Persistierende Angina pectoris nach erfolgreicher perkutaner Koronarintervention (postinterventionell persistierende Angina)

Persistent angina pectoris after successful percutaneous coronary intervention (persistent post-PCI angina)

Zusammenfassung

Die Evaluation von Patienten mit persistierender Angina pectoris trotz erfolgreicher perkutaner Koronarintervention (PCI) stellt für den klinisch tätigen Kardiologen oft eine Herausforderung dar. Von diesem Phänomen sind ca. 20–50 % der Patienten nach erfolgter Katheterintervention betroffen. Neben der optimalen medikamentösen Therapie kommt der Diagnostik der zugrunde liegenden Mechanismen eine wesentliche Bedeutung zu. Hierzu zählen strukturelle Mechanismen, wie z. B. die residuale Ischämie durch inkomplette Revaskularisation oder diffuse Atherosklerose. Zusätzlich können in der Mikrovaskulatur vorhandene Verengungen auch nach erfolgreicher PCI weiter Angina pectoris verursachen. Mögliche funktionelle Ursachen sind Koronarspasmen auf Ebene der epikardialen und/oder koronaren Mikrogefäße sowie eine eingeschränkte koronare Flussreserve. Die diagnostische Evaluation umfasst nichtinvasive (meist bildgebende Ischämiediagnostik) und invasive Methoden („optical coherence tomography“ [OCT]/„intravascular ultrasound“ [IVUS]), Acetylcholin-Test, Messungen von fraktioneller Flussreserve (FFR) und koronarer Flussreserve (CFR). Oft liegen bei einem Patienten mehrere Mechanismen gleichzeitig vor, was die Interpretation der Untersuchungsergebnisse und die Entscheidung bezüglich des weiteren Vorgehens erschweren kann. Nichtsdestotrotz sollte bei Patienten mit persistierender Angina eine möglichst genaue Charakterisierung der zugrunde liegenden Mechanismen erfolgen, um eine zielgerichtete Therapie einleiten zu können. Die Häufigkeit einer ursächlichen koronaren Vasomotionsstörung im Sinne einer vasospastischen Angina wird hierbei häufig noch unterschätzt. Prospektive Studien werden zeigen, von welchen diagnostischen und therapeutischen Algorithmen die Patienten am meisten profitieren.

Abstract

The evaluation of patients with persistent angina pectoris despite successful percutaneous coronary intervention (PCI) often represents a challenge for the clinical cardiologist. Approximately 20–50% of patients are affected by this condition after a successful catheter intervention. Apart from optimal pharmacological treatment, the diagnostics of the underlying mechanisms are of paramount importance. This includes assessment of structural causes, such as residual ischemia due to incomplete revascularization or diffuse atherosclerosis. Moreover, persistent angina post-PCI can be due to structural alterations in the coronary microcirculation, which remain after successful PCI of an epicardial stenosis. Possible functional causes are coronary spasms of the epicardial arteries and/or coronary microvessels as well as impaired coronary flow reserve (CFR). The diagnostic evaluation of such patients comprises noninvasive techniques, usually imaging stress tests for myocardial ischemia and also invasive techniques, such as optical coherence tomography (OCT)/intravascular ultrasound (IVUS), acetylcholine testing and measurement of the fractional flow reserve (FFR) and coronary flow reserve (CFR). In many patients multiple conditions are often simultaneously present and may overlap which makes interpretation of test results and decisions for further management challenging. Nevertheless, precise characterization of the underlying mechanisms of persistent post-PCI angina should be carried out to be able to initiate targeted treatment. The prevalence of a coronary vasomotor disorder in the sense of vasospastic angina in this setting is still underestimated. Prospective studies will reveal which diagnostic and therapeutic algorithms will be most beneficial for such patients.

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Danksagung

Die Autoren danken Frau S. Nägele und Frau V. Martínez Pereyra für die Hilfe beim Erstellen des Manuskriptes.

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Correspondence to PD Dr. med. Peter Ong.

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P. Ong, A. Seitz, R. Bekeredjian und U. Sechtem geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Peter Ong und Andreas Seitz teilen sich die Erstautorenschaft.

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Ong, P., Seitz, A., Bekeredjian, R. et al. Persistierende Angina pectoris nach erfolgreicher perkutaner Koronarintervention (postinterventionell persistierende Angina). Kardiologe (2020). https://doi.org/10.1007/s12181-020-00431-y

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Schlüsselwörter

  • Koronarspasmen
  • Koronare Flussreserve
  • Residuale Ischämie
  • Katheterintervention
  • Vasospastische Angina

Keywords

  • Coronary spasm
  • Coronary flow reserve
  • Residual ischemia
  • Catheter intervention
  • Vasospastic angina