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Therapieoptionen bei Patienten mit Angina pectoris infolge koronarer Vasomotionsstörungen

Treatment options in patients with angina pectoris due to coronary vasomotor disorders

Zusammenfassung

In Deutschland werden jedes Jahr ungefähr 900.000 Herzkatheteruntersuchungen aufgrund von Angina-pectoris-Beschwerden durchgeführt. Bei bis zu 50 % der Patienten mit Symptomen und/oder Anzeichen einer myokardialen Ischämie liegt keine obstruktive epikardiale Koronarerkrankung vor. Diese Konstellation wird auch als ANOCA (Angina pectoris ohne Koronarstenosen) bezeichnet. Bei ca. 75 % dieser Patienten lassen sich koronare Vasomotionsstörungen nachweisen. Diese umfassen eine eingeschränkte Vasodilatationsfähigkeit der Mikrozirkulation und/oder eine verstärkte Vasokonstriktionsneigung (Koronarspasmus). Ziel dieser Arbeit ist es, eine Übersicht über die aktuellen medikamentösen Therapieoptionen für diese Patienten zu geben. Hierzu wurde eine ausführliche Literaturrecherche mit Auswertung aller relevanten Therapiestudien, Übersichtsarbeiten, Metaanalysen und Leitlinienempfehlungen durchgeführt. Die medikamentöse Therapie bei Koronarspasmen umfasst kurz wirksame Nitrate im akuten Anfall sowie Kalziumantagonisten und Langzeitnitrate bzw. Molsidomin als Erstlinientherapie. Als Zweitlinientherapie kommen Ranolazin, Pentaerithrityltetranitrat sowie Nicorandil infrage. Auch eine Kombination von 2 unterschiedlichen Kalziumantagonisten kann hilfreich sein. Die medikamentöse Therapie bei einer mikrovaskulären Vasodilatationsstörung umfasst Statine, Acetylsalicylsäure (ASS) und Angiotensinkonversionsenzym(ACE)-Hemmer als Basistherapie, Betablocker und Kalziumantagonisten als Erstlinientherapie sowie Ivabradin, Nicorandil und Ranolazin als Zweitlinientherapie. Bei Patienten mit Mischformen dieser Vasomotionsstörungen gibt es noch keine klaren Therapieempfehlungen. Zukünftige Studien werden zeigen, wie effektiv eine auf den Pathomechanismus ausgerichtete medikamentöse Therapie bei diesen Patienten ist.

Abstract

In Germany approximately 900,000 coronary angiograms are performed every year due to angina pectoris symptoms. Up to 50% of patients exhibiting such symptoms and/or signs of myocardial ischemia do not have obstructive epicardial coronary artery disease. This constellation is also labelled as angina pectoris without obstructive coronary artery disease (ANOCA). Approximately 75% of such patients suffer from coronary vasomotion disorders causing the symptoms. The main mechanisms of disease are an impaired vasodilatory capacity of the microcirculation and/or an increased tendency to vasoconstriction (coronary spasm). The aim of this review is to provide an overview of the current pharmacological treatment options for ANOCA patients. For this purpose, a detailed literature search was conducted including the evaluation of all relevant treatment studies, reviews, meta-analyses and guideline recommendations. Pharmacotherapy for coronary spasm includes short-acting nitrates in the event of an angina attack as well as calcium antagonists and long-term nitrates or molsidomine as first-line treatment. Ranolazine, pentaerithrityltetranitrate and nicorandil can be used as second-line treatment. A combination of two different calcium channel blockers is also often helpful. Drug treatment for impaired microvascular vasodilation includes statins, acetylsalicylic acid (ASA) and Angiotensin-converting enzyme (ACE) inhibitors as basic treatment, beta blockers and calcium channel blockers as first-line treatment and ivabradine, nicorandil and ranolazine as second-line treatment. In patients with mixed forms of vasomotor disorders there are still not enough data for robust treatment recommendations. Future studies will assess the efficacy of pathomechanism-dependent drug treatment in ANOCA patients.

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Förderung

Finanzielle Unterstützung dieser Arbeit durch die Berthold-Leibinger-Stiftung Ditzingen (AH, SF, J McC, US, PO) und ein Promotionsstipendium der Deutschen Gesellschaft für Kardiologie e. V. (DGK) (CK).

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Correspondence to Peter Ong.

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Interessenkonflikt

C. Kroll, A. Hubert, S. Fröbel, A. Seitz, J. McChord, R. Bekeredjian, U. Sechtem und P. Ong 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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Kroll, C., Hubert, A., Fröbel, S. et al. Therapieoptionen bei Patienten mit Angina pectoris infolge koronarer Vasomotionsstörungen. Kardiologie 16, 233–241 (2022). https://doi.org/10.1007/s12181-022-00551-7

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  • DOI: https://doi.org/10.1007/s12181-022-00551-7

Schlüsselwörter

  • Vasospastische Angina
  • Epikardiale Koronarspasmen
  • Mikrovaskuläre Angina
  • Mikrovaskuläre Dysfunktion
  • Antianginöse Therapie

Keywords

  • Vasospastic angina
  • Epicardial coronary spasm
  • Microvascular angina
  • Coronary microvascular dysfunction
  • Antianginal pharmacotherapy