Langzeit-EKG-Monitoring beim kryptogenen Schlaganfall

Zusammenfassung

Die Definition, wann ein ischämischer Schlaganfall als „kryptogen“ bezeichnet wird, wird in der aktuellen Literatur uneinheitlich geführt. Insbesondere die kardiologische Diagnostik, die hier zur Abklärung des Schlaganfalls obligatorisch durchgeführt werden sollte, variiert stark. Daher ist es nicht verwunderlich, dass der Anteil von kryptogenen Schlaganfällen in den publizierten Studien einer großen Schwankungsbreite unterliegt. Gerade in dieser Gruppe wird aber vermutet, dass häufig ein unentdecktes, paroxysmales Vorhofflimmern (VHF) für den Schlaganfall verantwortlich gewesen sein könnte. Gehen aktuelle Empfehlungen davon aus, dass bei V. a. einen kardioembolischen Schlaganfall ein 24 h-Holter-EKG durchgeführt werden sollte, so zeigen inzwischen überzeugende Daten, dass ein prolongiertes EKG-Monitoring signifikant häufiger VHF zu detektieren vermag. Dies hätte in den meisten Fällen für den Patienten direkte therapeutische Konsequenzen, da dann eine orale Antikoagulation indiziert wäre, wodurch effektiv die Re-Schlaganfallrate gesenkt werden könnte. In der vorliegenden Arbeit werden die aktuellen Studien zur Detektion von VHF nach einem stattgehabten ischämischen Schlaganfall referiert, typische offene Fragestellungen diskutiert und die Entwicklung hinsichtlich Therapie und Langzeit-EKG-Diagnostik erörtert.

Abstract

The definition of cryptogenic ischemic stroke is inconsistently defined in the current literature. In particular, the compulsory cardiologic diagnostic work-up recommended for these patients varies greatly. Therefore, it is not surprising that there is a great variation in the reported percentage of cryptogenic among all ischemic strokes in published studies. Yet, especially in this group of stroke patients, undetected, paroxysmal atrial fibrillation (AF) is considered to be a frequent cause of ischemic stroke. Current guidelines recommend a 24-hour Holter ECG monitoring after suspected cardioembolic stroke; however, convincing data suggest that a prolonged Holter ECG monitoring significantly more frequently leads to the detection of paroxysmal AF. In a majority of cases, this would have a therapeutic consequence since oral anticoagulation is indicated in such cases to effectively prevent recurrent stroke. The following article reviews current studies assessing the detection of paroxysmal AF after ischemic stroke, discusses questions still open and delineates the development of therapy and long-term-ECG diagnostics.

Schlüsselwörter

paroxysmales Vorhofflimmern - ischämischer Schlaganfall - TOAST-Kriterien - kardiogene Embolie - embolic stroke of unknown source (ESUS)

Keywords

paroxysmal atrial fibrillation - ischemic stroke - TOAST criteria - cardioembolism - embolic stroke of unknown source (ESUS)

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