Besonderheiten der Antikoagulation bei Vorhofflimmern: Tripeltherapie und perioperatives Bridging

 

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Zusammenfassung

Vorhofflimmerpatienten haben zum Großteil eine Indikation zur Vollantikoagulation. Praktische Probleme ergeben sich, wenn zusätzlich die Indikation für eine Plättchen-hemmende Therapie im Rahmen einer Koronarintervention, die sog. Tripeltherapie besteht, oder aber auch wie man sich mit der Antikoagulation bei Operationen verhält. Die Studienlage für beide Fragen ist relativ gering. Im Prinzip ist in beiden Fällen ein individualisiertes Vorgehen anzustreben, das auf der einen Seite das Blutungs-, auf der anderen Seite das thrombembolische Risiko berücksichtigt. Im vorliegenden Artikel werden hierzu pragmatische Handlungsempfehlungen gegeben unter Berücksichtigung der aktuellen Studienlage.

Abstract

Patients with atrial fibrillation have in large parts an indication for full anticoagulation. Practical problems develop when there is an additional indication for a platelet inhibitory treatment, so called triple therapy, in case of percutaneous coronary intervention or how to manage anticoagulation in case of an operation. Clinical studies are relatively limited. Essentially, an individualized approach is necessary taking into account the bleeding on the one and the thromboembolic risk on the other side. In this review we a give a pragmatic treatment approach with discussion of the recent literature.

• Literatur

• 1 Holmes Jr. DR, Kereiakes DJ, Kleiman NS et al. Combining antiplatelet and anticoagulant therapies. J Am Coll Cardiol 2009; 54: 95-109
  CrossrefPubMedGoogle Scholar
• 2 Authors/Task Force, Windecker S. et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541-2619
  CrossrefPubMedGoogle Scholar
• 3 Valgimigli M, Patialiakas A, Thury A et al. Zotarolimus-eluting versus bare-metal stents in uncertain drug-eluting stent candidates. J Am Coll Cardiol 2015; 65: 805-815
  CrossrefPubMedGoogle Scholar
• 4 Dewilde WJ, Oirbans T, Verheugt FW et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115
  CrossrefPubMedGoogle Scholar
• 5 Fiedler KA, Maeng M, Mehilli J et al. Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation: The ISAR-TRIPLE Trial. J Am Coll Cardiol 2015; 65: 1619-1629
  Google Scholar
• 6 Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European Stroke Organisation (ESO). Eur Heart J 2016; DOI: 10.1093/eurheartj/ehw210.
  PubMedGoogle Scholar
• 7 Sarafoff N, Martischnig A, Wealer J et al. Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. J Am Coll Cardiol 2013; 61: 2060-2066
  CrossrefPubMedGoogle Scholar
• 8 Douketis JD, Spyropoulos AC, Spencer FA et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e326S-350S
  CrossrefPubMedGoogle Scholar
• 9 Douketis JD, Spyropoulos AC, Kaatz S et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373: 823-833
  CrossrefPubMedGoogle Scholar
• 10 Siegal D, Yudin J, Kaatz S et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 2012; 126: 1630-1639
  CrossrefPubMedGoogle Scholar
• 11 Lip GY, Windecker S, Huber K et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014; 35: 3155-3179
  CrossrefPubMedGoogle Scholar
• 12 Birnie DH, Healey JS, Wells GA et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368: 2084-2093
  CrossrefPubMedGoogle Scholar
• 13 European Heart Rhythm Association, European Association for Cardio-Thoracic Society, Camm AJ. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429
  CrossrefPubMedGoogle Scholar
• 14 Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17: 1467-1507
  CrossrefPubMedGoogle Scholar