Indikationsstellung zur PCI: Morphologie versus Funktion

Zusammenfassung

Die Indikationsstellung für eine PCI ist eine Herausforderung für den interventionellen Kardiologen. Bei stabiler Angina pectoris sollte eine PCI erwogen werden, wenn trotz optimaler antianginöser Therapie eine Beschwerdepersistenz und ein Ischämienachweis vorliegen, der zur Lokation der epikardialen Stenose passt. Bei Patienten mit ACS ist die PCI der Culprit Lesion Therapie der Wahl. Bei STEMI mit Mehrgefäßerkrankung sollten zunächst nur die Culprit Lesion versorgt und die verbliebenen Stenosen im Intervall auf ihre hämodynamische Relevanz überprüft werden. Bei chronischen Totalverschlüssen ergibt sich eine Indikation zur PCI bei therapierefraktärer Angina mit Vitalitäts- und Ischämienachweis im Versorgungsgebiet. Grundsätzlich zeichnet sich ein Trend ab weg von der rein strukturell-anatomischen Beurteilung epikardialer Stenosen hin zu einer mehr funktionellen Beurteilung der KHK, die standardmäßig mittels FFR-Messung erfolgen sollte. Darüber hinaus sind epikardiale und mikrovaskuläre Vasomotionsstörungen eine häufige Ursache für die hohe Rate an persistierender Angina pectoris trotz erfolgreicher PCI, die mittels Acetylcholintestung diagnostiziert werden können.

Abstract

Decision making for PCI is a challenge for the interventional cardiologist. In patients with stable angina PCI should be performed if despite optimal antianginal treatment symptoms persist and reversible ischemia caused by an epicardial stenosis is confirmed. In patients with ACS PCI of the culprit lesion is standard practice. In patients with STEMI and multivessel disease it is recommended to perform PCI of the culprit lesion only and assess severity of further stenosis at a later stage. Patients with a chronic total occlusion have an indication for PCI in case of refractory angina and proof of myocardial viability and ischemia in the respective territory. Generally, there is a trend from a more structural-anatomic assessment of epicardial lesions towards a more functional assessment primarily using FFR. Moreover, epicardial as well as coronary microvascular vasomotor disorders are a frequent cause for persisting angina after successful PCI and can be diagnosed using intracoronary acetylcholine provocation testing.

Schlüsselwörter

stabile Angina pectoris - akutes Koronarsyndrom - fraktionierte Flussreserve - perkutane Koronarintervention - Indikation

Key words

stable angina - acute coronary syndrome - fractional flow reserve - percutaneous coronary intervention - indication

• Literatur

• 1 Task Force Members. Montalescot G, Sechtem U et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949-3003
• 2 Toth G, De Bruyne B, Casselman F et al. Fractional flow reserve-guided versus angiography-guided coronary artery bypass graft surgery. Circulation 2013; 128: 1405-1411
• 3 Ellis SG, Kereiakes DJ, Metzger DC et al. ABSORB III Investigators. Everolimus-eluting bioresorbable scaffolds for coronary artery disease. N Engl J Med 2015; 373: 1905-1915
• 4 Windecker S, Kolh P, Alfonso F et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541-2619
• 5 Bertrand ME, Lablanche JM, Bauters C et al. Discordant results of visual and quantitative estimates of stenosis severity before and after coronary angioplasty. Cathet Cardiovasc Diagn 1993; 28: 1-6
• 6 Johnson NP, Kirkeeide RL, Gould KL. Is discordance of coronary flow reserve and fractional flow reserve due to methodology or clinically relevant coronary pathophysiology?. JACC Cardiovasc Imaging 2012; 5: 193-202
• 7 Tonino PA, De Bruyne B, Pijls NH et al. FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009; 360: 213-224
• 8 Kobayashi Y, Nam CW, Tonino PA et al. FAME Study Investigators. The prognostic value of residual coronary stenoses after functionally complete revascularization. J Am Coll Cardiol 2016; 67: 1701-1711
• 9 Ong P, Athanasiadis A, Borgulya G et al. High prevalence of a pathological response to acetylcholine testing in patients with stable angina pectoris and unobstructed coronary arteries. The ACOVA Study (Abnormal COronary VAsomotion in patients with stable angina and unobstructed coronary arteries). J Am Coll Cardiol 2012; 59: 655-662
• 10 Ong P, Sechtem U. Controversies in the treatment of patients with STEMI and multivessel disease: is it time for PCI of all lesions?. Clin Res Cardiol 2016; 105: 467-470
• 11 Christofferson RD, Lehmann KG, Martin GV et al. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 2005; 95: 1088-1091
• 12 Borgia F, Viceconte N, Ali O et al. Improved cardiac survival, freedom from MACE and angina-related quality of life after successful percutaneous recanalization of coronary artery chronic total occlusions. Int J Cardiol 2012; 161: 31-38
• 13 Claessen BE, Dangas GD, Weisz G et al. Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial. Eur Heart J 2012; 33: 768-775
• 14 Wijeysundera HC, Nallamothu BK, Krumholz HM et al. Meta-analysis: effects of percutaneous coronary intervention versus medical therapy on angina relief. Ann Intern Med 2010; 152: 370-379
• 15 Ong P, Athanasiadis A, Perne A et al. Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis. Clin Res Cardiol 2014; 103: 11-19
• 16 Bentz K, Ong P, Sechtem U. [Unstable angina pectoris—combination of an epicardial stenosis and a Prinzmetal spasm]. Dtsch Med Wochenschr 2013; 138: 2546-2549