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Chest pain after coronary interventional procedures

Herzschmerzen nach koronaren Interventionen. Inzidenz und Pathopysiologie

Incidence and pathophysiology

Abstract

Chest pain following successful percutaneous coronary interventions is a common problem. Although the development of chest pain after coronary interventions may be of benign character, it is disturbing to patients, relatives and hospital staff. Such pain may be indicative of acute coronary artery closure, coronary artery spasm or myocardial infarction, but may also simply reflect local coronary artery trauma. The distinction between these causes of chest pain is crucial in selecting optimal care. Management of these patients may involve repeat coronary angiography and additional intervention. Commonly, repeat coronary angiography following percutaneous transluminal coronary angioplasty (PTCA) in patients with chest pain demonstrates widely patent lesion sites suggesting that the pain was due to coronary artery spasm, coronary arterial wall stretching or was of non-cardiac origin. As reported by the National Heart, Lung and Blood Institute PTCA Registry, 4.6% of patients after angioplasty have coronary occlusions, 4.8% suffer a myocardial infarction, and 4.2% have coronary spasm. The frequency of chest pain after new device coronary interventions (atherectomy and stenting) seems to be even higher. However, only the minority of patients with post-procedural chest pain have indeed an ischemic event. Therefore, the vast majority of patients have recurrent chest pain without any signs of ischemia. There is some evidence that non-ischemic chest pain after coronary interventions is more common after stent implantation as compared to PTCA (41% vs. 12%). This may be due to the continuous stretching of the arterial wall by the stent as the elastic recoil occurring after PTCA is minimized. In conclusion, chest pain after coronary interventional procedures may potentially be hazardous when due to myocardial ischemia. However, especially after coronary stent placement, cardiologists must consider “stretch pain” due to the overdilation and stretching of the artery caused by the stent in the differential diagnosis. Clinically, it is, therefore, important to recognize that in addition to ischemia-related chest pain other types of chest pain do exist with cardiac origin.

Zusammenfassung

Angina pectoris nach erfolgreicher koronarer Intervention ist ein häufig vorkommendes Problem. Auch wenn die Entwicklung von Angina pectoris nach einem interventionellen Eingriff von benignem Charakter sein kann, ist sie beängstigend für die Patienten, die Angehörigen und das medizinische Personal. Brustschmerz kann ein Anzeichen sein für einen akuten Verschluß des Gefäßes, einen Spasmus der Koronararterie oder einen Myokardinfarkt; er kann aber auch durch ein lokales Trauma bedingt sein. Die Unterscheidung dieser Ursachen ist von großer Bedeutung für die Wahl der optimalen Therapie. Diese beinhaltet wiederholte koronare Angiographie und, wenn nötig, eine erneute Intervention. Häufig sieht man jedoch bei wiederholter Angiographie nach PTCA ein weit offenes Gefäß. In diesen Fällen ist die Ursache der Schmerzsymptomatik am ehesten auf einen bereits gelösten Koronararterienspasmus. Schmerzrezeptoren in der Gefäßwand oder nichtkardiale Genese zurückzuführen. Ein Bericht der „National Heart, Lung and Blood Institute PTCA Registry” zeigte, daß 4,6% der Patienten nach Angioplastie einen koronaren Verschluß haben 4,8% erleiden einen Myokardinfarkt, und 4,2% haben einen Koronarspasmus. Die Inzidenz von Brustschmerz nach koronarer Atherektomie und Stent-Implantation erscheint sogar noch höher. Eine Minderheit der Patienten mit post-interventionellem Brustschmerz erleidet jedoch nur ein ischämisches Ereignis. Die Mehrheit der Patienten leidet demnach an Brustschmerzen ohne ein schämisches Korrelat. Es gibt Hinweise darauf, daß der nichtischämische Brustschmerz nach koronarer Intervention häufiger nach Stent-Implantation auftritt als nach PTCA (41% vs. 12%). Das liegt möglicherweise an der Überdehnung des Gefäßes durch den Stent, da die elastischen Rückstellkräfte im Gegensatz zur PTCA blockiert werden.

Zusammenfassend läßt sich sagen, daß ein Brustschmerz nach koronarer Intervention ischämisch bedingt sein kann. Besonders nach koronarer Stent-Implantation muß jedoch auch der „Dehnungsschmerz” bedingt durch eine Überdehnung des Gefäßes durch den Stent, in der Differentialdiagnose berücksichtigt werden.

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Correspondence to Raimund Erbel.

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Jeremias, A., Kutscher, S., Haude, M. et al. Chest pain after coronary interventional procedures. Herz 24, 126–131 (1999). https://doi.org/10.1007/BF03043851

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  • DOI: https://doi.org/10.1007/BF03043851

Key Words

  • Chest pain
  • Coronary interventions
  • PTCA
  • Stent implantation

Schlüsselwörter

  • Angina pectoris
  • Koronare Intervention
  • PTCA
  • Stent-Implantation
  • Brustschmerz
  • Herzschmerz