Praktische Anwendung der neuen Antikoagulanzien bei Patienten mit TIA und Schlaganfall und Vorhofflimmern bei absoluter Arrhythmie

Zusammenfassung

Die direkten oralen Antikoagulanzien (DOAK) Apixaban, Dabigatran, Edoxaban und Rivaroxaban stellen eine Alternative zu Vitamin-K-Antagonisten (VKA) für die Prävention von Schlaganfällen bei Patienten mit Vorhofflimmern dar. Sie werden in fester oraler Dosierung angewandt und es besteht keine Notwendigkeit eines regelmäßigen Gerinnungsmonitorings. In der Sekundärprävention nach TIA und ischämischem Insult sind DOAK mindestens genauso wirksam wie eine Antikoagulation mit Warfarin. Das Risiko für intrazerebrale Blutungen ist um 40 – 70 % geringer als bei VKA. Für den klinischen Alltag gibt es jedoch eine Vielzahl von Fragen, die durch die aktuellen Studien nicht beantwortet werden. Der ideale Zeitpunkt des Beginns einer oralen Antikoagulation mit DOAK nach TIA und Schlaganfall ist nicht bekannt, da in den randomisierten Studien alle Patienten mit frischen zerebralen ischämischen Ereignissen ausgeschlossen wurden. Eine effektive Antikoagulation mit VKA und DOAK stellt derzeit eine Kontraindikation für die systemische Thrombolyse dar. Bisher gibt es keine prospektiv erhobenen Daten zur Behandlung von zerebralen Blutungen unter DOAK. Spezifische Antidots sind in Entwicklung. Diese Übersicht diskutiert zudem den Einsatz von DOAK bei Patienten mit kognitiven Einschränkungen, Gefahr von Stürzen, symptomatischer Karotisstenose, Nierenfunktionsstörungen, tiefen Beinvenenthrombosen und Lungenembolien. Außerdem werden prospektive Register und neue Indikationen in der Neurologie beschrieben.

Abstract

The direct oral anticoagulants (DOAC) apixaban, dabigatran, edoxaban and rivaroxaban are alternative treatment options to vitamin K antagonists (VKA) for the prevention of stroke in patients with atrial fibrillation. DOAC are given in a fixed oral dose and regular coagulation monitoring is not required. DOAC are at least as effective as warfarin in secondary stroke prevention in patients with atrial fibrillation who have had a TIA or ischemic stroke. The risk of intracranial bleeds is reduced by 40 – 70 % compared with VKA. The use of the DOAC in clinical routine leaves many questions open which were not addressed in the randomized trials. The best point of time to initiate anticoagulation after an acute ischemic stroke is unknown since patients with a recent stroke were excluded from the randomized trials. Effective anticoagulation with VKA or DOAC is a contraindication for systemic thrombolysis in acute stroke. No controlled trials on the treatment of cerebral hemorrhages in patients treated with DOAC have yet been carried out. Specific antidotes for DOAC are under development. This review addresses the use of DOAC in patients with cognitive impairment, increased risk of falls, symptomatic carotid stenosis, kidney failure, deep vein thrombosis and pulmonary embolism. Furthermore, prospective registries and new indications for DOAC in neurology are described.

Schlüsselwörter

Vorhofflimmern - Schlaganfall - Vitamin-K-Antagonisten - direkte orale Antikoagulanzien - intrakranielle Blutungen

Keywords

atrial fibrillation - stroke - vitamin-K antagonists - direct oral anticoagulants - intracranial bleeds

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