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Thromboembolieprophylaxe bei Vorhofflimmern

Wann orale Antikoagulanzien? Wann Aspirin? Wann Heparine? Wann Kombinationen?

Antithrombotic therapy in atrial fibrillation

When vitamin K antagonists? When aspirin? When heparine? When combinations of anticoagulant and antiplatelet drugs?

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Zusammenfassung

Die mit dem Vorhofflimmern verbundene erhöhte Morbidität und Mortalität ist in erster Linie auf thromboembolisch verursachte ischämische Schlaganfälle und periphere arterielle Embolien zurückzuführen. Die Prävention von thromboembolischen Komplikationen ist deshalb ein essenzieller Bestandteil der Therapie des Vorhofflimmerns. Die optimale antithrombotische Differenzialtherapie (orale Antikoagulanzien, Thrombozytenaggregationshemmer, unfraktioniertes oder niedermolekulares Heparin, Kombinationstherapien) wird sowohl durch das thromboembolische Risiko, das mit dem Vorhofflimmern verknüpft ist und für den Einzelfall durch verschiedene Stratifikationsschemata determiniert werden kann, als auch durch die vorliegenden kardialen oder extrakardialen Grunderkrankungen (koronare Herzkrankheit, prothetischer Klappenersatz, venöse oder arterielle Embolien u.a.m.) bestimmt. Andererseits beeinflusst das Blutungsrisiko, in erster Linie das Risiko intrazerebraler Blutungen, die Wahl der antithrombotischen Therapie. Die Problematik der Nutzen-Risiko-Kalkulation ist dadurch gekennzeichnet, dass die Prädiktoren sowohl für Thromboembolien als auch für Blutungen sehr ähnlich, zum Teil sogar identisch sind.

Gegenwärtig werden orale Vitamin-K-Antagonisten bei Patienten mit mittlerem oder hohem Schlaganfallrisiko empfohlen, wobei sich der sog. CHADS2-Score als einfache Hilfe zur Risikostratifizierung anbietet. Dabei wird Aspirin für Patienten mit niedrigem Risiko thromboembolischer Komplikationen (CHADS2-Score <1) als ausreichend erachtet, während orale Vitamin-K-Antagonisten bei einem CHADS2-Score >1 empfohlen werden. Die Kombination von Thrombozytenaggregationshemmern mit oralen Antikoagulanzien kommt bei Vorhofflimmerpatienten in Betracht, die einer PCI mit Stentimplantation unterzogen wurden oder an einem frischen Myokardinfarkt bzw. einem akuten Koronarsyndrom erkrankt sind. Allerdings ist das optimale Vorgehen in derartigen Fällen noch nicht befriedigend geklärt. Die Entwicklung neuer antithrombotischer Substanzen, die einfacher zu handhaben sind und ein günstigeres Nutzen-Risiko-Verhältnis aufweisen, lässt erwarten, dass künftig mehr Patienten mit dem Risiko thromboembolischer Komplikationen einer effektiven Prävention zugeführt werden können.

Abstract

Morbidity and mortality associated with atrial fibrillation are mainly related to thromboembolic complications, particularly ischemic strokes. The prevention of thromboembolism is an important component in the management of patients with atrial fibrillation. The choice of optimum antithrombotic therapy for a given patient depends on the risk of thromboembolism, on the one hand, and the risk of intracerebral hemorrhage, on the other hand. Concerning the benefit-to-risk stratification the problem lies in the similar and sometimes even identical risk factors for both thromboembolism and haemorrhage.

At present, oral vitamin K antagonists are recommended for patients with atrial fibrillation at moderate or high risk of ischemic stroke. The thromboembolic risk should be assessed using validated stratification schemes, such as the CHADS2 score. Aspirin alone is recommended for patients at low risk of thromboembolic complications. A combination of anticoagulant and antiplatelet drugs is necessary in patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation, but the optimal therapeutic management of these patients has not yet been defined. Hopefully, the development of new antithrombotic agents being easier to use and having a superior benefit-to-risk ratio will extend effective prevention of thromboembolic events to a greater part of the atrial fibrillation population at risk.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: Der federführende Autor (HV) erklärt, dass er für Vertragstätigkeit Honorare und für Forschungstätigkeit Unterstützung von Herstellern erhalten hat, deren Produkte im Zusammenhang mit der Publikation stehen (Bristol-Myers Squibb, Sanofi-Aventis).

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  1. Klinik für Innere Medizin/Kardiologie, Erzgebirgsklinikum Annaberg, 09456, Annaberg-Buchholz, Deutschland

    H. Volkmann, M. Walter, C. Bergmann, E. Rose, V. Krpciar & S. Vetter

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Correspondence to H. Volkmann.

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Volkmann, H., Walter, M., Bergmann, C. et al. Thromboembolieprophylaxe bei Vorhofflimmern. Herzschr. Elektrophys. 20, 61–69 (2009). https://doi.org/10.1007/s00399-009-0046-5

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