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.

Schlüsselwörter

neue orale Antikoagulanzien - Kardioversion - Vorhofflimmern - transösophageale Echokardiografie

Keywords

transesophageal echocardiography - novel oral anticoagulants - cardioversion - atrial fibrillation

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