Remodeling durch Vorhofflimmern und klinische Implikationen für die Kardioversion

Zusammenfassung

Vorhofflimmern (VHF) tritt zumeist in vorerkrankten Herzen auf. Es führt jedoch auch selbst zu beträchtlichen Umbauvorgängen („Remodeling“), insbesondere der Herzvorhöfe. Diese Vorgänge geschehen zeitabhängig, und es wurden elektrische, kontraktile, endotheliale und strukturelle Remodeling-Prozesse beschrieben. Die medikamentöse Therapie des VHF umfasst neben einer effektiven Antikoagulation gemäß der aktuellen Risikostratifikations-Systeme (CHADS2 oder CHA2DS2VASc) zunächst eine frequenzkontrollierende Behandlung. Sollten Patienten hiernach weiterhin symptomatisch bleiben, ist eine rhythmuskontrollierende Therapie indiziert. Um den Sinusrhythmus zu re-etablieren, kann eine Kardioversion (elektrisch oder pharmakologisch) durchgeführt werden. Die elektrische Kardioversion ist hoch-effektiv, erfordert jedoch eine Sedierung/Narkose zur Durchführung, pharmakologische Kardioversion sollte nur bei hämodynamisch stabilen Patienten mit kurzanhaltendem (< 48 Stunden) VHF durchgeführt werden. Es stehen verschiedene antiarrhythmische Substanzen (Amiodaron, Flecainid, Propafenon und das jüngst zugelassene vorhofselektive Antiarrhythmikum Vernakalant) zur pharmakologischen Kardioversion zur Verfügung. Während Amiodaron nur eine geringe Effektivität für eine rasche Kardioversion aufweist, kann es bei Patienten mit Herzinsuffizienz oder relevanter struktureller Herzerkrankung eingesetzt werden. Klasse-I-Antiarrhythmika können nur bei Patienten ohne relevante strukturelle Herzkrankheit eingesetzt werden, jedoch ist der Wirkeintritt im Vergleich zu Amiodaron rascher. Vernakalant kann bei stabilen Patienten mit struktureller Herzerkrankung angewandt werden und ist eine neue alternative Therapieoption zur raschen pharmakologischen Kardioversion.

Abstract

Atrial fibrillation (AF) most often occurs in pre-diseased hearts. On the other hand substantial alterations (particularly atrial) are induced by the arrhythmia itself. Such remodeling occurs in a time-dependent manner. Remodeling of electrical, contractile, endothelial and structural properties / components has been reported. Medical treatment of AF importantly comprises anticoagulation according to risk stratification scores (CHADS2 or CHA2DS2VASc) besides rate control measures. In patients who remain syptomatic despite rate control a rhythm control strategy is indicated. In order to re-establish sinus rhythm patients may undergo electrical or pharmacological cardioversion. Electrical cardioversion is highly efficient but requires conscious sedation, pharmacological cardioversion should only be performed in hemodynamically stable patients with recent (< 48 h) onset AF. Several anti-arrhythmic options exist for pharmacological cardioversion (amiodarone, flecainide, propafenone and the recently approved atrial-specific agent vernakalant). While amiodarone has low efficacy for rapid restoration of sinus rhythm, it can be given to patients with heart failure or significant structural heart disease. Class-I substances can only be applied to patients without significant structural heart disease but onset of action is more rapid. Vernakalant can be applied to hemodynamically stable patients with structural heart disease and represents a novel alternative option for rapid pharmacological cardioversion.

Vorhofflimmern - Kardioversion - vorhofselektive Antiarrhythmika

atrial fibrillation - cardioversion - atrial-specific drugs

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