Skip to main content
SpringerLink
Log in

Management der interventionellen Therapie von Patienten mit akutem Koronarsyndrom und Vorhofflimmern

Management of interventional therapy for patients with acute coronary syndrome and atrial fibrillation

  • CME Weiterbildung · Zertifizierte Fortbildung
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Das akute Koronarsyndrom ist in ca.10–12% durch das Auftreten von Vorhofflimmern kompliziert, was mit einer erhöhten intrahospitalen und Langzeitmortalität einhergeht. Mortalitätsbedingende Faktoren sind Blutungskomplikationen, ein erhöhtes Risiko für Schlaganfall, Herzinsuffizienz und kardiogener Schock. Zugangsbedingte arterielle Blutungskomplikationen bei primärer perkutaner transluminarer koronarer Angioplastie (PTCA) können durch einen transradialen Zugang deutlich vermindert werden. ASS und Clopidogrel verhindern die Stentthrombose, reduzieren aber das Schlaganfallrisiko im Langzeitverlauf nicht ausreichend. Für diese Patienten wird eine Triple-Therapie, bestehend aus ASS, Clopidogrel und Marcumar (INR 2,0–2,5), je nach Schlaganfallrisiko (CHA2DS2-VASc-Score), Blutungsrisiko (HAS-BLED), implantiertem Stent (BMS vs. DES), empfohlen. Die Triple-Therapie ist mit einem erhöhten Blutungsrisiko verbunden. β-Blocker, ACE-Hemmer, die elektrische Kardioversion oder Amiodaron sind effektive Maßnahmen, um den Sinusrhythmus frühzeitig wiederherzustellen und zu stabilisieren.

Abstract

Atrial fibrillation (AF) is a common arrhythmia following acute myocardial infarction and the overall percentage observed in previous studies ranges between 10 and 12%. Acute coronary syndrome (ACS) and AF are associated with a higher in-hospital and long-term mortality. Predisposing factors are higher bleeding complications, higher incidence of stroke, heart failure and cardiogenic shock. Access site complications can be significantly reduced using the transradial approach for PCI which improves the clinical outcome of these patients. Stroke is an important complication in patients hospitalized with ACS. The incidence of acute stroke in patients with ACS and AF varies between 0.5 and 1.3%. The increasing use of drug-eluting stents (DES) to minimize in-stent restenosis necessitates long-term dual antiplatelet therapy with aspirin plus a thienopyridine (at present most frequently clopidogrel) to reduce the risk of early and late stent thrombosis. Combined aspirin-clopidogrel therapy, however, is less effective in preventing stroke compared with oral anticoagulation (OAC) alone—and OAC alone is insufficient to prevent stent thrombosis. In patients with ACS and AF a triple therapy consisting of aspirin, clopidogrel and OAC (INR 2.0–2.5) is recommended according to the risk stratification (CHA2DS2-VASc score), the bleeding risk (HAS-BLED score), and the implanted stent (DES vs BMS). Triple therapy is associated with a higher bleeding risk and should be administered as briefly as necessary. Using beta-blockers, ACE inhibitors, direct current cardioversion or intravenous administration of amiodarone may reduce the incidence of AF and restore sinus rhythm which can reduce the duration of triple therapy.

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

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9
Abb. 10
Abb. 11
Abb. 12

Literatur

  1. Benjamin EJ, Wolf PA, D’Agostino RB et al (1998) Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98:946–952

    PubMed  CAS  Google Scholar 

  2. Camm AJ, Kirchhof P, Lip GY et al (2010) Guidelines for the management of atrial fibrillation. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) European Heart Rhythm Association (EHRA), European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 31:2369–2429

    Article  PubMed  Google Scholar 

  3. Nieuwlaat R, Prins H, Le Huezy et al (2008) Prognosis, disease progression, and treatement of atrial fibrillation patients during 1 year: follow up of the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 29:1181–1189

    Article  PubMed  Google Scholar 

  4. Nieuwlaat R, Capucci R, Camm AJ et al (2005) Atrial fibrillation management: a prospective survey in ESC member dountries. The Euro Heart Survey on Atrial Fibrillation. Eur Heart J 26:2422–2434

    Article  PubMed  Google Scholar 

  5. Van Werf F de, Bax J, Betriu A et al (2008) The Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. Eur Heart J 29:2909–2945

    Article  Google Scholar 

  6. Bassand JP, Hamm CH, Ardissino D et al (2007) The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 28:1598–1660

    Article  PubMed  CAS  Google Scholar 

  7. Lopes RD, Elliott LE, White HD et al (2009) Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial. Eur Heart J 30:2019–2028

    Article  PubMed  CAS  Google Scholar 

  8. Budaj A, Flasinska K, Gore JM et al (2005) Magnitude of and risk factors for in-hospital and postdischarge stroke in patients with acute coronary syndromes: findings from a global registry of acute coronary events. Circulation 111:3242–3247

    Article  PubMed  Google Scholar 

  9. Rathore SS, Berger AK, Weinfurt KP et al (2000) Acute myocardial infarction complicated by atrial fibrillation in the elderly – prevalence and outcomes. Circulation 101:969–974

    PubMed  CAS  Google Scholar 

  10. Lehto M, Snapinn S, Dickstein K et al (2005) Prognostic risk of atrial fibrillation in acute myocardial infarction complicated by left ventricular dysfunction: the OPTIMAAL experience. Eur Heart J 26:350–356

    Article  PubMed  Google Scholar 

  11. Haissaguerre M, Jais P, Shah DC et al (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659–666

    Article  PubMed  CAS  Google Scholar 

  12. Moe GK (1962) On the multiple wavelet hypothesis of atrial fibrillation. Arch Int Pharmacodyn Ther 140:183–188

    Google Scholar 

  13. Wijffels MCEF et al (1995) Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 92:1954–1968

    PubMed  CAS  Google Scholar 

  14. Dobrev D, Ravens U et al (2003) Remodeling of cardiomyocyte ion channels in human atrial fibrillation. Basic Res Cardiol 98:137–148

    PubMed  Google Scholar 

  15. Nattel S (2002) New ideas about atrial fibrillation 50 years on. Nature 415:219–226

    Article  PubMed  CAS  Google Scholar 

  16. Manning WJ, Silvermann DI, Katz SE et al (1994) Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation. J Am Coll Cardiol 23:1535–1540

    Article  PubMed  CAS  Google Scholar 

  17. Schotten U, Duytschaever M, Ausma J et al (2003) Electrical and contractile remodeling during the first days of atrial fibrillation go hand in hand. Circulation 107:1433–1439

    Article  PubMed  Google Scholar 

  18. Allessie M, Ausma J, Schotten U (2002) Electrical, contractile and structural remodeling during atrial fibrillation. Cardiovasc Res 54:230–246

    Article  PubMed  CAS  Google Scholar 

  19. Cappato R (2009) Atrial fibrillation complicating acute myocardial infarction: How should it be interpreted and how should it be treated and prevented? Eur Heart J 30:1035–1037

    Article  PubMed  Google Scholar 

  20. Schmitt J, Duray G, Gersh B et al (2009) Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J 30:1038–1045

    Article  PubMed  Google Scholar 

  21. Rao SV, Cohen MG, Kandzari DE et al (2010) The transradial approach to percutaneous coronary intervention. J Am Coll Cardiol 55:2187–2195

    Article  PubMed  Google Scholar 

  22. Doyle BJ, Rihal CS, Gastineau DA et al (2009) Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 53:2019–2027

    Article  PubMed  Google Scholar 

  23. Jolly SS, Amlani S, Hamon M et al (2009) Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 157:132–140

    Article  PubMed  Google Scholar 

  24. Pancholy S, Patel T, Sanghvi K et al (2010) Comparison of door-to-ballon times for primary PCI using transradial versus transfemoral approach. Catheter Cardiovasc Intervention 75:991–995

    Google Scholar 

  25. Sciahbasi A, Pristipino C, Ambrosio G et al (2009) Arterial access-site-related outcomes of patients undergoing invasive coronary procedures for acute coronary syndromes (from the ComPaRison of Early Invasive and Conservative Treatment in Patients With Non-ST-Elevation Acute Coronary Syndromes [PRESTO-ACS] Vascular Substudy) Am J Cardiol 103:796–800

    Google Scholar 

  26. Lip GYH, Huber K, Andreotti F et al (2010) Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary – a consensus document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 31:1311–1318

    Article  PubMed  Google Scholar 

  27. White HD, Kleiman NS, Mahaffey KW et al (2006) Efficacy and safety of enoxaparin compared with unfractionated heparin in high risk patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention in the superior yield of the new strategy of enoxaparin, revascularization and glycoprotein IIb/IIIa inhibitors (SYNERGY) trial. Am Heart J 152:1042–1050

    Article  PubMed  CAS  Google Scholar 

  28. Karjalainen PP, Vikman S, Niemelä M et al (2008) Safety of percutaneous coronary intervention during uninterrupted oral anticoagulant treatment. Eur Heart J 29:1001–1010

    Article  PubMed  Google Scholar 

  29. Lin Hj, Wolf PA, Kelly-Hayes et al (1996) Stroke severity in atrial fibrillation. The Framingham Study. Stroke 27:1760–1764

    Article  PubMed  CAS  Google Scholar 

  30. Watson T, Shantsila E, Lip GY (2009) Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet 373:155–166

    Article  PubMed  CAS  Google Scholar 

  31. Antonielli E, Pizzuti A, Pálinkás A et al (2002) Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation. J Am Coll Cardiol 39:1443–1449

    Article  PubMed  Google Scholar 

  32. Veinot JP, Harrity PJ, Gentile F et al (1997) Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts; implications of echocardiographic examinations. Circulation 96:3112–3115

    PubMed  CAS  Google Scholar 

  33. Pepi M, Evangelista A, Nihoyannopoulos P et al (2010) Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism. Eur J Echocardiogr 11:461–476

    Article  PubMed  Google Scholar 

  34. Hart RG, Pearce LA, Aguilar MI (2007) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have non valvular atrial fibrillation. Ann Intern Med 146:857–867

    PubMed  Google Scholar 

  35. Connolly S, Pogue J, Hart R et al (2006) ACTIVE Writing Group on behalf of the ACTIVE Investigators. 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  PubMed  CAS  Google Scholar 

  36. Lewalter T, Tebbenjohanns J, Wichter T et al (2008) Kommentar zu ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation – executive summary. Kardiologe 2:181–205

    Article  Google Scholar 

  37. Lip GY, Frison L, Halperin J et al (2010) Identifying patients at high risk for stroke despite anticoagulation. A comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke 41:2731–2738

    Article  PubMed  CAS  Google Scholar 

  38. Pisters MD, Lane D, Nieuwlaat R et al (2010) A novel user-friendly score (HAS-BLED) to assess one-year risk of major bleeding in atrial fibrillation patients: The Euro Heart Survey. Chest 138:1093–1100

    Article  PubMed  Google Scholar 

  39. Paikin JS, Wright DS, Crowther MA (2010) Triple antithrombotic therapy in patients with atrial fibrillation and coronary artery stents. Circulation 121:2067–2070

    Article  PubMed  Google Scholar 

  40. Silber S, Borggrefe M, Böhm M et al (2007) Positionspapier der DGK zur Wirksamkeit und Sicherheit von Medikamente freisetzenden Koronarstents (DES). Kardiologe 1:84–111

    Article  Google Scholar 

  41. Ruiz-Nodar J, Marin F, Hurtado J et al (2008) Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implication for bleeding risk and prognosis. J Am Coll Cardiol 51:818–825

    Article  PubMed  CAS  Google Scholar 

  42. Karjalainen PP, Porela P, Ylittalo A et al (2007) Safety and efficacy of combined antiplateled-warfarin therapy after coronary stenting. Eur Heart J 28:726–732

    Article  PubMed  CAS  Google Scholar 

  43. Biondi-Zoccai GG, Lotrionte M, Agostoni P et al (2006) A systemic review and meta-lysis on the hazard of discontinuing or not adhering to aspirin 50279 patients at risk of coronary artery disease. Eur Heart J 27:2667–2674

    Article  PubMed  Google Scholar 

  44. Airoldi F, Colombo A, Morici N et al (2007) Incidence and predictors of drug eluting stent-thrombosis during and after discontinuation of thienopyridine treatment. Circulation 116:745–754

    Article  PubMed  CAS  Google Scholar 

  45. Ho PM, Peterson ED, Wang L et al (2008) Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 299(5):532–539

    Article  PubMed  CAS  Google Scholar 

  46. Hohnloser SH, Pajitnev D, Pogue J et al (2007) Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy. An ACTIVE W Substudy. J Am Coll Cardiol 50(22):2156–2161

    Article  PubMed  CAS  Google Scholar 

  47. Pedersen OD, Baggert H, Køber L et al (1999) The occurrence and prognostic significance of atrial fibrillation/-flutter following acute myocardial infarction. TRACE Study Group. Eur Heart J 20:748–754

    Article  PubMed  CAS  Google Scholar 

  48. Mc Murray, Køber L, Robertson M et al (2005) Antiarrhythmic effect of carvedilol after acute myocardial infarction: results of the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction (CAPRICORN) trial. J Am Coll Cardiol 45(4):525–530

    Article  Google Scholar 

  49. Singh SN, Tang XC, Singh BN et al (2006) Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation. A Veterans Affairs Cooperative Studies Program Substudy. J Am Coll Cardiol 48(4):721–730

    Article  PubMed  Google Scholar 

  50. Fuster V, Ryden LE, Cannon DS et al (2006) ACC7AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Gudidelines 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. Circulation 114:257–354

    Article  Google Scholar 

  51. Jabre P, Roger V, Murad MH et al (2011) Mortality associated with atrial fibrillation in patients with myocardial infarction. A systematic review and meta-analysis. Circulation 123:1587–1597

    Article  PubMed  Google Scholar 

  52. Völler H, Alban S, Wetermann (2010) Neue orale Antikoagulanzien. Werden sie die Vitamin-K-Antagonisten verdrängen? Internist (Berl) 51:1571–1581

  53. Connolly SJ, Ezekowitz MD, Yusuf S et al (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361:1139–1151

    Article  PubMed  CAS  Google Scholar 

  54. Manesh R (2010) Stroke prevention using the oral direct factor Xa inhibitor rivaroxaban compared with warfarin in patients with nonvalvular atrail fibrillation (ROCKET-AF). Circulation 122:2215–2226

    Article  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Abteilung für Kardiologie, Augusta Krankenhaus, Düsseldorf-Rath, Universität Witten/Herdecke, Amalienstr. 9, 40472, Düsseldorf, Deutschland

    A. Wolf-Pütz, M. Wein & R.M. Klein

Authors
  1. A. Wolf-Pütz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Wein
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. R.M. Klein
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. Wolf-Pütz.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wolf-Pütz, A., Wein, M. & Klein, R. Management der interventionellen Therapie von Patienten mit akutem Koronarsyndrom und Vorhofflimmern. Kardiologe 5, 291–306 (2011). https://doi.org/10.1007/s12181-011-0358-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12181-011-0358-7

Schlüsselwörter

Keywords

Search

Navigation