Risikoadaptierte Antikoagulation zur Schlaganfallprävention bei Vorhofflimmern in Deutschland, Österreich und der Schweiz

Zusammenfassung

Hintergrund | Das Management von Patienten mit Vorhofflimmern (VHF) hat in den letzten Jahren zahlreiche Verbesserungen erfahren, unter anderem durch die Einführung neuer Scores zur Stratifizierung des Schlaganfallsrisikos, wie auch durch die Verfügbarkeit der nicht-Vitamin-K oralen Antikoagulanzien (NOAK). Ziel der PREFER-in-AF-Studie war es, die Versorgung von Patienten mit VHF unter besonderer Berücksichtigung der Schlaganfallprävention durch Antikoagulation zu untersuchen.

Patienten | In Deutschland, Österreich und der Schweiz wurden zwischen Januar 2012 bis Januar 2013 1771 Patienten in die Studie eingeschlossen (mittleres Alter 71,9 ± 9,2 Jahre; 63 % Männer). Zu Beobachtungsbeginn betrug die mittlere Zeit seit Erstdiagnose von VHF 4,8 ± 5,3 Jahre, wobei 30,7 % der Patienten paroxysmales, 11,0 % persistierendes, 4,7 % langanhaltend persistierendes, und 53,3 % permanentes VHF aufwiesen. Ein Sinusrhythmus lag bei 25,1 % vor. Der mittlere CHA₂DS₂-VASc-Score lag bei 3,7 ± 1,8 Punkten (0 Punkte bei 3,0 %, 1 Punkt bei 7,1 %, ≥ 2 Punkte bei 89,9 %).

Ergebnisse | Zur Prophylaxe thromboembolischer Ereignisse erhielten 68,1 % der Patienten Vitamin-K-Antagonisten (VKA, überwiegend Phenprocoumon), 11,6 % wurden mit einem NOAK behandelt (hauptsächlich Rivaroxaban oder Dabigatran), 7,6 % mit Thrombozytenaggregationshemmern (TAH) und 7,7 % mit VKA und TAH in Kombination. Keinerlei Thromboembolie-Prophylaxe erhielten 5,0 % der Patienten. Ein temporäres Absetzen von VKA bei Interventionen wurde bei 29,7 % in den 12 Monaten vor Einschluss berichtet. Die Rate von adäquat eingestellten Patienten (mindestens 2 von 3 INR-Werten im Bereich 2,0–3,0) lag bei 75,1 % (bezogen auf Patienten mit bekannten INR-Werten und Risikoscore).

Eine Blutungsneigung bzw. Blutungen in der Anamnese wurden bei 5,1 % der Patienten berichtet, Hospitalisierungen aufgrund größerer Blutungen in den letzten 12 Monaten bei 1,9 %. Mögliche Risikofaktoren für eine Antikoagulation bestanden bei 76,7 % der Patienten. Der mittlere HAS-BLED-Score betrug 2,1 ± 1,1 Punkte.

Schlussfolgerung | Die Rate der mit oraler Antikoagulation behandelten VHF-Patienten lag mit knapp 90 % deutlich höher als in älteren Beobachtungsstudien. NOAK wurden bei 12 % der Patienten eingesetzt.

Abstract

Background: The management of patients with atrial fibrillation (AF) has substantially improved in recent years, among others due to the introduction of new risk scores for the stratification of patients, as well as the availability of the non-vitamin K oral antagonists (NOAC). The PREFER-in-AF study aimed to document the management of AF patients with particular focus on stroke prevention on the basis of anticoagulants.

Methods and results: In Germany, Austria and Switzerland a total of 1771 patients were enrolled between January 2012 and January 2013 (mean age 71.9 ± 9.2 years; 63 % males).

At inclusion, the mean time since AF diagnosis was 4.8 ± 5.3 years. Paroxysmal AF was present in 30.7 %, persistent in 11 %, long standing persistent in 4.7 % and permanent AF in 53.3 % of the patients. 25.1 % of the Patients were in sinus rhythm. Mean CHA₂DS₂-VASc Score was 3.7 ± 1.8 points (0 points in 3.0 %, 1 point in 7.1 %, ≥ 2 points in 89.9 %).

For the prevention of thromboembolic events 68.1 % of patients received vitamin K antagonists (VKA, mainly phenprocoumon), 11.6 % received a NOAC (mainly rivaroxaban or dabigatran), 7.6 % an antiplatelet agent, and 7.7 % a combination of VKA plus an antiplatelet agent. 5.0 % of patients did not receive any anticoagulant. During the 12 months prior to inclusion, interruption of VKA therapy due to an interventions was reported in 29.7 %. In the group of patients with known INR values and available CHA₂DS₂-VASc score, 75.1 % were adequately controlled (defined as at least 2 of 3 INR values in the range of 2.0–3.0).

Bleeding propensity or bleedings in patient history were reported for 5.1 % of the patients, hospitalizations due to major bleeding events in the past 12 months for 1.9 %. Possible risk factors associated with anticoagulation were present in 76.7 %. Mean HAS-BLED score was 2.1 ± 1.1 points.

Conclusion: The rates of AF patients who received oral anticoagulation were about 90 % and substantially higher compared to previous observational studies. NAOCs were administered to 11.7 % of patients.

Schlüsselwörter

Register - Querschnittstudie - Antikoagulation - Vitamin K Antagonisten - Neue Orale Antikoagulanzien - Einstellung - INR

Keywords

Registry - Anticoagulation - Vitamin K antagonist - NOAC - INR control

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