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Kommentar zu den 2016 Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zum Management von Vorhofflimmern

Comments on the 2016 guidelines of the European Society of Cardiology (ESC) for the management of atrial fibrillation

  • Leitlinien
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Vorhofflimmern ist die mit Abstand häufigste Herzrhythmusstörung. Schätzungen zufolge entwickeln zumindest 25 % der aktuell 40-Jährigen im Verlauf ihres Lebens Vorhofflimmern. Es ist mit einer erhöhten Mortalität assoziiert und wesentliche Ursache für Schlaganfälle. Neue Entwicklungen der letzten Jahre waren Grundlage einer Überarbeitung der Leitlinien. Die aktuelle 2016 ESC-Leitlinie zum Vorhofflimmern gibt einen detaillierten Überblick über den aktuellen Wissensstand in der Behandlung von Vorhofflimmern. Im Vergleich zur letzten Aktualisierung aus dem Jahr 2012 sind der Patient und die interdisziplinäre Zusammenarbeit stärker in den Vordergrund gerückt. Von insgesamt 154 Empfehlungen wurden ca. zwei Drittel als Evidenz (Evidenzgrad A oder B) eingestuft, wobei allerdings nur 23 (15 %) auf Evidenzgrad A beruhen. Die Klassifikation von Vorhofflimmern hat sich geringfügig geändert. Paroxysmales Vorhofflimmern, das innerhalb von 7 Tagen kardiovertiert wird, wird weiterhin als paroxysmal und nicht als persistierend klassifiziert. In der Schlaganfallprävention treten Blutungsscores im Vergleich zum CHA2DS2-VASc in den Hintergrund und begründen in der Regel nicht den Verzicht auf eine Antikoagulation. Die Leitlinie spricht eine eindeutige Präferenz zugunsten von NOAK gegenüber Vitamin-K-Antagonisten aus. ASS hat unverändert zur letzten Leitlinie keinen Stellenwert in der Schlaganfallprävention bei Patienten mit Vorhofflimmern. Die Bedeutung des weiblichen Geschlechts als Risikofaktor für thrombembolische Ereignisse ist abgewertet worden. Frequenzregulation und Rhythmus erhaltende Therapie weisen demgegenüber kaum Änderungen auf, wobei chirurgische Ablationsverfahren in der Leitlinie größere Bedeutung erlangen. Der vorliegende Kommentar fasst wesentliche Änderungen zusammen und diskutiert die Leitlinie vor dem Hintergrund der Versorgungssituation in Deutschland.

Abstract

Atrial fibrillation (AF) remains one of the most important challenges in cardiovascular medicine. It is estimated that approximately 25% of currently 40-year-old adults will develop AF during their lifetime. AF is associated with increased mortality and is the major cause of stroke. The European Society of Cardiology (ESC) has issued new AF guidelines, which have a clinical focus on stroke prevention as well as rate and rhythm control and summarize current evidence-based therapy. The classification of paroxysmal and persistent AF have been slightly modified. With respect to anticoagulation, the correct indications as well as bleeding are discussed in detail. Non-vitamin K based oral anticoagulants (NOAC) are recommended as first-line therapy in suitable patients based on their safety. The role of female gender as an embolic risk factor has been downgraded. The guidelines emphasize integrated AF care, the need for early detection, and the patient’s individual role. The guidelines recommend a comprehensive approach covering five treatment issues: acute rate and rhythm control, management of precipitating factors, assessment of stroke risk, assessment of heart rate and assessment of symptoms. These comments summarize major aspects and changes of the new guidelines in light of the particular situation of AF patients in Germany and emphasize the need for further research for better understanding and therapy of AF.

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Authors and Affiliations

  1. Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland

    L. Eckardt

  2. Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Bad Neustadt a. d. Saale, Deutschland

    T. Deneke

  3. Klinik für Neurologie, Universitätsklinikum Essen, Essen, Deutschland

    H. C. Diener

  4. Abteilung für Rhythmologie, Herzzentrum Leipzig, Leipzig, Deutschland

    G. Hindricks

  5. Klinik für Kardiologie und Allg. Innere Medizin, Städt. Klinikum Solingen, Solingen, Deutschland

    H. M. Hoffmeister

  6. Klinik für Kardiologie, Abteilung für klinische Elektrophysiologie, J.-W. Goethe Universität Frankfurt, Frankfurt a. M., Deutschland

    S. H. Hohnloser

  7. Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, Großbritannien

    P. Kirchhof

  8. University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien

    P. Kirchhof

  9. Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, Großbritannien

    P. Kirchhof

  10. Klinik für Kardiologie und Internistische Intensivmedizin, Klinikum Bielefeld gGmbH, Bielefeld, Deutschland

    C. Stellbrink

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  1. L. Eckardt
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  2. T. Deneke
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  3. H. C. Diener
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  4. G. Hindricks
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  7. P. Kirchhof
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  8. C. Stellbrink
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Correspondence to L. Eckardt.

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C. Stellbrink für die Kommission für Klinische Kardiovaskuläre Medizin.

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Eckardt, L., Deneke, T., Diener, H.C. et al. Kommentar zu den 2016 Leitlinien der Europäischen Gesellschaft für Kardiologie (ESC) zum Management von Vorhofflimmern. Kardiologe 11, 193–204 (2017). https://doi.org/10.1007/s12181-017-0141-5

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