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Diagnostik der koronaren Herzkrankheit mittels kardialer Computertomographie

Diagnosis of coronary artery disease using cardiac computed tomography

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Clinical Research in Cardiology Supplements Aims and scope

Zusammenfassung

In der Praxis hängt die Behandlung von Patienten mit stabilen anginaverdächtigen Symptomen oder einer fraglichen Ischämie maßgeblich davon ab, ob eine strukturelle Koronarstenose sicher auszuschließen bzw. zu bestätigen und ein Bild der koronaren Plaquelast zu erhalten ist, um die Frage der Risikofaktorenbehandlung zu klären. Dies lässt sich durch die nichtinvasive CT-Angiographie (CTA) mittels Kardio-CT erreichen. Bei Patienten mit einer regelmäßigen, niedrigen Herzfrequenz wird eine robuste Bildqualität erzielt, sofern keine extreme Koronarverkalkung besteht. In zunehmendem Maße gelingt eine diagnostische Bildqualität auch bei Patienten mit einer höheren Herzfrequenz und Arrhythmien. Der sicherlich größte Nachteil der neuen Methode besteht in der Strahlendosis von 7–18 mSv. Die technische Entwicklung lässt aber eine deutliche Senkung der Strahlendosis erwarten, u. a. durch eine Reduktion der Aufnahmezeiten. Bereits jetzt bietet das Verfahren bei geeigneten Patienten eine wichtige diagnostische Möglichkeit im Rahmen der KHK-Abklärung. Hochgradige Koronarstenosen lassen sich mit sehr hoher Sicherheit ausschließen; analog zu den Erfahrungen aus der invasiven Koronarangiographie besteht bei diesen Patienten eine sehr günstige Prognose. Hochgradige Koronarstenosen werden ebenfalls mit hoher Sicherheit erkannt. Intermediären Stenosen können bezüglich ihrer hämodynamischen Bedeutung ähnlich schwer einzuschätzen sein wie bei der invasiven Angiographie. Durch die nichtinvasive Plaqueerkennung ergeben sich aber auch wichtige prognostische Aspekte.

Wenn die Strahlenexposition unproblematisch erscheint, ist die CTA bestens zum Einsatz bei Patienten mit einer niedrigen oder intermediären Vortestwahrscheinlichkeit einer stenosierenden KHK geeignet. Sie vermeidet die akuten Risiken der invasiven Diagnostik, bietet aber erstmals in der Geschichte der Kardiologie ein zuverlässiges Abbild der Koronararterien mit gleichzeitiger Darstellung von Koronarlumen und -wand.

Abstract

In the presence of stable angina-like symptoms or arguable ischemia, patients' treatment depends largely on the secure assessment of a possible fixed coronary stenosis and, for prognostic reasons, coronary plaque burden. On this basis, revascularisation, medical, and other therapies directed towards risk factor control can be initiated. Non-invasive coronary computed tomography angiography (CTA) provides for this information. In patients with regular sinus rhythm who can achieve a relatively low heart rate, image quality is very robust, extensive coronary calcifications being the only exception to this rule. Indeed, owing to technological advances, diagnostic image quality is also increasingly achieved in the presence of higher heart rates and arrhythmias.

Certainly, the greatest drawback of CTA lies in the associated radiation exposure of 7–18 mSv. However, future developments are expected to drastically reduce radiation dose, in part through further shortenings of image acquisition time. Today, CTA represents a valuable diagnostic modality in selected patients with suspected stenotic coronary artery disease (CAD). Severe stenoses can be ruled out with a high degree of certainty, and patients with a favourable prognosis can be identified. Although in analogy to invasive angiography, intermediate stenoses are sometimes difficult to classify regarding their potential hemodynamic relevance, assessment of the coronary arterial wall by CTA may provide for important additional prognostic information.

In patients for whom the radiation exposure appears acceptable, CTA is very well suited to be used in the setting of a low to moderate pretest probability of CAD. CTA avoids the acute risks of the invasive procedure. For the first time in the history of cardiology, a reliable non-invasive visualisation of the coronary lumen and the coronary wall is possible.

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Authors and Affiliations

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

    A. Schmermund FESC, A. Magedanz, H. Gufler, B. Nowak & T. Voigtländer

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  1. A. Schmermund FESC
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  2. A. Magedanz
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  3. H. Gufler
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Correspondence to A. Schmermund FESC.

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Schmermund, A., Magedanz, A., Gufler, H. et al. Diagnostik der koronaren Herzkrankheit mittels kardialer Computertomographie. Clin Res Cardiol Suppl 2, V37–V48 (2007). https://doi.org/10.1007/s11789-007-0023-7

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