Orale Antikoagulation bei Vorhofflimmern und stark eingeschränkter Nierenfunktion

ZUSAMMENFASSUNG

Vorhofflimmern ist die häufigste Herzrhythmusstörung. Weltweit ist die Prävalenz steigend und mit Komorbiditäten wie Niereninsuffizienz verbunden. Zur Prävention von Schlaganfällen sind Vitamin-K-Antagonisten (VKA) und Nicht-VKA orale Antikoagulanzien (NOAK) in nierenadaptierter Dosis nur bis zu einer Nierenfunktion mit einer glomerulären Filtrationsrate bis 15 mL/min verfügbar. Unterhalb dieser Nierenfunktion sowie für Patienten mit chronischer Hämodialyse gibt es keine hinreichende Evidenz für oder wider einer OAK. Große Observationsstudien aus den USA und skandinavischen Ländern zeigen Hinweise für ein erhöhtes Blutungsrisiko ohne signifikante Verbesserung von Mortalität oder Schlaganfällen. Die randomisierte kontrollierte VALKYRIE-Studie zeigte eine deutliche Überlegenheit von 10 mg Rivaroxaban (NOAK) im Vergleich zu VKA zur Prävention kardiovaskulärer Ereignisse bei Patienten mit VHF und chronischer Dialyse. Die randomisiert-kontrollierte AXADIA-AFNET-7-Studie vergleicht 2,5 mg Apixaban (NOAK) 2-mal täglich mit VKA in VHF-Patienten mit Dialyse und wird Mitte 2022 abgeschlossen sein. Dadurch werden wichtige neue Erkenntnisse in diesem sensiblen Bereich gewonnen.

ABSTRACT

Atrial fibrillation (AF) is the most common arrhythmia in the world. Prevalence is rising and co-morbidities like chronic kidney disease (CKD) are common. Oral anticoagulation (OAC) is used for stroke prevention in AF but limited to patients without reduced kidney function. Vitamin-K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) are only available for patients with a glomerular filtration function (GFR) above 15 mL/min. In patients with lower GFR or on chronic hemodialysis limited data on efficacy in prevention of stroke is available. Observational data from large cohorts in the United States and Scandinavian countries hinted at increased risk for major bleedings without significant effects of mortality or strokes. The randomized-controlled VALKYRIE study showed that 10 mg of rivaroxaban (NOAC) was associated with less cardiovascular events compared with VKA. The randomized-controlled AXADIA-AFNET 7 study will compare apixaban 2.5 mg BID (NOAC) with VKA in patients with AF and chronic hemodialysis. Enrollment will end in June 2022 and the results will provide importance evidence in this field that has been noted for need for stronger evidence to adequately help AF patients with reduced kidney function.

Schlüsselwörter

Vorhofflimmern - orale Antikoagulation - Schlaganfall - Niereninsuffizienz - Dialyse

Key words

Atrial fibrillation - oral anticoagulation - stroke - hemodialysis - chronic kidney disease

Publikationsverlauf

Artikel online veröffentlicht:
07. Juni 2022

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