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Koronarer Spasmus — Ein klinisch relevantes Problem?

Coronary vasospasm — A clinically relevant problem?

  • Koronare Atherosklerose — Funktionelle Konsequenzen
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Zusammenfassung

Koronarspasmen sind reversible Koronarstenosen, die zu einer kritischen Einschränkung des koronaren Blutflusses unter Ruhebedingungen führen. Die vasospastische Angina kann durch den Nachweis der erhöhten Kontraktilität der Koronararterien entweder durch spontane Spasmen oder durch geeignete Provokationstests diagnostiziert werden. Obwohl verschiedene Stimuli Koronarspasmen auslösen können, ist mit Ergonovin die höchste Spezifität und Sensitivität im Vergleich zur klinischen Symptomatik belegt. Charakteristischerweise manifestieren sich Koronarspasmen als Angina pectoris in Ruhe, von besonderer klinischer Bedeutung sind Myokardinfarkte oder Synkopen. Die Prävalenz der Erkrankung ist mangels systematisch durchgeführter Provokationstests nicht bekannt, die Häufigkeit positiver Provokationstests hängt stark von der Symptomatik des untersuchten Patientenkollektivs ab (0 bis 54%). Spasmen treten fast immer in zumindest gering arteriosklerotisch veränderten Koronarsegmenten auf. Abweichend von der koronaren Herzkrankheit prädisponiert nur Zigarettenrauchen, nicht aber die anderen Risikofaktoren zum Auftreten von Koronarspasmen. Der endogene Mediator und die zellulären Mechanismen bei der Erkrankung sind unbekannt. Die Prognose quoad vitam ist günstig. Die Therapie der Wahl ist die Behandlung mit Calciumantagonisten und Nitraten, während β-Blocker bei diesen Patienten nicht angewandt werden sollten. Die Symptomatik persistiert oder rekurriert jedoch häufig trotz medikamentöser Therapie.

Summary

Coronary spasms are defined as reversible coronary stenosis, which limits coronary blood flow under resting conditions. The demonstration of either spontaneous or provoked coronary spasm proves coronary hypercontractility and thus the diagnosis of variant angina. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity has been shown with ergonovine. Alternatively acetylcholine or, with less sensitivity, but high specificity, hyperventilation may be employed. Typically coronary vasospasm presents with angina pectoris at rest; the manifestation with myocardial infarction or syncope are of great clinical importance. The prevalence of the disease is unknown due to the rarely performed provocation tests in Western countries. The incidence of positive test results strongly depends on the symptoms of the patients; from 0% in patients without any evidence for myocardial ischemia up to 54% in patients with typical angina at rest have been observed. Coronary vasospasm is closely related to atherosclerotic coronary artery disease, since intravascular ultrasound studies reveal atherosclerotic plaques in almost any spastic segment. Risk factors for coronary artery disease and coronary vasospasm, however, differ profoundly. For the latter cigarette smoking is the only established risk factor. Although several candidates and predisposing factors (serotonin, histamine, thromboxane, endothelin) have been described, the mediators and the pathogenesis of the disease remains unknown. Endothelial dysfunction alone is not sufficient to explain the features of variant angina. Some evidence supports the hypothesis of local inflammation. The mortality in variant angina depends on the extent of the coronary artery disease. Pure coronary vasospasm does not lead to increased mortality; patients with highly active disease presenting with syncope may have an increased risk. Medical treatment should include long-acting calcium antagonists or nitrates, β-blockers may even favor the occurrence of ischemic attacks. Although the benefit has not been proven, the use of aspirin® may considered in highly active disease.

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  1. Medizinische Klinik IV (Kardiologie/Nephrologie), Klinikum der Johann-Wolfgang-Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, D-60590, Frankfurt am Main

    Wolfgang Auch-Schwelk

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Auch-Schwelk, W. Koronarer Spasmus — Ein klinisch relevantes Problem?. Herz 23, 106–115 (1998). https://doi.org/10.1007/BF03044541

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