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Analyse des kardiovaskulären Risikos mittels Kardio-CT und Koronarkalkbestimmung

Analysis of cardiovascular risk using cardio-CT and coronary calcium measurements

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Clinical Research in Cardiology Supplements Aims and scope

Zusammenfassung

Die koronare Herzkrankheit manifestiert sich häufig durch ein akutes Koronarsyndrom als Indexereignis. Vor dem Hintergrund der Entwicklung von Adipositas und Diabeteshäufigkeit fällt die Inzidenzrate der Erkrankung nicht weiter ab und wird möglicherweise sogar wieder ansteigen. Angesichts der hohen Letalität des akuten Myokardinfarkts in der Prähospitalphase kommt die medizinische Versorgung für viele Patienten zu spät. Die Koronarkalkbestimmung kann eine wichtige Hilfe zur Identifizierung asymptomatischer Personen mit erhöhtem Koronarrisiko und zur Einleitung einer Behandlung zur Risikoreduktion sein.

Koronarkalk ist ein weitgehend spezifischer Ausdruck der koronaren Atherosklerose und korreliert mit dem koronaren Gesamtplaquevolumen. Aufgrund der komplexen Gefäßwandbiologie mit kompensatorischem Remodeling zeigt Koronarkalk nicht notwendigerweise eine signifikante Stenosierung an. Eine Vielzahl unabhängiger Studien in Kollektiven mit gesunden, durch Werbung, Überweisung und Selbsteinweisung gewonnenen Teilnehmern beschreibt übereinstimmend die prädiktive Wertigkeit der Koronarkalkbestimmung im Hinblick auf koronare und kardiovaskuläre Ereignisse. Nach Adjustierung für die etablierten Risikofaktoren sind erhöhte Kalkscores mit einem 5- bis 10fach erhöhten Risiko kardialer Ereignisse assoziiert. In jüngster Zeit wurden auch Ergebnisse aus strikt unselektierten, bevölkerungsweiten Kollektiven bekannt, welche die prädiktive Wertigkeit der Koronarkalkbestimmung bestätigen. In Deutschland bietet dazu die bevölkerungsbasierte Heinz-Nixdorf-Recall-Studie im Ruhrgebiet eine wichtige Datengrundlage.

In Übereinstimmung mit den aktuellen Empfehlungen der amerikanischen und europäischen Fachgesellschaften wird die Koronarkalkbestimmung insbesondere bei Patienten eingesetzt, die ein intermediäres Risiko auf der Basis der klinischen Befunde und Risikofaktorenanalyse aufweisen. Deutlich erhöhte Kalkscores geben dem behandelnden Arzt eine Rationale zur intensiven Risikotherapie. Dies gilt auch für ältere Patienten, bei denen die etablierten Risikofaktoren einen Teil ihrer prädiktiven Wertigkeit verlieren. Die Anwendung des Verfahrens bei Selbsteinweisern oder als primäres Mittel der Risikostratifizierung kann nicht empfohlen werden.

Abstract

Frequently, myocardial infarction or sudden coronary death are the index manifestations of coronary artery disease. After decades of falling incidence rates, it is expected that against the background of recent trends in the prevalence of obesity and diabetes, we will see a stabilized incidence or even increase in coronary artery disease in the coming years. In view of the high out-of-hospital mortality of acute myocardial infarction, medical care is unable to provide a benefit for many patients. Coronary calcium measurements allow for identification of asymptomatic subjects with an increased coronary risk who are likely to benefit from risk-modifying therapy.

Coronary calcium is a largely specific expression of coronary atherosclerosis and is correlated with overall coronary plaque volume. Due to the complex biology of the vessel wall and its ability to undergo compensatory remodelling, coronary calcium does not necessarily indicate significant stenosis. A number of studies including healthy self-referred and physician-referred volunteers consistently describe the predictive value of coronary calcium with regard to coronary and cardiovascular clinical events. After adjusting for coronary risk factors, increased amounts of coronary calcium are associated with a 5- to 10-times elevated relative risk. Recently, first results from strictly unselected, population-based cohorts have been reported which confirm the predictive ability of coronary calcium measurements. In Germany, important data are provided by the population-based Heinz Nixdorf Recall study.

Concordant with actual guidelines issued by US and European expert panels, coronary calcium measurements can be used especially in patients with an indeterminate risk on the basis of clinical assessment and risk factor analysis. Substantially elevated coronary calcium scores provide a rationale for intensified risk-modifying therapy. This is also true for elderly patients in whom the established risk factors lose some of their predictive power. The use of coronary calcium measurements in self-referred patients or as a primary means for risk stratification is not encouraged.

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Authors and Affiliations

  1. Cardioangiologisches Centrum Bethanien, Im Prüfling 23, 60389, Frankfurt am Main, Germany

    A. Schmermund

  2. Westdeutsches Herzzentrum Essen, Klinik für Kardiologie, Essen, Germany

    S. Möhlenkamp & R. Erbel

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  1. A. Schmermund
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  2. S. Möhlenkamp
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Schmermund, A., Möhlenkamp, S. & Erbel, R. Analyse des kardiovaskulären Risikos mittels Kardio-CT und Koronarkalkbestimmung. Clin Res Cardiol Suppl 3, 48–57 (2008). https://doi.org/10.1007/s11789-008-0038-8

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