Quantifizierung von Koronarkalk zur Risikostratifizierung kardialer Ereignisse

Zusammenfassung

Der Nachweis koronarer Kalzifizierungen anhand von empfindlichen Röntgenmethoden bietet erstmals die Möglichkeit, die koronare Atherosklerose frühzeitig nichtinvasiv zu erkennen und zu quantifizieren. Koronarkalzifizierungen sind identisch mit einer eine Atherosklerose der Koronararterien. Das Ausmaß der Koronarkalzifizierungen korreliert mit dem Ausmaß der gesamten koronaren Plaquelast. Die sensitive Erfassung einer kalzifizierenden Koronarsklerose erfolgte in den letzten 10 Jahren anhand der Elektronenstrahl-Computertomographie (EBCT = EBT). Weiterentwicklungen in der Technologie führten zu Multi-Slice-CT-Geräten; deren entscheidender Vorteil liegt in den geringeren Anschaffungskosten und in der daraus resultierende größeren Verfügbarkeit.

Der Nachweis von Koronarkalk ist keinesfalls gleichbedeutend mit dem Vorliegen relevanter Koronarstenosen. Daher muss auch im Falle eines Nachweises von Koronarkalk die Entscheidung zum Herzkatheter unverändert vom Vorhandensein einer Angina pectoris und/oder eines objektiven Ischämienachweis abhängig gemacht werden. Im Gegensatz hierzu ist der negative prädiktive Wert des Koronarscannings mit nahezu 100 % sehr hoch. Die zentrale praktische Bedeutung der Koronarkalkquantifizierung liegt in der prognostischen Aussagekraft: Unter Berücksichtigung der Perzentilenverteilung gelingt es sogar, Patienten mit einem „KHK-Äquivalent”zu identifizieren. Die „Gretchenfrage”, ob der Kalk-Score eine über die klassischen Risikofaktoren hinausgehende Zusatzinformation liefert, kann aufgrund neuerer Publikationen weitgehend bejaht werden.

Obwohl das „Kalzium-Scanning” heute weit verbreitet ist, sollte es nicht unkritisch als Screeningmethode angewendet werden. Entsprechend neuer ACC/AHA Richtlinien kann die Koronarkalkbestimmung bei ausgewählten asymptomatischen Personen eingesetzt werden, wenn eine über die klassische Risikofaktorenanalyse hinausgehende Entscheidungshilfe hinsichtlich weiterer therapeutischer Strategien zu erwarten ist. Die Indikationsstellung zum Koronarkalknachweis muss durch einen internistisch-kardiologisch ausgebildeten Arzt unter Gesamtschau des klinischen Bildes und der Laborbefunde erfolgen.

Literatur

• 1 Achenbach S, Ropers D, Pohle K, Leber A, Thilo C, Knez A, Menendez T, Maeffert R, Kusus M, Regenfus M, Bickel A, Haberl R, Steinbeck G, Moshage W Daniel WG. Influence of Lipid-Lowering Therapy on the Progression of Coronary Artery Calcification: A Prospective Evaluation.  Circulation. 2002;  106 1077-1082
• 2 Agatston A S, Janowitz W R, Hildner F J, Zusmer N R, Viamonte M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography.  J Am Coll Cardiol. 1990;  15 827-832
• 3 Ambrose J A, Tannenbaum M A, Alexopoulos D, Hjemdahl-Monsen C E, Leavy J, Weiss M, Borrico S, Gorlin R, Fuster V. Angiographic progression of coronary artery disease and the development of myocardial infarction.  J Am Coll Cardiol. 1988;  12 56-62
• 4 Arad Y, Spadaro L, Goodman K, Lledo-Perez A, Sherman S, Lerner G, Guerci A D. Predictive value of electron beam computed tomography of the coronary arteries.  Circulation. 1996;  93 1951-1953
• 5 Arad Y, Spadaro L A, Goodman K, Newstein D, Guerci A D. Prediction of coronary events with electron beam computed tomography.  J Am Coll Cardiol. 2000;  36 1253-1260
• 6 Blankenhorn D H, Stern D. Coronary arterial calcification. A review.  Am J Med Sci. 1961;  242 41-49
• 7 Budoff M J, Diamond G A, Raggi P, Arad Y, Guerci A D, Callister T Q, Berman D. Continuous Probabilistic Prediction of Angiographically Significant Coronary Artery Disease Using Electron Beam Tomography.  Circulation. 2002;  105 1791-1796
• 8 Budoff M J, Georgiou D, Brody A, Agatston A S, Kennedy J, Wolfkiel C, Stanford W, Shields P, Lewis R J, Janowitz W R, Rich S, Brundage B H. Ultrafast computed tomography as a diagnostic modality in the detection of coronary artery disease: a multicenter study.  Circulation. 1996;  93 898-904
• 9 Buffon A, Biasucci L M, Liuzzo G, D’Onofrio G, Crea F, Maseri A. Widespread Coronary Inflammation in Unstable Angina.  NEJM. 2002;  347 5-12
• 10 Burke A P, Kolodgie F D, Farb A, Weber D, Malcolm G T, Smialek J, Virmani R. Healed plaque ruptures and sudden coronary death: evidence that sublcinical rupture has a role in plaque progression.  Circulation. 2001;  103 934-940
• 11 Burke A P, Kolodgie F D, Farb A, Weber D, Virmani R. Morphological predictors of arterial remodeling in coronary atherosclerosis.  Circulation. 2002;  105 297-303
• 12 Burke A P, Taylor A, Farb A, Lalcom G T, Virmani R. Coronary calcification: insights from sudden coronary death victims.  Z Kardiol. 2000;  89 (Suppl 2) 49-53
• 13 Callister T Q, Cooil B, Raya S P, Lippolis N J, Russo D J, Raggi P. Coronary Artery Disease: Improved Reproducibility of Calcium Scoring with an Electron-Beam CT Volumetric Method.  Radiology. 1998;  208 807-814
• 14 Callister T Q, Raggi P, Cooil B, Lippolis N J, Russo D J. Effect of HMG-CoA Reductase Inhibitors on Coronary Artery Disease as Assessed by Electron-Beam Computed Tomography.  N Engl J Med. 1998;  339 1972-1978
• 15 Colhoun H M, Rubens M B, Underwood S R, Fuller J H. Cross sectional study of differences in coronary artery calcification by socioeconomic status.  BMJ. 2000;  321 1262-1263
• 16 Detrano R C, Wong N D, Shavelle R, Tang W, Doherty T M, Ginzton L E, Budoff M J, Narahara K A. Coronary calcium does not accurately predict near-term future coronary events in high-risk adults.  Circulation. 1999;  99 2633-2638
• 17 Devereux R B, Alderman M H. Role of Preclinical Cardiovascular Disease in the Evolution From Risk Factor Exposure to Development of Morbide Events.  Circulation. 1993;  88 1444-1455
• 18 Erbel R, Schmermund A, Möhlenkamp S, Sack S, Baumgart D. Electron-beam computed tomography for detection of early signs of arteriosclerosis.  Eur Heart J. 2000;  21 720-732
• 19 Giroud D, Li J M, Urban P, Meier B, Rutishauer W. Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography.  Am J Cardiol. 1992;  69 729-732
• 20 Greenland P, Smith S C, Grundy S M. Improving coronary heart disease risk assessment in asymptomatic people.  Circulation. 2001;  104 1863-1867
• 21 Grundy S M, Pasternak R, Greenland P, Smith S, Fuster V. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Faktor Assessment Equations. A Statement for Healthcare Professionals From the American Heart Association and the American College of Cardiology.  J Am Coll Cardiol. 1999;  34 1348-1359
• 22 Grundy S M. Coronary Calcium as a Risk Factor: Role in Global Risk Assessment.  J Am Coll Cardiol. 2001;  37 1512-1515
• 23 Grundy S M. Age as a risk factor: you are as old as your arteries.  Am J Cardiol. 1999;  83 1455-1457
• 24 Haberl R, Becker A, Leber A, Knez A, Becker C, Lang C, Brüning R, Reiser M, Steinbeck G. Correlation of Coronary Calcification and Angiographically Documented Stenoses in Patients With Suspected Coronary Artery Disease: Results of 1,764 Patients.  J Am Coll Cardiol. 2001;  37 451-457
• 25 Hackett D, Davies G, Maseri A. Pre-existing coronary stenoses in patients with first myocardial infarction are not necessarily severe.  European Heart Journal. 1988;  9 1317-1323
• 26 Hackett D, Verwilghen J, Davies G, Maseri A. Coronary stenoses before and after acute myocardial infarction.  Am J Cardiol. 1989;  63 1517-1518
• 27 Heart Protection Study Collaborative Group . MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial.  Lancet. 2002;  360 7-22
• 28 Hecht H S, Superko H R. Electron Beam Tomography and National Cholesterol Education Program Guidelines in Asymptomatic Women.  J Am Coll Cardiol. 2001;  37 1506-1511
• 29 Hecht H S, Superko H R, Smith L K, McColgan B P. Relation of Coronary Artery Calcium Identified by Electron Beam Tomography to Serum Lipoprotein Levels and Implications for Treatment.  Am J Cardiol. 2001;  87 406-412
• 30 Hecht H S. Practice Guidelines for Electron Beam Tomography: A Report of the Society of Atherosclerosis Imaging.  Am J Cardiol. 2000;  86 705-706
• 31 Hunt M E, OŽMalley G O, Vernalis M N, Feuerstein I M, Taylor A J. C-reactive protein is not associated with the presence or extent of calcified subclinical atherosclerosis.  Am Heart J. 2001;  141 206-210
• 32 Iribarren C, Sidney S, Bild D E, Liu K, Markovitz J H, Roseman J M, Matthews K. Association of Hostility With Coronary Artery Calcification in Young Adults.  JAMA. 2000;  283 2546-2551
• 33 Janowitz W R, Agatston A S, Viamonte M. Comparison of serial quantitative evaluation of calcified coronary artery plaque by ultrafast computed tomography in persons with and without obstructive coronary artery disease.  Am J Cardiol. 1991;  68 1-6
• 34 Kachelrieß M, Kalender W A. ECG-correlated image reconstruction from subsecond spiral CT scans of the heart.  Med Phys. 1998;  25 2417-2431
• 35 Keelan P C, Bielak L F, Ashai K, Jamjoum L S, Denktas A E, Rumberger J A, Sheedy P F, Peyser P A, Schwartz R S. Long-Term Prognostic Value of Coronary Calcification Detected by Electron-Beam Computed Tomography in Patients Undergoing Coronary Angiography.  Circulation. 2001;  104 412-417
• 36 Kennedy J, Shavelle R, Wang S, Budoff M, Detrano R C. Coronary calcium and standard risk factors in symptomatic patients referred for coronary angiography.  Am Heart J. 1998;  135 696-702
• 37 Klein U, Locher D, Silber S. Röntgendiagnostische und nuklearmedizinische Untersuchungen im Deutschen Herzzentrum München.  Herz. 1976;  1 108-117
• 38 Knez A, Becker C, Becker A, Leber A, White C, Reiser M, Steinbeck G. Determination of coronary calcium with Multi-slice Spiral Computed tomography: a comparative study with Electron-beam CT.  Int J Cardiovasc Imaging. 2002;  18 295-303
• 39 Lai S, Lai H, Meng Q, Tong W, Vlahov D, Celentano D, Strathdee S, Nelson K, Fishman E K, Lima J AC. Effect of cocaine use on coronary calcium among black adults in Baltimore, Maryland.  Am J Cardiol. 2002;  90 326-328
• 40 LaMont D H, Budoff M J, Shavelle D M, Shavelle R, Brundage B H, Hagar J M. Coronary calcium scanning adds incremental value to patients with positive stress tests.  Am Heart J. 2002;  143 861-867
• 41 Little W C, Constantinescu M, Applegate R J, Kutcher M A, Burrows M T, Kahl F R, Santamore W P. Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease?.  Circulation. 1988;  78 1157-1166
• 42 McLaughlin V V, Balogh T, Rich S. Utility of Electron Beam Computed Tomography to Stratify Patients Presenting to the Emergency Room With Chest Pain.  Am J Cardiol. 1999;  84 327-328
• 43 Moise A, Lesperance J, Theroux P, Taeymans Y, Goulet C, Bourassa M G. Clinical and angiographic predictors of new total coronary occlusion in coronary artery disease: analysis of 313 nonoperated patients.  Am J Cardiol. 1984;  54 1176-1181
• 44 National Cholesterol Education Program Expert Panel on Detection . Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).  JAMA. 2001;  285 2486-2497
• 45 Nobuyoshi M, Tanaka M, Nosaka H, Kimura T, Yokoi H, Hamasaki N, Kim K, Shindo T, Kimura K. Progression of Coronary Atherosclerosis: Is Coronary Spasm Related to Progression?.  J Am Coll Cardiol. 1991;  18 904-910
• 46 Oei H HS, Vliegenthart R, Hak E, del S ol AI, Hofman A, Oudkerk M, Witteman J CM. The Association Between Coronary Calcification Assessed by Electron Beam Computed Tomography and Measures of Extracoronary Atherosclerosis.  JACC. 2002;  39 1745-1751
• 47 O’Malley P G, Taylor A J, Jackson J L, Doherty T M, Detrano R C. Prognostic value of coronary electron-beam computed tomography for coronary heart disease events in asymptomatic populations.  Am J Cardiol. 2000;  85 945-948
• 48 O’Rourke R A, Brundage B, Froelicher V F, Greenland P, Grundy S M, Hachamovitch R, Pohost G, Shaw L J, Weintraub W S, Winters W L. ACC/AHA Expert Consensus Document on electron-beam computed tomography fro the diagnosis and prognosis of coronary artery disease.  Circulation. 2000;  102 126-140
• 49 Peyser P A, Bielak L F, Chu J S, Turner S T, Ellsworth D L, Boerwinkle E, Sheedy P F. Heritability of Coronary Artery Calcium Quantity Measured by Electron Beam Computed Tomography in Asymptomatic Adults.  Circulation. 2002;  106 304-308
• 50 Proudfit W L, Bruschke V G, Sones F M. Clinical course of patients with normal or slightly or moderately abnormal coronary arteriograms: 10-year follow-up of 521 patients.  Circulation. 1980;  62 712-717
• 51 Raggi P, Callister T Q, Cooil B, He Z X, Lippolis N, Russo D, Zelinger A, Mahmarian J. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography.  Circulation. 2000;  101 850-855
• 52 Redberg R F, Rifai N, Gee L, Ridker P M. Lack of Association of C-Reactive Protein and Coronary Calcium by Electron Beam Computed Tomography in Postmenopausal Women: Implications for Coronary Artery Disease Screening.  J Am Coll Cardiol. 2000;  36 39-43
• 53 Rifkin  RD, Parisi A F, Folland E. Coronary calcification in the diagnosis of coronary artery disease.  Am J Cardiol. 1979;  44 141-147
• 54 Rumberger J A, Simons D B, Fitzpatrick L A, Sheedy P F, Schwartz R S. Coronary Calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area.  Circulation. 1995;  92 2157-2162
• 55 Sangiorgi G, Rumberger J A, Severson A, Edwards W D, Gregoire J, Fitzpatrick L A, Schwartz R S. Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: A histologic study of 723 coronary artery segments using nondecalcifying methodology.  J Am Coll Cardiol. 1998;  31 126-133
• 56 Schmermund A, Baumgart D, Görge G, Seibel R, Gronemeyer D, Ge J, Haude M, Rumberger J, Erbel R. Coronary Calcium in acute coronary syndromes. A comparative study of electron beam computed tomography, coronary angiography, and intracoronary ultrasound in survivors of acute myocardial infarction and unstable angina.  Circulation. 1997;  96 1461-1469
• 57 Schmermund A, Denktas A E, Rumberger J A, Christian T F, Sheedy I I PF, Bailey K R, Schwartz R S. Independent and Incremental Value of Coronary Artery Calcium for Predicting the Extent of Angiographic Coronary Artery Disease.  J Am Coll Cardiol. 1999;  34 777-786
• 58 Schmermund A, Erbel R, Silber  S. for the MUNICH Registry Study Group . Age and gender distribution of coronary artery calcium measured by four-slice computed tomography in 2,030 persons with no symptoms of coronary artery disease.  American J Cardiol. 2002;  90 168-173
• 59 Schmermund A, Schwartz R S, Adamzik M, Sangiorgi G, Pfeifer E A, Rumberger J A, Burke A P, Farb A, Virmani R. Coronary atherosclerosis in unheralded sudden coronary death under age fifty: histo-pathologic comparison with „healthy” subjects dying out of hospital.  Atherosclerosis. 2001;  155 499-508
• 60 Shaw L J, OŽRourke R A. Editorial Comment. The Challenge of Improving Risk Assessment in Asymptomatic Individuals: The Additive Prognostic Value of Electron Beam Tomography?.  J Am Coll Cardiol. 2000;  36 1261-1264
• 61 Shemesh J, Apter S, Rozenman J, Lusky A, Rath S, Itzchak Y, Motro M. Calcification of Coronary Arteries: Detection and Quantification with Double-Helix CT.  Radiology. 1995;  197 779-783
• 62 Shemesh J, Tenenbaum A, Fisman E Z, Apter S, Rath S, Rozenman J, Itzchak Y, Motro M. Absence of Coronary Calcification on Double-Helical CT Scans: Predictor of Angiographically Normal Coronary Arteries in Elderly Women?.  Radiology. 1996;  199 665-668
• 63 Silber S  f. ür das MUNICH-Register . Bedeutung der EKG-Triggerung mit dem Multi-Slice-CT zum Ausschluss einer Koronararterienverkalkung bei Personen ohne bekannte KHK.  Herz. 2001;  26 260-272
• 64 Silber S. Comparison of spiral and electron beam tomography in the evaluation of coronary calcification in asymptomatic persons, letter to the editor.  Int J Cardiol. 2002;  82 297
• 65 Smith S C, Greenland P, Grundy S M. Prevention Conference V. Beyond secondary prevention. identifying the high-risk patient for primary prevention: Executive summary.  Circulation. 2000;  101 111-116
• 66 Taylor A, Burke A P, OŽMalley P, Farb A, Malcom G T, Smialek J, Virmani R. A Comparison of the Framingham Risk Index, Coronary Artery Calcification, and Culprit Plaque Morphology in Sudden Cardiac Death.  Circulation. 2001;  101 1243-1248
• 67 Taylor A J, Feuerstein I, Wong H, Barko W, Brazaitis M, OŽMalley P G. Do conventional risk factors predict subclinical coronary artery disease? Results from the Prospective Army Coronary Calcium Project.  Am Heart J. 2001;  141 463-468
• 68 Tinana A, Mintz G S, Weissman N J. Volumetric intravascular ultrasound quantification of the amount of atherosclerosis and calcium in nonstenotic arterial segments.  Am J Cardiol. 2002;  89 757-760
• 69 Wang T J, Larson M G, Levy D, Benjamin E J, Kupka M J, Manning W J, Clouse M E, D’Agostino R B, Wilson P WF, O’and D onnell CJ. C-Reactive Protein Is Associated With Subclinical Epicardial Coronary Calcification in Men and Women. The Framingham Heart Study.  Circulation. 2002;  106 1189-1191
• 70 Wayhs R, Zelinger A, Raggi P. High Coronary artery calcium scores pose an extremely elevated risk for hard events.  J Am Coll Cardiol. 2002;  39 225-230
• 71 Wexler L, Brundage B, Crouse J, Detrano R, Fuster V, Maddahi J, Rumberger J, Stanford W, White R, Taubert K. Coronary Artery Calcification: Pathophysiology, Epidemiology, Imaging Methods, and Clinical Implications.  Circulation. 1996;  94 1175-1192
• 72 Wong N D, Budoff M J, Pio J, Detrano R C. Coronary calcium and cardiovascular event risk: Evaluation by age- and sex-specific quartiles.  Am Heart J. 2002;  143 456-459
• 73 Wong N D, Detrano R C, Diamond G, Rezayat C, Mahmoudi R, Chong E C, Tang W, Puentes G, Kang X, Abrahamson D. Does Coronary Artery Screening by Electron Beam Computed Tomography Motivate Potentially Beneficial Lifestyle Behaviors?.  Am J Cardiol. 1996;  78 1220-1223
• 74 Wong N D, Hsu J C, Detrano R C, Diamond G, Eisenberg H, Gardin J M. Coronary Artery Calcium Evaluation by Electron Beam Computed Tomography and Its Relation to New Cardiovascular Events.  Am J Cardiol. 2000;  86 495-498
• 75 Yokoya K, Takatsu H, Suzuki T, Hosokawa H, Ojio S, Matsubara T, Tanaka T, Watanabe S, Morita N, Nishigaki K, Takemura G, Noda T, Minatoguchi S, Fujiwara H. Process of Progression of Coronary Artery Lesions From Mild or Moderate Stenosis to Moderate or Severe Stenosis. A Study Based on Four Serial Coronary Arteriograms per Year.  Circulation. 1999;  100 903-909