Periphere arterielle Verschlusskrankheit als Zusatzdiagnose bei koronarer Herzerkrankung – Einfluss auf Diagnostik, Therapie und Prognose

Zusammenfassung

Das Vorliegen einer PAVK verschlechtert die Prognose eines Patienten mit KHK und sollte daher bei Diagnostik und Therapieplanung berücksichtigt werden. Ist eine weiterführende Diagnostik bei V. a. eine KHK geplant, sollte man an mögliche Limitationen durch das Vorliegen einer PAVK denken. Bei einer Ergometrie sind PAVK Patienten möglicherweise aufgrund einer Claudicatio weniger gut belastbar, bei einer invasiven Diagnostik können Probleme beim Gefäßzugang auftreten. Die Einstellung der kardiovaskulären Risikofaktoren ist bei allen Manifestationen der Arteriosklerose wichtig. Herbei sind die Empfehlungen der Leitlinien bei PAVK und KHK vergleichbar. Ebenso sind Thrombozytenaggregationshemmer sowohl bei Vorliegen einer KHK als auch bei PAVK indiziert. Eine Bewegungstherapie führt nicht nur zur Verbesserung der schmerzfreien Gehstrecke bei Patienten mit Claudicatio intermittens sondern auch zur Verbesserung der Prognose bei Arteriosklerose.

Abstract

Peripheral arterial disease (PAD) increases cardiovascular event rate in patients with coronary artery disease (CAD). Therefore PAD should be considered in patients with CAD with regard to diagnostic and therapeutic strategies. PAD may difficult diagnostic tests in CAD patients. Patients with PAD and CAD may be limited in stress testing by decreased leg perfusion. In addition, arterial puncture can be more difficult in sclerotic femoral arteries. Cardiovascular risk factors should be treated carefully in all manifestations of atherosclerosis. Target values from current guidelines are similar for PAD and CAD. Inhibitors of platelet aggregation are indication in both CAD and PAD. Exercise not only improves walking distance in patients with intermittent claudication but also improves cardiovascular prognosis in patients with atherosclerosis.

Schlüsselwörter

Periphere arterielle Verschlusskrankheit (PAVK) - Koronare Herzkrankheit (KHK) - Kardiovaskuläre Prognose

Keywords

Peripheral arterial disease (PAD) - Coronary artery disease (CAD) - Cardiovascular prognosis

• Literatur

• 1 Ahimastos AA, Walker PJ, Askew C et al. Effect of ramipril on walking times and quality of life among patients with peripheral artery disease and intermittent claudication: a randomized controlled trial. JAMA 2013; 309: 453-460
• 2 Antithrombotic Trialists‘ Collaboration. Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002; 324: 71-86
• 3 Aung PP, Maxwell HG, Jepson RG et al. Lipid-lowering for peripheral arterial disease of the lower limb. Cochrane Database Syst Rev 2007; (04) CD000123
• 4 Bertomeu V, Morillas P, Gonzalez-Juanatey JR et al. Prevalence and prognostic influence of peripheral arterial disease in patients > or = 40 years old admitted into hospital following an acute coronary events. Eur J Vasc Endovasc Surg 2008; 36: 189-196
• 5 CAPRIE Steering Committee. A randomized, blinded, trial of Clopidogrel versus aspirin in patients at risk of ischaemic events. Lancet 1996; 348: 1329-1339
• 6 Cassar A, Poldermans D, Rihal CS et al. The management of combined coronary artery disease and peripheral vascular disease. Eur Heart J 2010; 31: 1565-72
• 7 Diehm C, Allenberg JR, Pittrow D et al. Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease. Circulation 2009; 120 (21) 2053-2061
• 8 Eagle KA, Rihal CS, Foster ED et al. Long-term survival in patients with coronary artery disease: importance of peripheral vascular disease. The Coronary Artery Surgery Study (CASS) investigators. J Am Coll Cardiol 1994; 23: 1091-1095
• 9 Espinola-Klein C, Rupprecht HJ, Bickel C et al. Different calculations of ankle brachial index and their impact on cardiovascular risk prediction. Circulation 2008; 118: 961-967
• 10 Espinola-Klein C, Rupprecht HJ, Voigtländer T et al. Comparison of arterial and venous blood flow between patients with pressure dressing or a new hemostatic puncture closure device after cardiac catheterization. J Intervent Cardiol 1997;  10: 357-363
• 11 Espinola-Klein C, Weisser G, Jagodzinski A et al. Beta Blockers in Patients with Intermittent Claudication and Arterial Hypertension: Results from the Nebivolol or Metoprolol in Arterial Occlusive Disease. Hypertension 2011; 58: 148-154
• 12 Grag PK, Tian L, Criqui MH et al. Physical activity during daily life and mortality in peripheral arterial disease. Circulation 2006; 114: 242-248
• 13 Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 Practice Guidelines for the Management of Patients with Peripheral Arterial Disease. Circulation 2006; 113: 463-654
• 14 Lawall H, Diehm C, Pittrow P. Deutsche Gesellschaft für Angiologie, Gesellschaft für Gefäßmedizin. Leitlinien zur Diagnostik und Therapie der peripheren arteriellen Verschlusskrankheit (PAVK). VASA 2009; 38: 1-72
• 15 Layden J, Michaels J, Bermingham S et al. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ 2012; 345: 4947-4950
• 16 Mukherjee D, Eagle KA, Kline-Rogers E et al. Impact of prior peripheral arterial diease and stroke on outcome of acute coronary syndromes and effect of evidence based therapies. Am J Cardiol 2007; 100: 1-6
• 17 Murphy TP, Cutlip DE, Regensteiner JG et al. Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease: Six-Month Outcomes From the Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) Study. Circulation 2012; 125: 130-139
• 18 Norgren L, Hiatt W, Dormandy J et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007; 33 (Suppl. 01) S1-S75
• 19 Resnick HE, Linsay RS, McDermott MM et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation 2004; 109: 733-739
• 20 Tendera M, Aboyans V, Bartelink ML et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J 2011; 32 (22) 2851-2906