Herzrhythmusstörungen nach Schlaganfall

Zusammenfassung

Jeder vierte Patient leidet in der Akutphase des Schlaganfalles unter klinisch relevanten Herzrhythmusstörungen, die den Krankheitsverlauf durch hämodynamische Instabilität verkomplizieren, die körperliche Leistungsfähigkeit des Patienten während der Neurorehabilitation limitieren und das Rezidivrisiko des Schlaganfalles erhöhen können. Auf der Stroke Unit erreicht eine gezielte Analyse der kontinuierlichen EKG-Ableitung in Form einer „Rhythmusvisite“ nahezu eine Verdoppelung der Detektionsrate von paroxysmalem Vorhofflimmern im Vergleich zum konventionellen Monitoring. Nach unauffälliger stationärer Diagnostik kommen bei begründetem Verdacht auf unerkannte kardiale Arrhythmien innovative Techniken zum ambulanten Langzeitmonitoring zum Einsatz. Therapeutisch steht für den Neurologen neben dem Notfallmanagement der Arrhythmie insbesondere die differenzierte antithrombotische Therapie zur Sekundärprophylaxe des Schlaganfalles im Vordergrund. Dabei ergeben sich besondere Fragestellungen und klinische Herausforderungen.

Abstract

1 in 4 patients with acute stroke suffers from clinically relevant cardiac arrhythmia that may complicate the clinical course by hemodynamic instability, limit the success of rehabilitation care and increase the risk for stroke recurrence. A structured analysis of the continuous ECG recordings at the stroke unit can double the detection rate of paroxysmal atrial fibrillation compared to conventional monitoring. In case of suspected cardiac arrhythmia, ambulatory long-term rhythm monitoring is available for patients with stroke of unknown cause. Apart from the emergency management of arrhythmia, different aspects of the antithrombotic treatment for secondary prevention are of major therapeutic relevance and represent clinical challenges for the neurologist.

Schlüsselwörter

Schlaganfall - Arrhythmien - Embolie - Vorhofflimmern

Keywords

stroke - arrhythmia - embolism - atrial fibrillation

• Literatur

• 1 Kapa S, DeSimone CV, Asirvatham SJ. Innervation of the heart: An invisible grid within a black box. Trends Cardiovasc Med 2016; 26: 245-257
• 2 Coote JH, Chauhan RA. The sympathetic innervation of the heart: Important new insights. Auton Neurosci 2016; 199: 17-23
• 3 Soros P, Hachinski V. Cardiovascular and neurological causes of sudden death after ischaemic stroke. Lancet Neurol 2012; 11: 179-188
• 4 Jahn K, Dichgans M. Heart-brain interaction in intensive care medicine. Dtsch med Wochenschr 2010; 135: 2347-2352
• 5 Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet Neurol 2010; 9: 105-118
• 6 Cechetto DF. Identification of a cortical site for stress-induced cardiovascular dysfunction. Integr Physiol Behav Sc 1994; 29: 362-373
• 7 Schwartz PJ. Cardiac sympathetic denervation to prevent life-threatening arrhythmias. Nat Rev Cardiol 2014; 11: 346-353
• 8 Noheria A, Patel SM, Mirzoyev S. et al. Decreased postoperative atrial fibrillation following cardiac transplantation: the significance of autonomic denervation. Pacing and clinical electrophysiology: PACE 2013; 36: 741-747
• 9 Cohn WE, Gregoric ID, Radovancevic B. et al. Atrial fibrillation after cardiac transplantation: experience in 498 consecutive cases. Ann Thorac Surg 2008; 85: 56-58
• 10 Wake E, Brack K. Characterization of the intrinsic cardiac nervous system. Auton Neurosc 2016; 199: 3-16
• 11 Lu Z, Scherlag BJ, Lin J. et al. Autonomic mechanism for initiation of rapid firing from atria and pulmonary veins: evidence by ablation of ganglionated plexi. Cardiovasc Res 2009; 84: 245-252
• 12 Krogh A, Lindhard J. The regulation of respiration and circulation during the initial stages of muscular work. J Physiol 1913; 47: 112-136
• 13 Critchley HD, Mathias CJ, Josephs O. et al. Human cingulate cortex and autonomic control: converging neuroimaging and clinical evidence. Brain 2003; 126: 2139-2152
• 14 Duschek S, Worsching J, Reyes Del Paso GA. Autonomic cardiovascular regulation and cortical tone. Clin Physiol Funct Imaging 2015; 35: 383-392
• 15 Oppenheimer SM, Gelb A, Girvin JP. et al. Cardiovascular effects of human insular cortex stimulation. Neurology 1992; 42: 1727-1732
• 16 Cechetto DF. Cortical control of the autonomic nervous system. Exp Physiol 2014; 99: 326-331
• 17 Seifert F, Kallmunzer B, Gutjahr I. et al. Neuroanatomical correlates of severe cardiac arrhythmias in acute ischemic stroke. J Neurol 2015; 262: 1182-1190
• 18 Kallmunzer B, Breuer L, Kahl N. et al. Serious cardiac arrhythmias after stroke: incidence, time course, and predictors – A systematic, prospective analysis. Stroke 2012; 43: 2892-2897
• 19 Rem JA, Hachinski VC, Boughner DR. et al. Value of cardiac monitoring and echocardiography in TIA and stroke patients. Stroke 1985; 16: 950-956
• 20 Kwok CS, Rashid M, Beynon R. et al. Prolonged PR interval, first-degree heart block and adverse cardiovascular outcomes: a systematic review and meta-analysis. Heart 2016; 102: 672-680
• 21 Rincon F, Dhamoon M, Moon Y. et al. Stroke location and association with fatal cardiac outcomes: Northern Manhattan Study (NOMAS). Stroke 2008; 39: 2425-2431
• 22 Hilz MJ, Schwab S. Stroke-induced sudden-autonomic death: areas of fatality beyond the insula. Stroke 2008; 39: 2421-2422
• 23 Samuels MA. The brain-heart connection. Circulation 2007; 116: 77-84
• 24 Hawkins WE, Clower BR. Myocardial damage after head trauma and simulated intracranial haemorrhage in mice: the role of the autonomic nervous system. Cardiovasc Res 1971; 5: 524-529
• 25 Koppikar S, Baranchuk A, Guzman JC. et al. Stroke and ventricular arrhythmias. Int J Cardiol 2013; 168: 653-659
• 26 Katsanos AH, Korantzopoulos P, Tsivgoulis G. et al. Electrocardiographic abnormalities and cardiac arrhythmias in structural brain lesions. Int J Cardiol 2013; 167: 328-334
• 27 Stead LG, Gilmore RM, Bellolio MF. et al. Prolonged QTc as a predictor of mortality in acute ischemic stroke. J Stroke Cerebrovasc Dis 2009; 18: 469-474
• 28 Bobinger T, Kallmunzer B, Kopp M. et al. Prevalence and impact on outcome of electrocardiographic early repolarization patterns among stroke patients: a prospective observational study. Clin Res Cardiol 2015; 104: 666-671
• 29 Friberg L, Rosenqvist M, Lindgren A. et al. High prevalence of atrial fibrillation among patients with ischemic stroke. Stroke 2014; 45: 2599-2605
• 30 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-989
• 31 Watson T, Shantsila E, Lip GY. Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet 2009; 373: 155-166
• 32 Brambatti M, Connolly SJ, Gold MR. et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation 2014; 129: 2094-2099
• 33 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
• 34 Martin DT, Bersohn MM, Waldo AL. et al. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. Eur Heart J 2015; 36: 1660-1668
• 35 Akoum N. New perspectives on atrial fibrillation and stroke. Heart 2016;
• 36 Kamel H, Okin PM, Elkind MS. et al. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke 2016; 47: 895-900
• 37 Chen PS, Chen LS, Fishbein MC. et al. Role of the autonomic nervous system in atrial fibrillation: pathophysiology and therapy. Circul Res 2014; 114: 1500-1515
• 38 Viskin S, Golovner M, Malov N. et al. Circadian variation of symptomatic paroxysmal atrial fibrillation. Data from almost 10 000 episodes. Eur Heart J 1999; 20: 1429-1434
• 39 Sposato LA, Riccio PM, Hachinski V. Poststroke atrial fibrillation: cause or consequence? Critical review of current views. Neurology 2014; 82: 1180-1186
• 40 Scheitz JF, Erdur H, Haeusler KG. et al. Insular cortex lesions, cardiac troponin, and detection of previously unknown atrial fibrillation in acute ischemic stroke: insights from the troponin elevation in acute ischemic stroke study. Stroke 2015; 46: 1196-1201
• 41 Gonzalez Toledo ME, Klein FR. et al. Atrial fibrillation detected after acute ischemic stroke: evidence supporting the neurogenic hypothesis. J Stroke Cerebrovasc Dis 2013; 22: e486-e491
• 42 Rizos T, Horstmann S, Dittgen F. et al. Preexisting heart disease underlies newly diagnosed atrial fibrillation after acute ischemic stroke. Stroke 2016; 47: 336-341
• 43 Chung MK, Martin DO, Sprecher D. et al. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation 2001; 104: 2886-2891
• 44 Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). Eur Heart J 2016, Epub 2016/08/28
• 45 Kurka N, Bobinger T, Kallmunzer B. et al. Reliability and limitations of automated arrhythmia detection in telemetric monitoring after stroke. Stroke 2015; 46: 560-563
• 46 Rizos T, Guntner J, Jenetzky E. et al. Continuous stroke unit electrocardiographic monitoring versus 24-hour Holter electrocardiography for detection of paroxysmal atrial fibrillation after stroke. Stroke 2012; 43: 2689-2694
• 47 Kallmunzer B, Breuer L, Hering C. et al. A structured reading algorithm improves telemetric detection of atrial fibrillation after acute ischemic stroke. Stroke 2012; 43: 994-999
• 48 Kallmunzer B, Bobinger T, Kahl N. et al. Peripheral pulse measurement after ischemic stroke: A feasibility study. Neurology 2014; 83: 598-603
• 49 Sanna T, Diener HC, Passman RS. et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478-2486
• 50 Gladstone DJ, Spring M, Dorian P. et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370: 2467-2477
• 51 Link MS, Berkow LC, Kudenchuk PJ. et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132 (Suppl. 02) S444-S464
• 52 Vadmann H, Nielsen PB, Hjortshoj SP. et al. Atrial flutter and thromboembolic risk: a systematic review. Heart 2015; 101: 1446-1455
• 53 Ntaios G, Papavasileiou V, Diener HC. et al. Nonvitamin-K-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials. Stroke 2012; 43: 3298-3304
• 54 Graham DJ, Reichman ME, Wernecke M. et al. Stroke, bleeding, and mortality risks in elderly medicare beneficiaries treated with dabigatran or rivaroxaban for nonvalvular atrial fibrillation. JAMA 2016; 176: 1662-1671
• 55 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;
• 56 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;
• 57 Paciaroni M, Agnelli G, Micheli S. et al. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke 2007; 38: 423-430
• 58 Macha K, Volbers B, Bobinger T. et al. Early initiation of anticoagulation with direct oral anticoagulants in patients after transient ischemic attack or ischemic. Stroke 2016; 25: 2317-2321
• 59 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24: 35-41
• 60 Hart RG, Diener HC, Coutts SB. et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13: 429-438
• 61 Suissa L, Bertora D, Lachaud S. et al. Score for the targeting of atrial fibrillation (STAF): a new approach to the detection of atrial fibrillation in the secondary prevention of ischemic stroke. Stroke 2009; 40: 2866-2868
• 62 Nolte CH, Scheitz JF, Endres M. Troponin elevation in ischemic stroke patients. Med Klin Intensivmed Notfallmed 2015; epub ahead of print
• 63 Koenig MA, Puttgen HA, Prabhakaran V. et al. B-type natriuretic peptide as a marker for heart failure in patients with acute stroke. Intens Care Med 2007; 33: 1587-1593
• 64 Baturova MA, Sheldon SH, Carlson J. et al. Electrocardiographic and Echocardiographic predictors of paroxysmal atrial fibrillation detected after ischemic stroke. BMC Cardiovas Disord 2016; 16: 209
• 65 Ntaios G, Papavasileiou V, Milionis H. et al. Embolic strokes of undetermined source in the Athens stroke registry: an outcome analysis. Stroke 2015; 46: 2087-2093
• 66 Kishore A, Vail A, Majid A. et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45: 520-526
• 67 Kapa S, DeSimone CV, Asirvatham SJ. Innervation of the heart: An invisible grid within a black box. Trends Cardiovasc Med 2016; 26: 245-257
• 68 Kallmünzer B, Breuer L, Hering C. et al. A structured reading algorithm improves telemetric detection of atrial fibrillation after acute ischemic stroke. Stroke 2012; 43: 994-999