Herzrhythmusstörungen und deren Therapie entsprechend aktuellen Empfehlungen

Zusammenfassung

Die Therapie von Herzrhythmusstörungen hat sich in den letzten Jahren erheblich verändert: nichtmedikamentöse Verfahren wie die Katheterablation werden frühzeitiger eingesetzt und haben teilweise die medikamentöse Therapie abgelöst. Häufig dient die medikamentöse Therapie noch als Überbrückung bis zur definitiven Therapie durch Katheterablation. Ein weiterer Schwerpunkt ist die begleitende antiarrhythmische Behandlung bei Patienten mit implantierbaren Cardioverter-Defibrillatoren (ICD). Bei der Akutbehandlung einiger Herzrhythmusstörungen, wie z. B. dem Vorhofflimmern, sind medikamentöse Ansätze unverzichtbar und weiterhin als primäre Therapie etabliert. Die medikamentöse Therapie mit den „klassischen” ionenkanalblockierenden Substanzen ist in der Effektivität limitiert und birgt insbesondere das Risiko der Proarrhythmie. Pharmaka haben in der Langzeittherapie jedoch häufig nur eine eingeschränkte Wirksamkeit und potenzielle Nebenwirkungen. Aus diesem Grund sollte eine Dauertherapie nur bei strenger Indikationsstellung und engmaschiger kardiologischer Überwachung erfolgen. Wegen dieser Limitationen wird nach Alternativen der pharmakologischen Behandlungsprinzipien (nicht-ionenkanalblockierende Substanzen wie z. B. ACE-Hemmer, Sartane, Statine) gesucht. Anders als klassische Antiarrhythmika beruht ihr Wirkprinzip vor allem in der Beeinflussung von strukturellen kardialen Veränderungen.

Abstract

Therapy guidelines for treating heart rhythm disturbances have changed substantially within the last years: Catheter ablation treatment strategies support or even replace classical pharmacological treatment. Nowadays, medical therapy is commonly used as bridging therapy until definite catheter ablation therapy is performed. Yet, pharmacological treatment remains a cornerstone of concomitant treatment in patients with implantable cardioverters/defibrillators (ICD). In acute onset atrial fibrillation, pharmacological treatment is still indispensable as established first line strategy. However, medical therapy with „classical” ion channel blocking agents has limited effects and even proarrhythmic propensity. Indication for long-term pharmacological treatment should be thoroughly checked and patients should be closely monitored, as such treatment comes along with undesired side effects. Therefore, novel pharmacological treatment strategies with non-ion channel blocking agents such as ACE-inhibitors, Sartans, and Statins may be an option. Different from classical antiarrhythmic agents, these agents have an impact on structural changes of the diseased heart.

Arrhythmie - Antiarrhythmika - Herz - Defibrillator - Katheterablation

arrhythmia - antiarrhythmic agents - catheter ablation - heart - defibrillator

Literatur

• 1 Alboni P, Botto G L, Boriani G. et al . Intravenous administration of flecainide or propafenone in patients with recent-onset atrial fibrillation does not predict adverse effects during ‘pill-in-the-pocket’ treatment.  Heart. 2010;  96 546-549
• 2 Bardy G H, Lee K L, Mark D B. et al . Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.  N Engl J Med. 2005;  352 225-237
• 3 Bellocq C, van Ginneken A C, Bezzina C R. et al . Mutation in the KCNQ1 gene leading to the short QT-interval syndrome.  Circulation. 2004;  109 2394-2397
• 4 Blackshear J L, Safford R E. AFFIRM and RACE trials: implications for the management of atrial fibrillation.  Card Electrophysiol Rev. 2003;  7 366-369
• 5 Blomstrom-Lundqvist C, Scheinman M M, Aliot E M. et al . ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias – executive summary. 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 develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society.  J Am Coll Cardiol. 2003;  42 1493-1531
• 6 Brendorp B, Torp-Pedersen C, Elming H, Kober L. Survival after withdrawal of dofetilide in patients with congestive heart failure and a short baseline QTc interval; a follow-up on the Diamond-CHF QT substudy.  Eur Heart J. 2003;  24 274-279
• 7 Brugada R, Hong K, Dumaine R. et al . Sudden death associated with short-QT syndrome linked to mutations in HERG.  Circulation. 2004;  109 30-35
• 8 Camm A J, Kirchhof P, Lip G Y. et al . Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).  Eur Heart J. 2010;  31 2369-2429
• 9 Cappato R, Calkins H, Chen S A. et al . Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation.  J Am Coll Cardiol. 2009;  53 1798-1803
• 10 Cappato R, Calkins H, Chen S A. et al . Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.  Circulation. 2005;  111 1100-1105
• 11 Connolly S J, Gent M, Roberts R S. et al . Canadian implantable defibrillator study (CIDS) : a randomized trial of the implantable cardioverter defibrillator against amiodarone.  Circulation. 2000;  101 1297-1302
• 12 Connolly S J, Hallstrom A P, Cappato R. et al . Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study.  Eur Heart J. 2000;  21 2071-2078
• 13 Dorian P. Rate control in atrial fibrillation.  N Engl J Med. 2010;  362 1439-1441
• 14 Duray G Z, Schmitt J, Hohnloser S H. Dronedarone Therapy in Atrial Fibrillation: A Summary of Recent Controlled Trials.  J Cardiovasc Pharmacol Ther. 2010;  Epub ahead of print
• 15 Fuster V, Ryden L E, Cannom D S. et al . ACC/AHA/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 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.  Circulation. 2006;  114 e257-e354
• 16 Gaita F, Giustetto C, Bianchi F. et al . Short QT Syndrome: a familial cause of sudden death.  Circulation. 2003;  108 965-970
• 17 Giustetto C, Di M F, Wolpert C. et al . Short QT syndrome: clinical findings and diagnostic-therapeutic implications.  Eur Heart J. 2006;  27 2440-2447
• 18 Goette A. Möglichkeiten und Grenzen der derzeitigen medikamentösen Behandlung von Vorhofflimmern.  Dtsch Med Wochenschr. 2010;  135 Suppl 2 S33-S37
• 19 Goette A, Bukowska A, Dobrev D. et al . Acute atrial tachyarrhythmia induces angiotensin II type 1 receptor-mediated oxidative stress and microvascular flow abnormalities in the ventricles.  Eur Heart J. 2009;  30 1411-1420
• 20 Goette A, Honeycutt C, Langberg J J. Electrical remodeling in atrial fibrillation. Time course and mechanisms.  Circulation. 1996;  94 2968-2974
• 21 Goldberg A S, Bathina M N, Mickelsen S, Nawman R, West G, Kusumoto F M. Long-term outcomes on quality-of-life and health care costs in patients with supraventricular tachycardia (radiofrequency catheter ablation versus medical therapy).  Am J Cardiol. 2002;  89 1120-1123
• 22 Greene H L. The CASCADE Study: randomized antiarrhythmic drug therapy in survivors of cardiac arrest in Seattle. CASCADE Investigators.  Am J Cardiol. 1993;  72 70F-74F
• 23 Gussak I, Wright R S, Kopecky S L, Hammill S C. Exercise-induced ST segment elevation in Q wave leads in postinfarction patients: defining its meaning and utility in today’s practice.  Cardiology. 2000;  93 205-209
• 24 Haissaguerre M, Warin J F, Lemetayer P, Saoudi N, Guillem J P, Blanchot P. Closed-chest ablation of retrograde conduction in patients with atrioventricular nodal reentrant tachycardia.  N Engl J Med. 1989;  320 426-433
• 25 Hammwöhner M, Goette A. Will Warfarin soon be passe? New approaches to stroke prevention in atrial fibrillation.  J Cardiovasc Pharmacol. 2008;  52 18-27
• 26 Haverkamp W. Kongenitales Long-QT-Syndrom.  Herz. 2007;  32 201-205
• 27 Hohnloser S H, Crijns H J, EM. et al . Dronedarone in patients with congestive heart failure: insights from ATHENA.  Eur Heart J. 2010;  31 1717-1721
• 28 Hsu L F, Jais P, Sanders P. et al . Catheter ablation for atrial fibrillation in congestive heart failure.  N Engl J Med. 2004;  351 2373-2383
• 29 Jackman W M, Beckman K J, McClelland J H. et al . Treatment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow-pathway conduction.  N Engl J Med. 1992;  327 313-318
• 30 Jais P, Hocini M, Hsu L F. et al . Technique and results of linear ablation at the mitral isthmus.  Circulation. 2004;  110 2996-3002
• 31 Khan M N, Jais P, Cummings J. et al . Pulmonary-vein isolation for atrial fibrillation in patients with heart failure.  N Engl J Med. 2008;  359 1778-1785
• 32 Kirchhof P, Bax J, Blomstrom-Lundquist C. et al . Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference ‘research perspectives in AF’.  Eur Heart J. 2009;  30 2969-77c
• 33 Kontula K, Laitinen P J, Lehtonen A, Toivonen L, Viitasalo M, Swan H. Catecholaminergic polymorphic ventricular tachycardia: recent mechanistic insights.  Cardiovasc Res. 2005;  67 379-387
• 34 Kuck K H, Cappato R, Siebels J, Ruppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH).  Circulation. 2000;  102 748-754
• 35 Kuck K H, Ernst S, Dorwarth U. et al . Leitlinien zur Kathe.  Clin Res Cardiol. 2007;  96 833-849
• 36 Kuck K H, Schaumann A, Eckardt L. et al . Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial.  Lancet. 2010;  375 31-40
• 37 Lafuente-Lafuente C, Mouly S, Longas-Tejero M A, Bergmann J F. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev; 2007 CD005049
• 38 Lafuente-Lafuente C, Mouly S, Longas-Tejero M A, Mahe I, Bergmann J F. Antiarrhythmic drugs for maintaining sinus rhythm after cardioversion of atrial fibrillation: a systematic review of randomized controlled trials.  Arch Intern Med. 2006;  166 719-728
• 39 Lai L P, Su M J, Lin J L. et al . Down-regulation of L-type calcium channel and sarcoplasmic reticular Ca(2+)-ATPase mRNA in human atrial fibrillation without significant change in the mRNA of ryanodine receptor, calsequestrin and phospholamban: an insight into the mechanism of atrial electrical remodeling.  J Am Coll Cardiol. 1999;  33 1231-1237
• 40 Marian A J. Contemporary treatment of hypertrophic cardiomyopathy.  Tex Heart Inst J. 2009;  36 194-204
• 41 Marian A J. Hypertrophic cardiomyopathy: from genetics to treatment.  Eur J Clin Invest. 2010;  40 360-369
• 42 Mason J W. A comparison of electrophysiologic testing with Holter monitoring to predict antiarrhythmic-drug efficacy for ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators.  N Engl J Med. 1993;  329 445-451
• 43 Mason J W. A comparison of seven antiarrhythmic drugs in patients with ventricular tachyarrhythmias. Electrophysiologic Study versus Electrocardiographic Monitoring Investigators.  N Engl J Med. 1993;  329 452-458
• 44 Moss A J, Zareba W, Benhorin J. et al . ECG T-wave patterns in genetically distinct forms of the hereditary long QT syndrome.  Circulation. 1995;  92 2929-2934
• 45 Moss A J, Zareba W, Hall W J. et al . Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.  N Engl J Med. 2002;  346 877-883
• 46 Moss A J, Zareba W, Hall W J. et al . Effectiveness and limitations of beta-blocker therapy in congenital long-QT syndrome.  Circulation. 2000;  101 616-623
• 47 Nademanee K, McKenzie J, Kosar E. et al . A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate.  J Am Coll Cardiol. 2004;  43 2044-2053
• 48 Natale A, Newby K H, Pisano E. et al . Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter.  J Am Coll Cardiol. 2000;  35 1898-1904
• 49 Nattel S. New ideas about atrial fibrillation 50 years on.  Nature. 2002;  415 219-226
• 50 Ouyang F, Bansch D, Ernst S. et al . Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-Lasso technique in paroxysmal atrial fibrillation.  Circulation. 2004;  110 2090-2096
• 51 Pedersen O D, Brendorp B, Kober L, Torp-Pedersen C. Prevalence, prognostic significance, and treatment of atrial fibrillation in congestive heart failure with particular reference to the DIAMOND-CHF study.  Congest Heart Fail. 2003;  9 333-340
• 52 Priori S G, Barhanin J, Hauer R N. et al . Genetic and molecular basis of cardiac arrhythmias; impact on clinical management. Study group on molecular basis of arrhythmias of the working group on arrhythmias of the european society of cardiology.  Eur Heart J. 1999;  20 174-195
• 53 Priori S G, Pandit S V, Rivolta I. et al . A novel form of short QT syndrome (SQT3) is caused by a mutation in the KCNJ2 gene.  Circ Res. 2005;  96 800-807
• 54 Rautaharju P M, Zhou S H, Wong S. et al . Sex differences in the evolution of the electrocardiographic QT interval with age.  Can J Cardiol. 1992;  8 690-695
• 55 Reddy V Y, Reynolds M R, Neuzil P. et al . Prophylactic catheter ablation for the prevention of defibrillator therapy.  N Engl J Med. 2007;  357 2657-2665
• 56 Roy D, Talajic M, Dorian P. et al . Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators.  N Engl J Med. 2000;  342 913-920
• 57 Schauerte P, Scherlag B J, Pitha J. et al . Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation.  Circulation. 2000;  102 2774-2780
• 58 Scheinman M M. NASPE Survey on Catheter Ablation.  Pacing Clin Electrophysiol. 1995;  18 1474-1478
• 59 Schilling R J. Cardioversion of atrial fibrillation: the use of antiarrhythmic drugs.  Heart. 2010;  96 333-338
• 60 Schimpf R, Bauersfeld U, Gaita F, Wolpert C. Short QT syndrome: successful prevention of sudden cardiac death in an adolescent by implantable cardioverter-defibrillator treatment for primary prophylaxis.  Heart Rhythm. 2005;  2 416-417
• 61 Schulze-Bahr E, Breithardt G. Short QT interval and short QT syndromes.  J Cardiovasc Electrophysiol. 2005;  16 397-398
• 62 Shlofmitz R A, Hirsch B E, Meyer B R. New-onset atrial fibrillation: is there need for emergent hospitalization?.  J Gen Intern Med. 1986;  1 139-142
• 63 Singh S N, Singh B N, Reda D J. et al . Comparison of sotalol versus amiodarone in maintaining stability of sinus rhythm in patients with atrial fibrillation (Sotalol-Amiodarone Fibrillation Efficacy Trial [Safe-T]).  Am J Cardiol. 2003;  92 468-472
• 64 Steven D, Lutomsky B, Rostock T, Willems S. Moderne Pharmakotherapie bei supraventrikulären und ventrikulären Herzrhythmusstörungen. Ein Update zur konventionellen Therapie.  Internist (Berl). 2006;  47 1013-20, 1022
• 65 Tome Esteban M T, Garcia-Pinilla J M, McKenna W J. [Update in arrhythmogenic right ventricular cardiomyopathy: genetic, clinical presentation and risk stratification].  Rev Esp Cardiol. 2004;  57 757-767
• 66 Van Gelder I C, Groenveld H F, Crijns H J. et al . Lenient versus strict rate control in patients with atrial fibrillation.  N Engl J Med. 2010;  362 1363-1373
• 67 Van Gelder I C, Hagens V E, Bosker H A. et al . A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation.  N Engl J Med. 2002;  347 1834-1840
• 68 Van Wagoner D R. Electrophysiological remodeling in human atrial fibrillation.  Pacing Clin Electrophysiol. 2003;  26 1572-1575
• 69 Wanless R S, Anderson K, Joy M, Joseph S P. Multicenter comparative study of the efficacy and safety of sotalol in the prophylactic treatment of patients with paroxysmal supraventricular tachyarrhythmias.  Am Heart J. 1997;  133 441-446
• 70 Wittkowsky A K. The „pill-in-the-pocket” approach to atrial fibrillation.  N Engl J Med. 2005;  352 1150-1151
• 71 Wolf P A, Dawber T R, Thomas Jr H E, Kannel W B. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study.  Neurology. 1978;  28 973-977
• 72 Wolpert C, Schimpf R, Veltmann C, Borggrefe M. Kurzes QT-Syndrom.  Herz. 2007;  32 206-210
• 73 Wyse D G, Waldo A L, DiMarco J P. et al . A comparison of rate control and rhythm control in patients with atrial fibrillation.  N Engl J Med. 2002;  347 1825-1833
• 74 Ylanen K, Poutanen T, Hiippala A, Swan H, Korppi M. Catecholaminergic polymorphic ventricular tachycardia.  Eur J Pediatr. 2010;  169 535-542
• 75 Zipes D P, Camm A J, Borggrefe M. et al . ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.  Europace. 2006;  8 746-837