Zusammenfassung
Vorhofflimmern ist die häufigste Arrhythmie im Erwachsenenalter. Die Therapie hat sich in den letzten Jahren erheblich verändert. Basistherapie sind β-Rezeptorenblocker und – insbesondere bei struktureller Herzkrankheit – ACE-Inhibitoren bzw. AT1-Blocker. Klasse-1C-Antiarrhythmika (Flecainid bzw. Propafenon) sollen nur bei normaler oder leicht eingeschränkter linksventrikulärer Funktion eingesetzt werden. Für therapierefraktäre Patienten und solche mit deutlich eingeschränkter linksventrikulärer Funktion ist Amiodaron die derzeit einzig verbleibende medikamentöse Alternative. Patienten mit symptomatischen, aber seltenen Anfällen von Vorhofflimmern und normaler linksventrikulärer Funktion können mit einer sog. „Pill-in-the-pocket-Therapie“ behandelt werden.
Durch die 2006 publizierten europäischen und US-amerikanischen Leitlinien wurde die Katheterablation bei Vorhofflimmern in die „alltägliche Praxis“ eingeführt. Hochsymptomatische Patienten mit paroxysmalem oder kurz dauerndem anhaltendem Vorhofflimmern können unter folgenden Umständen mit der Katheterablation behandelt werden: Es besteht keine schwerwiegende Herzkrankheit, der linke Vorhof ist nicht wesentlich vergrößert und es besteht Therapierefraktärität oder Intoleranz gegenüber Antiarrhythmika. Bei allen anderen Patienten (z. B. solchen mit Herzinsuffizienz oder Herzklappenfehlern) ist die interventionelle Katheterablation von Vorhofflimmern derzeit experimentell und nur im Einzelfall als Heilversuch indiziert.
Abstract
Atrial fibrillation is the most common arrhythmia in the adult. During recent years the therapeutic strategy has markedly changed. Some of these changes can be summarized as follows: Basis therapy includes betablockers and – in patients with structural heart disease – ACE-inhibitors and AT1-Blockers respectively. Class 1C-antiarrhythmic agents (flecainide or propafenon) should be restricted to patients with no or minimal left ventricular impairment. Amiodaron is the drug of choice in patients refractory to class 1C-agents and in those with already reduced left ventricular function. The “pill-in-the-pocket” regime can be used successfully in patients without structural heart disease and rare episodes of atrial fibrillation.
Catheter ablation for paroxysmal and short lasting chronic atrial fibrillation was introduced into the clinical practice in 2006. The European and US-American guidelines recommend this technique for patients with no or minimal structural heart disease who are highly symptomatic and refractory or intolerant to antiarrhythmic agents. Decisions for curative catheter ablation in patients with long standing atrial fibrillation, heart failure or valvular heart disease should be individualized but are to date not generally recommended.
Literatur
Alboni P, Botto GL, Baldi N et al. (2004) Outpatient treatment of recent-onset atrial fibrillation with the „pill-in-the-pocket“ approach. N Engl J Med 351: 2384–2391
Calkins H, Brugada J, Packer D et al. (2007) HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Association (HERA) and the European Cardiac Arrhythmia Society (ECAS) in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm society. Europace 9: 335–379
Corley SD, Epstein AE, DiMarco JP et al.; AFFIRM Investigators (2004) Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation 109: 1509–1513
de Denus S, Sanoski CA, Carlsson J et al. (2005) Rate vs rhythm control in patients with atrial fibrillation: a meta-analysis. Arch Intern Med 165: 258–262
Falk RH (2005) Is rate control or rhythm control preferable in patients with atrial fibrillation? Rate control is preferable to rhythm control in the majority of patients with atrial fibrillation. Circulation 111: 3141–3150 discussion 3157
Fetsch T, Bauer P, Engberding R et al.; Prevention of Atrial Fibrillation after Cardioversion Investigators. (2004) Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial. Eur Heart J 25: 1385–1394
Fuster V, Ryden LE, Cannom DS et al. (2006) ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee of Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114: 257–354
Haissaguerre M, Jais P, Shah D et al. (1998) Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339: 659–666
Hsu L, Jais P, Sanders P et al. (2004) Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 351: 2373–2383
Lafuente-Lafuente C, Mouly S, Longás-Tejero MA et al. (2006) Antiarrhythmic drugs for maintaining sinus rhythm after cardioversion of atrial fibrillation: a systematic review of randomized controlled trials. Arch Intern Med 166: 719–728
Miyasaka Y, Barnes ME, Gersh BJ et al. (2006) Incidence and mortality risk of congestive heart failure in atrial fibrillation patients: a community-based study over two decades. Eur Heart J 27: 936–941
Nademanee K, Schwab M, Kosar E et al. (2008) Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol 51: 843–849
Ouyang F, Antz M, Ernst S et al. (2005) Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: Lessons from double Lasso technique. Circulation 111: 127–135
Patlolla V, Alsheikh-Ali AA, Al-Ahmad AM (2006) The renin-angiotensin system: a therapeutic target in atrial fibrillation. Pacing Clin electrophysiol 29: 1006–1012
Riley MJ, Marrouche NF (2006) Ablation of atrial fibrillation. Curr Probl Cardiol 31: 361–390
Singh BN, Singh SN, Reda DJ et al.; Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) Investigators (2005) Amiodarone versus sotalol for atrial fibrillation. N Engl J Med 352: 1861–1872
Steven D, Rostock T, Lutomsky B et al. (2008) What is the real atrial fibrillation burden after catheter ablation of atrial fibrillation? A prospective rhythm analysis in pacemaker patients with continuous atrial monitoring. Eur Heart J 29: 1037–1042
Verma A, Natale A (2005) Should atrial fibrillation ablation be considered first-line therapy for some patients? Why atrial fibrillation ablation should be considered first-line therapy for some patients. Circulation 112: 1214–1222 discussion 1231
Wachtell K, Lehto M, Gerdts E et al. (2005) Angiotensin II receptor blockade reduces new-onset atrial fibrillation and subsequent stroke compared to atenolol: the Losartan Intervention for End Point Reduction in Hypertension (LIFE) study. J Am Coll Cardiol 45: 712–719
Waldo AL (2006) A perspective on antiarrhythmic drug therapy to treat atrial fibrillation: there remains an unmet need. Am Heart J 151: 771–778
Wazni OM, Marrouche NF, Martin DO et al. (2005) Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. Jama 293: 2634–2640
Willems S, Klemm H, Rostock T et al. (2006) Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Eur Heart J 27: 2871–2878
Wright M, Haissaguerre M, Knecht S et al. (2008) State of the art: catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 19: 583–592
Interessenkonflikt
Keine Angaben.
Author information
Authors and Affiliations
Corresponding authors
Rights and permissions
About this article
Cite this article
Meinertz, T., Willems, S. Die Behandlung von Vorhofflimmern im Alltag. Internist 49, 1437–1445 (2008). https://doi.org/10.1007/s00108-008-2152-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00108-008-2152-6