Diagnostik des chronischen Koronarsyndroms

Das chronische Koronarsyndrom kann auf unterschiedliche pathophysiologische epikardiale oder mikrovaskuläre Gefäßmechanismen zurückgeführt werden. In der aktuellen ESC-Leitlinie erfolgte die Entwicklung eines Diagnose-Algorithmus, basierend auf einer risikofaktorgewichteten individuellen Prätestwahrscheinlichkeit. Der folgende Beitrag stellt die diagnostischen Schritte und deren Bedeutung vor.

Abstract

The chronic coronary syndrome can be attributed to different pathophysiological epicardial or microvascular mechanisms. In the current ESC guideline from 2024, a diagnostic algorithm was developed based on a risk-factor-weighted individual pre-test probability. The baseline diagnostic includes anamnesis, electrocardiogram, and a laboratory chemical analysis, especially to exclude an acute coronary syndrome. The early and direct assessments for risk-factor-weighted individual pre-test probability are calculated by taking into account clinical symptoms, individual cardiovascular risk factors, age, and gender. Resting ECG, echocardiography and the evaluation of the peripheral arteries and data on possible known vascular calcifications in previous imaging examinations can further adjust and modify the pre-test probability. Non-invasive imaging methods (computed tomography angiography, magnetic resonance imaging, stress echocardiography, SPECT, PET) or invasive coronary angiography can be used to confirm or exclude the diagnosis of chronic coronary syndrome.

Kernaussagen

• Eine frühe und effektive Diagnostik des CCS ist von essenzieller Bedeutung.

• Eine Basisdiagnostik mit Anamnese, 12-Kanal-Ruhe-EKG und Bestimmung der kardialen Biomarker stellt die Grundlage dar, insbesondere zum Ausschluss eines akuten Koronarsyndroms (ACS).

• Anhand der individuellen risikofaktorgewichteten Prätestwahrscheinlichkeit wird die weitere Diagnostik definiert.

• Zur Bestätigung oder zum Ausschluss eines CCS dienen sowohl nicht invasive anatomische und funktionelle Bildgebungsmodalitäten als auch invasive Untersuchungsmethoden, die individuell gewählt und nach lokaler Verfügbarkeit durchgeführt werden sollen.

Schlüsselwörter

chronisches Koronarsyndrom - mikrovaskuläre Erkrankung - Prätestwahrscheinlichkeit - Angina pectoris - koronare CT

Keywords

chronic coronary syndrome - microvascular disease - pretest probability - Angina pectoris - coronary CT

Publication History

Article published online:
06 May 2025

• Literatur

• 1 Vrints C, Andreotti F, Koskinas KC. et al. 2024 ESC Guidelines for the management of chronic coronary syndromes: Developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45: 3415-3537
• 2 Douglas PS, Nanna MG, Kelsey MD. et al. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8: 904-914
• 3 Douglas PS, Hoffmann U, Patel MR. et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015; 372: 1291-1300
• 4 Kannel WB, Abbott RD, Savage DD. et al. Coronary heart disease and atrial fibrillation: the Framingham Study. Am Heart J 1983; 106: 389-396
• 5 Winther S, Schmidt SE, Mayrhofer T. et al. Incorporating Coronary Calcification Into Pre-Test Assessment of the Likelihood of Coronary Artery Disease. J Am Coll Cardiol 2020; 76: 2421-2432
• 6 Zhou J, Zhao J, Li Z. et al. Coronary calcification improves the estimation for clinical likelihood of obstructive coronary artery disease and avoids unnecessary testing in patients with borderline pretest probability. Eur J Prev Cardiol 2022; 29: e105-e107
• 7 Winther S, Murphy T, Schmidt SE. et al. Performance of the American Heart Association/American College of Cardiology Guideline-Recommended Pretest Probability Model for the Diagnosis of Obstructive Coronary Artery Disease. J Am Heart Assoc 2022; 11: e027260
• 8 Daly CA, De Stavola B, Sendon JL. et al. Predicting prognosis in stable angina – results from the Euro heart survey of stable angina: prospective observational study. BMJ 2006; 332: 262-267
• 9 Cerqueira MD, Weissman NJ, Dilsizian V. et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002; 105: 539-542
• 10 Eek C, Grenne B, Brunvand H. et al. Strain echocardiography and wall motion score index predicts final infarct size in patients with non-ST-segment-elevation myocardial infarction. Circ Cardiovasc Imaging 2010; 3: 187-194
• 11 Shaw LJ, Bugiardini R, Merz CN. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol 2009; 54: 1561-1575
• 12 Galderisi M, Cosyns B, Edvardsen T. et al. Standardization of adult transthoracic echocardiography reporting in agreement with recent chamber quantification, diastolic function, and heart valve disease recommendations: an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2017; 18: 1301-1310
• 13 Knuuti J, Ballo H, Juarez-Orozco LE. et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J 2018; 39: 3322-3330
• 14 Serruys PW, Kotoku N, Nørgaard BL. et al. Computed tomographic angiography in coronary artery disease. EuroIntervention 2023; 18: e1307-e1327
• 15 Newby DE, Adamson PD, Berry C. et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med 2018; 379: 924-933
• 16 Celeng C, Leiner T, Maurovich-Horvat P. et al. Anatomical and Functional Computed Tomography for Diagnosing Hemodynamically Significant Coronary Artery Disease: A Meta-Analysis. JACC Cardiovascular imaging 2019; 12: 1316-1325
• 17 Curzen N, Nicholas Z, Stuart B. et al. Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial. Eur Heart J 2021; 42: 3844-3852
• 18 Maron DJ, Hochman JS, Reynolds HR. et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020; 382: 1395-1407
• 19 Neumann FJ, Sousa-Uva M, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87-165