Antikoagulation und neue Therapieoptionen bei Vorhofflimmern

Zusammenfassung

Der oralen Antikoagulation kommt bei Patienten mit Vorhofflimmern eine entscheidende Rolle zu, da sie bei den meisten Patienten zur Reduktion des Schlaganfallrisikos indiziert ist. Sinnvoll ist eine Abschätzung des Schlaganfallrisikos mit Hilfe des CHA₂DS₂-VASc-Scores und des Blutungsrisikos anhand des HAS-BLED-Scores. Die orale Antikoagulation ist prinzipiell indiziert bei allen Patienten mit valvulärem Vorhofflimmern (Vorhofflimmern bei relevanter Mitralklappenstenose oder Kunstklappe) sowie bei Patienten mit nicht-valvulärem Vorhofflimmern ab einem CHA₂DS₂-VASc-Score von 1 – 2 Punkten. Die Indikation erfolgt zumeist unabhängig davon, ob Vorhofflimmern paroxysmal, persistierend oder permanent auftritt.

Nicht-Vitamin-K-Antagonisten (NOAK) stellen für viele Patienten die Therapie der ersten Wahl dar. Die Wahl des geeigneten Antikoagulans sollte in Abhängigkeit von Patienten- und Arztpräferenz anhand weiterer Faktoren wie Niereninsuffizienz, Ko-Medikation und Blutungsrisiko erfolgen.

Insbesondere für Patienten mit Kontraindikation für eine orale Antikoagulation stellt der interventionelle Vorhofohrverschluss eine Therapiealternative dar.

Abstract

Oral anticoagulation plays an essential role in the treatment of patients with atrial fibrillation as it is indicated for most patients to reduce the risk of stroke. It is prudent to assess the risks of stroke and bleeding using the CHA₂DS₂-VASc and HAS-BLED scores. Oral anticoagulation is indicated in general for all patients with valvular atrial fibrillation (atrial fibrillation in moderate to severe mitral stenosis or mechanical prosthetic valve) as well as for patients with a CHA₂DS₂-VASc-Score of 1 – 2 points or higher. The indication is irrespective of the form of atrial fibrillation: paroxysmal, persistent or permanent.

Non-vitamin K antagonists (NOAK) are first-line therapy for many patients. The selection of the appropriate drug should be based on preference of patient and physician as well as other factors such as renal insufficiency, co-medication and bleeding risk.

Percutaneous left atrial appendage closure is a therapeutic alternative especially for patients with a contraindication for oral anticoagulation.

Schlüsselwörter

Antikoagulation - NOAK - Vorhofohrverschluss

Keywords

anticoagulation - NOAK - left atrial appendage closure

• Literatur

• 1 Kirchhoff P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;
• 2 Hohnloser SH, Pajitnev D, Pogue J et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. J Am Coll Cardiol 2007; 50: 2156-2161
• 3 Vanassche T, Lauw MN, Eikelboom JW et al. Risk of ischaemic stroke according to pattern of atrial fibrillation: analysis of 6563 aspirin-treated patients in ACTIVE-A and AVERROES. Eur Heart J 2015; 36: 281-287
• 4 Lip GY, Frison L, Grind M et al. Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation. J Intern Med 2008; 264: 50-61
• 5 Senoo K, Lip GY, Lane DA et al. Residual Risk of Stroke and Death in Anticoagulated Patients According to the Type of Atrial Fibrillation: AMADEUS Trial. Stroke 2015; 46: 2523-2528
• 6 January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS guideline 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 Heart Rhythm Society. Circulation 2014; 130: e199-267
• 7 Fauchier L, Lecoq C, Clementy N et al. Oral Anticoagulation and the Risk of Stroke or Death in Patients With Atrial Fibrillation and One Additional Stroke Risk Factor: The Loire Valley Atrial Fibrillation Project. Chest 2016; 149: 960-968
• 8 Chao TF, Liu CJ, Wang KL et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation?. J Am Coll Cardiol 2015; 65: 635-642
• 9 Pisters R, Lane DA, Nieuwlaat R et al. A novel userfriendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138: 1093-1100
• 10 Kirchhof P, Goette A, Gulba D et al. Kommentar zu den Leitlinien der ESC zum Vorhofflimmern. Kardiologe 2012; 6: 12-27
• 11 Diener HC, Aisenberg J, Ansell J et al. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J 2016; pii: ehv643
• 12 Glotzer TV, Daoud EG, Wyse DG et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009; 2: 474-480
• 13 Daoud EG, Glotzer TV, Wyse DG et al. Temporal relationship of atrial tachyarrhythmias, cerebrovascular events, and systemic emboli based on stored device data: a subgroup analysis of TRENDS. Heart Rhythm 2011; 8: 1416-1423
• 14 Healey JS, Connolly SJ, Gold MR et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366: 120-129
• 15 Lamas G. How much atrial fibrillation is too much atrial fibrillation?. N Engl J Med 2012; 366: 178-180
• 16 Ruff CT, Giugliano RP, Braunwald E et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383: 955-962
• 17 Granger CB, Alexander JH, McMurray JJ et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011; 365: 981-992
• 18 Connolly SJ, Ezekowitz MD, Yusuf S et al. Dabigatran versus warfarin in patients with atrial fi brillation. N Engl J Med 2009; 361: 1139-1151
• 19 Patel MR, Mahaff ey KW, Garg J et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-891
• 20 Giugliano RP, Ruff CT, Braunwald E et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369: 2093-2104
• 21 Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17: 1467-1507
• 22 Mischke K, Knackstedt C, Marx N. Anticoagulant and antiplatelet therapy in patients with atrial fibrillation and coronary artery disease. Thrombosis 2012; 2012: 184573
• 23 Connolly SJ, Eikelboom J, Joyner C et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364: 806-817
• 24 De Caterina R, Husted S, Wallentin L et al. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis–Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110: 1087-1107
• 25 Diener HC, Aisenberg J, Ansell J et al. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J 2016; pii: ehw069
• 26 Mant J, Hobbs F, Fletcher K et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493-503
• 27 Chatterjee S, Alexander JC, Pearson PJ et al. Left atrial appendage occlusion: lessons learned from surgical and transcatheter experiences. Ann Thorac Surg 2011; 92: 2283-2292
• 28 Kanderian AS, Gillinov AM, Pettersson GB et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008; 52: 924-929
• 29 Healey JS, Crystal E, Lamy A et al. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J 2005; 150: 288-293
• 30 Whitlock R, Healey J, Vincent J et al. Rationale and design of the left atrial appendage occlusion study (LAAOS) III. Ann Cardiothorac Surg. 2014; 3: 45-54
• 31 Windecker S, Kolh P, Alfonso F et al. 2014 ESC/EACTS guidelines on myocardial revascularization: The task force on myocardial revascularization of the European Society Of Cardiology (ESC) and The European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014; 35: 2541-2619
• 32 Bartus K, Han FT, Bednarek J et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol 2013; 62: 108-118
• 33 Holmes Jr DR, Doshi SK, Kar S et al. Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation: A Patient-Level Meta-Analysis. J Am Coll Cardiol 2015; 65: 2614-2623
• 34 Pillarisetti J, Reddy YM, Gunda S et al. Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm 2015; 12: 1501-1507
• 35 Park JW, Bethencourt A, Sievert H et al. Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv 2011; 77: 700-706
• 36 Brzeziński M, Bury K, Dąbrowski L et al. The New 3D Printed Left Atrial Appendage Closure with a Novel Holdfast Device: A Pre-Clinical Feasibility Animal Study. PLoS One 2016; 24 (11) e0154559