Eisen und Digitalis bei Herzinsuffizienz

Zusammenfassung

Neben der medikamentösen Standardtherapie der Herzinsuffizienz (HI) gilt es, Patienten zu identifizieren, die von einer Eisensupplementation oder Therapie mit Digitalis profitieren können. Wir haben die aktuelle Evidenz für diese Therapien zusammengestellt und beschreiben, wie die HI-Therapie mit Eisen und Digitalis individualisiert werden kann. Eine Eisensupplementation verbessert Leistungsfähigkeit, Symptome und Lebensqualität bei Patienten mit symptomatischer Herzinsuffizienz und Eisenmangel. Die Daten aus der unlängst publizierten AFFIRM-AHF-Studie zeigen, dass eine Eisentherapie mit Eisencarboxymaltose zudem HI-Hospitalisationen verhindert. Die Therapie mit Digitalis sollte bei fortgeschrittenen Stadien der Herzinsuffizienz mit reduzierter systolischer Funktion trotz leitliniengerechter Pharmako- und Devicetherapie in Erwägung gezogen werden, insbesondere, wenn diese aufgrund von Komorbiditäten nur eingeschränkt möglich ist. Auch bei koexistentem Vorhofflimmern ist Digitalis zur Herzfrequenzkontrolle von großem Wert. Serumkonzentrationen von Digitalis im niedrigen therapeutischen Bereich sind anzustreben.

Abstract

It is important to identify patients who may derive benefit from iron supplementation or digitalis beyond guideline-directed therapy for heart failure (HF). Here we review current evidence for both HF therapies and describe how iron supplementation and digitalis can be utilized to personalize medical therapy in HF. Iron supplementation improves exercise tolerance, symptoms, and quality of life in patients with HF with reduced ejection fraction (HFrEF) and iron deficiency. Data from the recently published AFFIRM-AHF trial show that treatment with iron carboxymaltose also prevents HF hospitalizations in these patients. Treatment with digitalis should be considered in advanced stages of HF despite guideline-directed pharmaco- and device-therapy, especially if these are difficult to establish due to comorbidities. In patients with HF and atrial fibrillation digitalis still is of great value for heart rate control. Digitalis serum concentrations in the lower therapeutic range should be achieved.

Was ist wichtig?

• Eisenmangel, eine häufige Komorbidität bei Herzinsuffizienz (HI), verschlechtert die Leistungsfähigkeit, Lebensqualität und Prognose der Patienten. Daher sollte ein Eisenmangel unbedingt diagnostiziert werden, um Patienten zu identifizieren, die von einer Eisensupplementation zusätzlich zur etablierten HI-Medikation profitieren.

• Die aktuelle AFFIRM-AHF-Studie belegt, dass eine Eisensupplementation bei HI-Patienten mit reduzierter linksventrikulärer Ejektionsfraktion und Eisenmangel gut verträglich ist und HI-Hospitalisationen verhindert. Weitere randomisierte klinische Studien zum Einfluss der Eisensupplementation auf Mortalität und Morbidität bei HI laufen.

• Digitalis erscheint bei fortgeschrittener HI mit reduzierter systolischer Funktion und insbesondere bei koexistentem Vorhofflimmern unter Einhaltung niedriger Ziel-Serumkonzentrationen von therapeutischem Nutzen und sicher einsetzbar.

• In nicht randomisierten klinischen Studien täuscht ein signifikanter Behandlungsbias (Einsatz bei per se kränkeren Patienten) einen ungünstigen Effekt von Digitalis auf die Prognose vor. Laufende randomisierte klinische Studien werden den Einfluss von Digitalis auf Mortalität und Morbidität bei HI und/oder Vorhofflimmern klären.

Schlüsselwörter

Herzinsuffizienz - Eisen - Digitalis

Keywords

heart failure - iron - glycosides

Publication History

Article published online:
06 August 2021

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