31:1622–1626

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Neurogische Klinik, Städtisches Klinikum Karlsruhe, Moltkestr. 90, 76133, Karlsruhe, Deutschland

    G. Gahn

Authors
  1. G. Gahn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. Gahn.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gahn, G. Schlaganfall und Vorhofflimmern. Herzschr. Elektrophys. 20, 70–72 (2009). https://doi.org/10.1007/s00399-009-0045-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00399-009-0045-6

Schlüsselwörter

Keywords

Search

Navigation