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.
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Prof. Dr. med. S. Silber
Kardiologische Praxis, Klinik Dr. Müller
Am Isarkanal 36
81379 München
Phone: 089/74215130
Email: ssilber@med.de
