Antikoagulationssituation bei hohem thromboembolischem Risiko nach Vorhofflimmerablation: Daten des Ablations-Qualitätsregisters

Zusammenfassung

Hintergrund und Fragestellung: Die Katheterablation bei Vorhofflimmern (VHF) hat als kurative Therapie von medikamentös therapierefraktärem VHF an Bedeutung gewonnen. Um nach erfolgreicher Ablation Thromboembolien zu vermeiden ist die dauerhafte orale Antikoagulation in Abhängigkeit vom CHA₂DS₂-VASc-Score indiziert. Wir untersuchten die Antikoagulationssituation ein Jahr nach Ablation bei erhöhtem thromboembolischem Risiko und identifizierten Determinanten, die zur Unterversorgung mit einer oralen Antikoagulation führen.

Methodik: Zwischen Januar 2007 und Januar 2010 wurden in 52 deutschen Zentren insgesamt 13 092 Patienten in ein prospektives, multizentrische Register eingeschlossen. 41 von diesen Zentren führten Katheterablation bei VHF durch. In diese Analyse wurden nur Patienten eingeschlossen, die nach Katheterablation bei VHF mit einer oralen Antikoagulation entlassen wurden und einen CHA₂DS₂-VASc-Score von mindestens 2 aufwiesen. Ein zentralisiertes 1-Jahres-Follow-up wurde telefonisch durchgeführt. Der Verzicht auf orale Antikoagulanzien trotz prinzipiell gegebener Indikation im 1-Jahres-Follow-Up wurde als bewusstes Absetzen interpretiert.

Ergebnisse: 1300 Patienten erfüllten die Einschlusskriterien. Ein Jahr nach Vorhofflimmerablation waren nur noch 51,8 % der Patienten mit einem CHA₂DS₂-VASc-Score von ≥ 2 antikoaguliert. Als signifikante Determinanten für das Absetzen trotz gegebener Indikation wurde die Rezidivfreiheit im Follow-Up (Adjustierte Odds Ratio [OR] 2,14; 95 %-Konfidenzintervall [KI] 1,73–2,66; P < 0,001) und paroxysmales VHF (OR 1,53; 95 %-KI 1,29–1,81; P < 0,001) identifiziert. Faktoren, die eine Fortführung der oralen Antikoagulation positiv beeinflussen sind das Patientenalter (OR je 10 Jahre: 0,79; 95 %-KI 0,68–0,91; P = 0,002), Herzklappenvitien (OR 0,67; 95 %-KI 0,48–0,92; P = 0,013), das Vorhandensein eines aktiven Herzrhythmusimplantates (OR 0,55; 95 %-KI 0,41–0,74; P < 0,001) sowie neurologische Ereignisse stationär oder im Follow-Up (OR 0,40; 95 %-KI 0,18–0,88; P = 0,022).

Folgerung: Fast die Hälfte der Patienten mit einer Indikation zur oralen Antikoagulation wird ein Jahr nach Katheterablation bei VHF nicht mehr leitliniengerecht therapiert. Paroxysmales VHF oder subjektive Rezidivfreiheit sind signifikant mit einem Absetzen der oralen Antikoagulation assoziiert.

Abstract

Background: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA₂DS₂-VASc-Score [3]. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC.

Methods: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA₂DS₂-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone.

Results: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73–2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29–1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68–0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48–0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41–0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18–0.88], P < 0.022).

Conclusion: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Schlüsselwörter

Vorhofflimmern - Katheterablation - Antikoagulation - Leitlinien - CHA₂DS₂-VASc-Score

Keywords

atrial fibrillation - catheter ablation - anticoagulation - guidelines - CHA₂DS₂-VASc-Score

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