Abstract
Regelmäßige körperliche Aktivität reduziert die
kardiovaskuläre Morbidität und Mortalität und verbessert die
Lebensqualität und das kardiovaskuläre Risikoprofil bei Gesunden und
Kranken. Hohe Belastungen sind jedoch mit einem erhöhten Ereignisrisiko
assoziiert; ein Phänomen, das als „Paradox of Exercise“
beschrieben wird. In einer großen prospektiven Studie bei
> 50-jährigen Marathonläufern haben wir die Ausprägung
der subklinischen Arteriosklerose (gemessen als Koronarverkalkung, CAC) und
deren Zusammenhang mit traditionellen und neuen Risikofaktoren, mit
subklinischen Myokardschädigungen und mit der Prognose untersucht. Wir
fanden ein wesentlich günstigeres Risikoprofil bei Marathonläufern
als in der gleichaltrigen Allgemeinbevölkerung. Es zeigte sich jedoch eine
hierzu diskrepante und unerwartet hohe Prävalenz und Ausprägung der
Koronarsklerose. Ferner fanden wir überzufällig häufig Hinweise
für einen Myokardschaden. Die Langzeitprognose für Ereignisse stieg
mit zunehmender Koronarverkalkung. Zur Evaluation des kardiovaskulären
Risikos bei älteren Marathonläufern sollte zusätzlich zum
12-Punkte-Algorithmus der AHA auch das Lipidprofil bestimmt und die
Risikofaktorenanamnese erhoben werden. In Einzelfällen sollte
weiterführende nicht-invasive Diagnostik einschließlich der modernen
bildgebenden Verfahren zur verbesserten Risikostratifikation erwogen werden.
Die Läufer sollten sorgfältig über die Symptome einer koronaren
Herzkrankheit und die Risiken einer Marathonbelastung aufgeklärt
werden.
Kernaussagen
-
Durch regelmäßige körperliche Aktivität
werden die meisten kardiovaskulären Risikofaktoren günstig
beeinflusst. Ein langjähriges Ausdauertraining könnte dabei einen
noch positiveren Effekt haben, als dies aus kontrollierten prospektiven Studien
bisher deutlich wurde.
-
Koronarkalk ist ein Maß für die Ausprägung der
koronaren Atherosklerose. Er verbessert die prognostische Trennschärfe
für koronare und kardiovaskuläre Ereignisse jenseits der etablierten
kardiovaskulären Risikofaktoren.
-
Es gibt Hinweise darauf, dass regelmäßiges
Marathonlaufen bei Läufern ohne Atherosklerose vor dem Auftreten einer
Atherosklerose schützt. Dennoch wird die Ausprägung der koronaren
Atherosklerose bei Marathonläufern eher unterschätzt,
möglicherweise weil nicht wenige Marathonläufer in jüngeren
Lebensjahren geraucht haben und/oder anderen Risikofaktoren ausgesetzt
waren.
-
Bei Marathonläufern kommen sowohl ein peripheres
atherosklerotisches Remodeling als auch ein metabolisch bedingtes Remodeling
vor.
-
Geschädigtes Myokard (im Sinne von Strukturschäden,
wie sie durch LGE nachweisbar sind) ist bei Marathonläufern häufiger
als bei altersentsprechenden Personen. Die Zahl der absolvierten
Marathonwettkämpfe und die Kalklast korreliert mit der Prävalenz des
LGE.
-
Zur Risikoeinschätzung auch älterer
Marathonläufer und Ausdauersportler sollte zunächst der
12-Punkte-Algorithmus verwendet werden, der durch die Lipidwerte und
Nüchtern-Glukosewerte ergänzt wird. Selbst mit zusätzlichem
Ruhe- und Belastungs-EKG bleibt jedoch die subklinische KHK einiger Sportler
unerkannt.
-
Selbst bei großzügiger Indikationsstellung einer
kardiovaskulären Bildgebung und entsprechenden Vorsichtsmaßnahmen
(individuelle Trainingspläne, keine Maximalbelastung, Aufklärung der
Sportler) bleibt ein kardiales Restrisiko bei jeder Art der körperlichen
Aktivität.
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Priv.-Doz. Dr. med. Stefan Möhlenkamp
Krankenhaus Bethanien Moers
Medizinische Klinik
II
Kardiologie, Internistische Intensivmedizin
Bethanienstr. 21
47441 Moers
Email: stefan.moehlenkamp@bethanienmoers.de
