Herz

, Volume 37, Issue 3, pp 252–257

Kardiale Bildgebung beim (asymptomatischen) Diabetiker

Schwerpunkt

Zusammenfassung

Der koronaren Herzkrankheit (KHK) kommt bei Diabetikern eine äußerst wichtige Bedeutung zu, da Diabetiker mit einer KHK eine stark erhöhte Mortalität aufweisen. Die Frage stellt sich, ob und wie Diabetiker auf eine KHK gescreent werden sollten. Bei Patienten mit Angina Pectoris und auch atypischen sowie anginaäquivalenten Symptomen (v. a. Dyspnoe) ist eine weitere Abklärung indiziert. Ein generelles Screening von asymptomatischen Patienten scheint unselektioniert nicht sinnvoll zu sein. Die einzige große prospektive Studie in dieser Hinsicht hat keinen Überlebensvorteil für gescreente Patienten gezeigt. Allerdings stellt sich die Frage, ob besondere Hochrisikogruppen identifiziert und gescreent werden sollten. Eine spezielle Situation stellt in dieser Hinsicht die präoperative Risikostratifikation dar.

Werden die Patienten gescreent, stellt sich die Frage, ob beim Screening ein anatomischer Test (z. B. Kalzium-Scoring oder nichtinvasive Koronarangiographie) oder ein funktioneller Test (Ischämiesuche) zur Anwendung kommen soll. Bei Diabetikern mit bereits ausgebauter Therapie hinsichtlich koronarer Prävention dürfte eine anatomische Darstellung als erster Schritt weniger Sinn machen als eine funktionelle (außer bei fehlenden Veränderungen mit dann ausgezeichnet negativ prädiktivem Wert). Diese Aussage begründet sich damit, dass lediglich eine prognostisch relevante Ischämie eine invasive Abklärung nach sich ziehen würde, wogegen Verkalkungen oder weiche Plaques ohne Ischämie darin bestärken, dass Diabetiker eine gute Prävention brauchen. Somit ist es wichtig, Patienten individuell zu beraten und langfristig zu begleiten, insbesondere solange keine evidenzbasierten Guidelines verfügbar sind.

Schlüsselwörter

Koronare Herzkrankheit Diabetes Screening Kardiale Bildgebung 

Cardiac imaging in (asymptomatic) diabetic patients

Abstract

Coronary artery disease (CAD) plays an important role in diabetic patients because they have a very high cardiovascular mortality risk. Therefore the question arises if all diabetic patients should be screened for CAD. In patients with (a)typical angina or anginal equivalents (e.g. shortness of breath) an extended CAD evaluation is indicated. Unselected screening in diabetic patients, however, does not seem to make sense as the only large prospective randomized study in this field did not demonstrate a survival benefit in the screened patient population. It is noteworthy that preoperative risk stratification deserves special consideration in diabetic patients.

If screening is considered there is the anatomic approach (calcium score, non-invasive coronary angiography) or the functional approach (stress testing, ischemia evaluation). In diabetic patients who in general should already have all the medication with respect to coronary prevention, functional rather than anatomic testing makes sense because revascularization can be considered in patients with extensive ischemia. In contrast, anatomic testing if positive would only be confirming that a medical preventive strategy is necessary. On the other hand a normal anatomic test has a very high negative predictive value. Therefore, CAD evaluation should follow an individual patient tailored approach as long as evidence-based guidelines are lacking.

Keywords

Coronary artery disease Diabetes Screening Cardiac imaging techniques 

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Copyright information

© Urban & Vogel, Muenchen 2012

Authors and Affiliations

  1. 1.Kardiologische KlinikUniversitätsspitalBaselSchweiz

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