Dilemmata im Management der koronaren Herzkrankheit

Zusammenfassung

Die koronare Herzkrankheit (KHK) weist eine komplexe Pathophysiologie auf, der eine dichotome Klassifizierung in „KHK vorhanden“ oder „KHK nicht vorhanden“ nicht gerecht wird. Eine Einteilung in Stadien wäre sinnvoller, wobei durch den episodischen Charakter der Entwicklung der KHK auch Stadien übersprungen oder ausgelassen werden können. Drei verschiedene Entitäten sind bei der Beurteilung einer KHK zu berücksichtigen, bestehend aus Morphologie (Stenosen und Plaques), Funktion (Ischämie) und Prognose (Risiko für Herzinfarkt oder kardiovaskulären Tod). Methodische Limitationen in der Zuverlässigkeit der Symptomatik (Angina pectoris) und der nicht invasiven Tests erschweren dabei die Diagnosestellung der stabilen KHK. Die morphologische Klassifizierung einer Atherosklerose der Koronararterien als entweder nicht obstruktiv, Eingefäßerkrankung oder Mehrgefäßerkrankung ist nicht ausreichend. Vielmehr ist entscheidend, ob eine Ischämie durch die Veränderungen hervorgerufen wird und inwiefern die Prognose beeinträchtigt ist. Nicht obstruktive Koronarveränderungen sind in den Behandlungsempfehlungen bisher nicht ausreichend berücksichtigt.

Abstract

Coronary artery disease (CAD) has a complex pathophysiology, which is not adequately displayed in a dichotomous classification such as “CAD present” or “CAD absent”. A classification into stages would be useful, although stages might be skipped due to the episodic nature of the disease. Three different entities are important when assessing CAD, which are the following: morphology (stenosis and plaques), function (ischemia) and prognosis (risk of myocardial infarction or cardiovascular death). Diagnosis of stable CAD is difficult due to unreliability of subjective symptoms (angina pectoris) as well as limitations of non-invasive testing. Classifying coronary atherosclerosis solely by morphology, e.g. as non-obstructive atherosclerosis, single vessel or multi vessel disease, is not enough. It is more important to determine whether coronary atherosclerosis is associated with ischemia and whether prognosis is impaired. Thereby, patients with non-obstructive coronary atherosclerosis are not adequately addressed in current guidelines.

Schlüsselwörter

koronare Herzkrankheit - Primärprävention - Herzinfarkt - Prognose

Key words

coronary artery disease - primary prevention - myocardial infarction - prognosis

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