Vorhofflimmern bei Schlaganfall – Immer noch unterschätzt?

Kardioembolische Schlaganfälle bei Vorhofflimmern zeigen einen besonders ernsten Verlauf und eine hohe Mortalität. Dank innovativer Techniken für das ambulante EKG-Langzeitmonitoring gelingt es heute, bei über 30 % der Patienten mit ischämischem Schlaganfall Vorhofflimmern nachzuweisen. Für die Betroffenen steht dann die orale Antikoagulation als hochwirksame Therapie für die Sekundärprophylaxe thrombembolischer Komplikationen zur Verfügung. Post-hoc-Analysen aus großen Studien deuten darauf hin, dass paroxysmales Vorhofflimmern anders als bisher angenommen ein geringeres Schlaganfallrisiko birgt als permanentes Vorhofflimmern. Keine belastbaren Daten liegen allerdings zum Risiko sehr kurzer, subklinischer Vorhofflimmerepisoden vor, die nun mithilfe des Langzeitmonitorings vermehrt auch bei Patienten mit niedrigem vaskulären Risiko nachzuweisen sind. Nachdem sich Vorhofflimmer-assoziierte Schlaganfälle auch ohne zeitlichen Zusammenhang mit vorangegangenen arrhythmischen Episoden ereignen können, dient der Nachweis von Vorhofflimmern in diesen Fällen vor allem als Surrogat eines hohen zerebrovaskulären Risikos, das auch nach Konversion in den Sinusrhythmus fortbesteht.

Cardioembolic stroke in atrial fibrillation is a disease with sever prognosis and high mortality. Advanced techniques of long-term rhythm-monitoring have revealed a particular high prevalence of atrial fibrillation among stroke victims, with atrial fibrillation affecting every third patient. Oral anticoagulation provides highly effective secondary prevention among these patients. Post-hoc analyses from large multicenter trials suggest that the stroke risk of paroxysmal episodes may be lower than the risk of permanent atrial fibrillation. However, data on the risk of subclinical, short episodes, which are frequently detected by long-term monitoring even among patients with low vascular risk, are lacking. As thromboembolic events may occur without temporal relationship to preceding episodes of atrial fibrillation, the arrhythmia likely represents a surrogate for a thromboembolic state with high stroke risk, that persists even beyond the conversion to sinusrhythm.

Key words

Stroke - atrial fibrillation - embolism - arrhythmia

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