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Aktuelle Kardiologie 2017; 6(06): 424-430
DOI: 10.1055/s-0043-118669
Übersichtsarbeit
Georg Thieme Verlag KG Stuttgart · New York

Kryptogener Schlaganfall: Rhythmusdetektion versus pragmatische orale Antikoagulation

Cryptogenic Stroke: Rhythm-Monitoring Versus Pragmatic Oral Anticoagulation
Clemens Jilek
Klinik für Kardiologie und Internistische Intensivmedizin, Internistisches Klinikum München Süd – Peter Osypka Herzzentrum
,
Thorsten Lewalter
Klinik für Kardiologie und Internistische Intensivmedizin, Internistisches Klinikum München Süd – Peter Osypka Herzzentrum
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Publication History

Publication Date:
06 December 2017 (online)

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Zusammenfassung

Der kryptogene Schlaganfall betrifft 20 – 25% der ischämischen Schlaganfälle und wird vom Mechanismus als embolisch angesehen. Zur Identifikation von rhythmogenen Ursachen stehen implantierbare Event-Recorder zur Verfügung, die in der CRYSTAL-AF-Studie bei bis zu 30% der Patienten mit kryptogenem Schlaganfall innerhalb von 3 Jahren Vorhofflimmern nachweisen konnten. Event-Recorder sind effektiv und im britischen Gesundheitssystem kostendeckend. Studien zur pragmatischen oralen Antikoagulation mit Warfarin konnten dagegen keinen Vorteil bez. Verhinderung ischämischer Schlaganfälle zeigen und gingen überwiegend mit hohem Blutungsrisiko einher. Lediglich Sub-Subgruppen zeigten einen geringen Vorteil. Nicht-Vitamin-K-abhängige orale Antikoagulanzien (nOAK) zeigen im Vergleich zu Vitamin-K-Antagonisten ein besseres Effektivitäts- und Sicherheitsprofil. Drei randomisierte Studien rekrutieren aktuell Patienten, um den Wert der pragmatischen oralen Antikoagulation in der Vermeidung von Schlaganfällen bei Patienten mit stattgehabtem kryptogenem Schlaganfall zu evaluieren. Zusammengefasst liegt eine Klasse-IB-Indikation für das Rhythmusmonitoring nach kryptogenem Schlaganfall vor. Für eine pragmatische orale Antikoagulation fehlen bisher überzeugende Daten. Ergebnisse der nOAK-Studien sollten ab Ende 2018 verfügbar sein.

Abstract

Cryptogenic stroke accounts for 20 – 25% of ischemic stroke in Germany. Embolism may be the main mechanism. Rhythm monitoring with implantable event recorder has proven in the CRYSTAL-AF trial to identify atrial fibrillation in up to 30% of patients with cryptogenic stroke in a period of 3 years. Cost-effectiveness was shown for the British health system. Trials for pragmatic oral anticoagulation among patients with cryptogenic stroke showed no advantage for warfarin mainly due to high bleeding risk. Only in specific sub-subgroups warfarin could have a slight benefit. Non-Vitamin-K-dependent oral anticoagulants (nOAC) show a better safety and efficacy profile compared to Vitamin-K-antagonists. Three randomized trials are recruiting patients to verify the value of nOACs among patients with cryptogenic stroke. In conclusion, there is a Class IB recommendation for rhythm monitoring with implantable event recorder after cryptogenic stroke. Warfarin is not recommended, whereas the data for nOAC are expected to be available beginning end of 2018.

Was ist wichtig?

  • Der kryptogene Schlaganfall macht 20 – 25% aller ischämischen Schlaganfälle in Deutschland aus. 58% der kryptogenen Schlaganfälle scheinen kardioembolischer Genese zu sein.

  • Implantierbare Event-Recorder sind Langzeit-EKG-Untersuchungen in der Detektion von Vorhofflimmern bei kryptogenem Schlaganfall deutlich überlegen. Es besteht eine Klasse-IB-Empfehlung für die Implantation von Event-Recordern nach kryptogenem Schlaganfall.

  • Die pragmatische orale Antikoagulation mit Vitamin-K-Antagonisten hat keinen effektiven Nutzen bei Patienten mit kryptogenem Schlaganfall zum jetzigen Zeitpunkt. Nicht-Vitamin-K-abhängige orale Antikoagulanzien könnten eine Möglichkeit zur pragmatischen oralen Antikoagulation darstellen. Ergebnisse aus randomisierten Studien sind ab Ende 2018 zu erwarten.

Schlüsselwörter

kryptogener Schlaganfall - embolischer Schlaganfall unbestimmten Ursprungs (ESUS) - Event-Recorder - orale Antikoagulation

Key words

cryptogenic stroke - embolic stroke of undetermined source (ESUS) - loop recorder - oral anticoagulation
 

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