Summary
Today’s definition of coronary artery disease (CAD) comprises two forms: obstructive and non-obstructive CAD. The 31–72% chance of a life-threatening event—like a myocardial infarction—with non-obstructive CAD is well documented in numerous studies. The objective in modern strategies of diagnosis and therapy should therefore be expedient identification of patients at high risk for coronary events, who will benefit from a customized therapy. Before initiating diagnostic procedures of CAD, a well defined strategy should be pursued. There are two possible primary objectives:
Assessment of the individual risk for a coronary event:
Assessment of the individual “absolute” risk for a coronary event is not possible using single traditional risk factors. The individual risk can be estimated by integrating several of the traditional risk factors into a scoring system. These so-called risk scores (e.g. Framingham score and Procam score), however, have been associated with shortcomings: insufficient discrimination of high-risk from low-risk individuals. The calcium score has therefore become increasingly established; this Agatston score is independent of the traditional risk factors, so there is no correlation between Agatston and Procam scores. Today, the calcium score is considered the superior test for identifying individuals at high risk for a coronary event and its use is recommended by the European Society of Cardiology (ESC) guidelines for prevention of cardiovascular diseases.
Proof or exclusion of a hemodynamically significant coronary stenosis:
Another concept is the definitive proof or exclusion of a hemodynamically “significant” coronary narrowing. The probability of an obstructive CAD is traditionally assessed by the type of chest pain, age, gender and stress-ECG. In patients with a low probability of an obstructive CAD, cardiac catheterization is not indicated, whereas in patients with a high probability of a hemodynamically significant coronary stenosis, an invasive strategy should be performed. Since non-invasive coronary angiography (CTA) with cardiac-CT has been shown to provide a high negative predictive value, CTA (with good imaging quality) is suitable for ruling out a significant obstructive CAD in the group at intermediate risk for an obstructive CAD. Another approach could be a functional test to initially prove a relevant, inducible myocardial ischemia: In a large cohort it was shown that patients will only prognostically benefit from revascularization procedures if the ischemic myocardial area is greater than 10%. Therefore, the assessment of the extent of myocardial ischemia is the domain of modern stress imaging tests. Stress-echocardiography and myocardial scintigraphy have almost the same sensitivity (74–80%, 84–90%, respectively) and specificity (84–89%, 77–86%, respectively), which are considerably higher than for stress-ECG.
Cardiac MR is most suitable for the assessment of myocardial perfusion, because it traces the first pass dynamics of gadolinium at rest and during stress in reproducible slices at an acceptable spatial and a high temporal resolution without ionizing radiation. Whether the non-invasive coronary angiography with cardiac-CT and the Adenosin-perfusion imaging with cardiac-MR will completely replace diagnostic cardiac catheterization and stress-echocardiography as well as myocardial scintigraphy remains to be evaluated in further studies.
Zusammenfassung
Heute wird die KHK in die stenosierende und in die nichtstenosierende Form eingeteilt. Die Gefährlichkeit der nichtstenosierenden KHK geht aus zahlreichen Studien hervor die belegen, dass „nichtsignifikante“ Koronarstenosen in 31–72% einen Herzinfarkt verursachten. Ziel moderner Strategien in Diagnostik und Therapie der KHK muss es daher sein, Patienten mit hohem Risiko für ein koronares Ereignis frühzeitig zu erkennen und einer optimalen Therapie zuzuführen. Zu Beginn einer Koronardiagnostik muss man sich aber zuerst darüber im Klaren sein, welche Fragestellung primär beantwortet werden soll:
Bestimmung des individuellen Risikos für ein koronares Ereignis:
Eine definitive Berechnung des individuellen, „absoluten“ Risikos für das Auftreten eines koronaren Ereignisses ist aus einem einzelnen der klassischen Risikofaktoren nicht möglich. Hierzu benötigt man die Integration mehrerer Risikofaktoren, die „Scores“. Aufgrund zahlreicher Limitationen dieser Scores hat sich der „Kalk-Score“ zunehmend klinisch etabliert. Für diesen Agatston-Score gilt aufgrund der wissenschaftlichen Datenlage, dass er eine von den klassischen Risikofaktoren unabhängige prognostische Aussagekraft besitzt. Folgerichtig besteht zwischen dem PROCAM-Score und dem Agatston-Score keine Korrelation. Der Kalk-Score ist zur Bestimmung des individuellen koronaren Risikos auch in den ESC-Leitlinien zur kardiovaskulären Prävention empfohlen.
Nachweis bzw. Ausschluss einer hämodynamisch wirksamen Koronarstenose:
Ziel dieses Konzeptes ist der möglichst weitgehende Nachweis bzw. Ausschluss einer höhergradigen, „hämodynamisch wirksamen“ Koronarstenose—im Sinne der „alten“ KHK Definition. Die Wahrscheinlichkeit des Vorliegens einer stenosierenden KHK wird klassisch anhand der Anamnese der Thoraxschmerzen, dem Alter, Geschlecht und des Ergebnisses des Belastung-EKGs ermittelt. Bei Patienten mit dementsprechend niedriger Wahrscheinlichkeit des Vorliegens einer Koronarstenose ist eine Herzkatheteruntersuchung nicht indiziert, während Patienten mit hoher Wahrscheinlichkeit des Vorliegens einer stenosierenden KHK einer Herzkatheteruntersuchung zugeführt werden sollten. Die nichtinvasive Koronarangiographie mit dem Kardio-CT (CTA) weist einen besonders hohen negativen prädiktiven Wert auf, so dass man diese nichtinvasive Koronarangiographie v.a. zum Ausschluss einer stenosierenden KHK diskutieren kann. Als Alternative zu dem primär morphologisch-anatomischenen Ansatz des Nachweises oder Ausschlusses einer Koronarstenose kann man ebenso begründet den Ischämienachweis in den Vordergrund der Diagnostik stellen: Aus einer größeren Untersuchung an über 10 000 Patienten ging hervor, dass Patienten nur von einer Myokardrevaskularisation prognostisch profitierten, wenn das ischämische Areal mindestens 10% der Muskelmasse ausmachte. Die Beurteilung der Ausdehnung sowie die regionale Zuordnung einer induzierten transienten Myokardischämie ist Domäne der Bild gebenden Verfahren: So liegen die Werte für Sensitivität und Spezifität für die Stressechokardiographie mit 74–80% bzw. 84– 89% deutlich höher als die des Belastungs-EKG und entsprechen der Sensitivität und Spezifität der Myokardszintigraphie mit 84–90% bzw. 77–86%.
Das Kardio-MR ist für die Beurteilung der Perfusion besonders geeignet, weil es ohne ionisierende Strahlen mit akzeptabler räumlicher und hoher zeitlicher Auflösung in reproduzierbaren Schichten die First-Pass-Dynamik des Gadoliniums vor und nach Adenosingabe bildlich erfasst. Inwieweit die nichtinvasive Koronarangiographie mit dem Kardio-CT die Herzkatheterdiagnostik und der Adenosin-Perfusionstest mit dem Kardio-MR die Stressechokardiographie bzw. die Myokardszintigraphie ersetzen wird, bleibt in Abhängigkeit von den Ergebnissen künftiger Studien abzuwarten.
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Silber, S., Richartz, B.M. Stellenwert von Kardio-CT und Kardio-MR zur Bestimmung des koronaren Risikos. ZS Kardiologie 94 (Suppl 4), iv70–iv80 (2005). https://doi.org/10.1007/s00392-005-1416-6
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DOI: https://doi.org/10.1007/s00392-005-1416-6