Vorhofflimmern und NOAK-Therapie: Benötigen wir eine transösophageale Echokardiografie vor Kardioversion?

Zusammenfassung

Vorhofflimmern ist ein häufiger Grund für einen Schlaganfall. Insbesondere Patienten ohne adäquate Antikoagulation haben ein erhöhtes Risiko für thromboembolische Ereignisse (ca. 5–7%). Es liegt eine Assoziation zwischen Kardioversionen und embolischen Ereignissen vor. Durch eine orale Antikoagulation (OAK) mit Nicht-Vitamin-K-Antagonisten (NOAK) kann dieses Risiko auf unter 1% reduziert werden. Es gibt 2 unterschiedliche Kardioversionsstrategien. Zum einen kann eine Kardioversion nach 3-wöchiger effektiver Antikoagulation ohne weitere Bildgebung durchgeführt werden. Zum anderen kann nach Ausschluss einer intrakardialen Thrombenbildung durch eine TEE umgehend sicher kardiovertiert werden. Bei Vorhofflimmern sollte nach der Kardioversion eine effektive Antikoagulation für mindestens 4 Wochen erfolgen, unabhängig vom CHA2DS2-VASc-Score. Eine Bildgebung mittels TEE ist notwendig, wenn die Dauer einer effektiven Antikoagulation <3 Wochen ist, Unsicherheiten bezüglich der regelmäßigen und lückenlosen Medikamenteneinnahme bestehen oder ein hohes Risiko für linksatriale Thromben besteht.

Abstract

Atrial fibrillation is a common cause of stroke. In particular, patients without adequate anticoagulation are at increased risk of thromboembolic events (approximately 5–7%). There is an association between cardioversions (CV) and embolic events. Oral anticoagulation (OAC) with non-Vitamin K antagonist (NOAC) can reduce this risk to less than 1%. There are two different strategies for cardioversion. CV can be performed after 3 weeks of effective anticoagulation without further imaging or without delay but after ruling out intracardiac thrombus formation by TOE. In AF, effective anticoagulation should be given for at least 4 weeks after CV regardless of CHA2DS2VASc score. TOE is recommended if the duration of effective anticoagulation is shorter than 3 weeks, if there remains any uncertainty regarding daily intake of anticoagulation or in patients at high risk of left atrial thrombus formation.

Was ist wichtig?

Vorhofflimmern ist ein häufiger Grund für einen embolischen Schlaganfall. Darüber hinaus liegt eine Assoziation zwischen Kardioversionen und embolischen Schlaganfällen vor. Verschiedene Faktoren beeinflussen die Rate an Vorhofohrthromben trotz NOAK-Therapie (z.B. CHA₂DS₂-VASc-Score >3, vormals Thromboembolien, Herzinsuffizienz, Diabetes mellitus, Alter ≥75 Jahre). Durch eine effektive Antikoagulation kann die Rate embolischer, zerebraler Ischämien gesenkt werden. Die ESC-Leitlinien von 2016 und 2020 empfehlen, eine neue und dauerhafte Antikoagulation mit einem NOAK anstelle eines VKA zu beginnen. Im Gegensatz zur späten Kardioversionsstrategie erfordert die frühe Kardioversion eine Bildgebung mittels TEE.

Schlüsselwörter

neue orale Antikoagulanzien - Kardioversion - Vorhofflimmern - transösophageale Echokardiografie

Keywords

transesophageal echocardiography - novel oral anticoagulants - cardioversion - atrial fibrillation

Publication History

Article published online:
14 June 2021

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