Skip to main content
Erschienen in: Herz 4/2016

01.06.2016 | Koronare Herzerkrankung | CME

Koronare mikrovaskuläre Dysfunktion

Klinik, Diagnose, Therapie

verfasst von: Dr. P. Ong, U. Sechtem

Erschienen in: Herz | Ausgabe 4/2016

Einloggen, um Zugang zu erhalten

Zusammenfassung

Wie bei epikardialen Stenosen führt eine koronare mikrovaskuläre Dysfunktion (MVD) zu einem Missverhältnis zwischen myokardialem Sauerstoffbedarf und -angebot. Die Fehlfunktion liegt auf Ebene der Gefäße mit einem Durchmesser < 500 μm, und strukturelle sowie funktionelle Veränderungen der Gefäße sind beschrieben worden. Die zugrunde liegenden Mechanismen umfassen u. a. chronische Inflammation, Östrogenmangel oder genetische/familiäre Prädisposition. Klinisch ist eine koronare MVD häufig bei Patienten mit Angina pectoris und/oder Dyspnoe anzutreffen, die keine relevanten Koronarstenosen oder Myokarderkrankungen aufweisen. Für die Diagnosestellung kommen nicht-invasive Verfahren wie die Kombination aus Computertomographie (CT)-Koronarangiographie und Stressmagnetresonanztomographie (Stress-MRT) oder CT-Koronarangiographie und Positronenemissionstomographie (PET), aber auch invasive Vasomotionstestungen infrage. Bislang gibt es nur wenig Evidenz bezüglich der Effektivität einer medikamentösen Therapie. Die Leitlinie der Europäischen Gesellschaft für Kardiologie (ESC) zum Management der stabilen koronaren Herzkrankheit von 2013 empfiehlt Acetylsalicylsäure (ASS) und ein Statin sowie Betablocker- und/oder Kalziumantagonisten. Patienten mit koronarer MVD haben ein erhöhtes Risiko für Koronarereignisse und Tod von etwa 1,7 % pro Jahr. Außerdem besteht eine erhöhte Morbidität mit häufigen Vorstellungen in Praxis und Notaufnahme. Die klinische Forschung sollte die zugrunde liegenden Mechanismen genauer charakterisieren, um gezielte Therapiekonzepte ableiten zu können.
Literatur
1.
Zurück zum Zitat Schannwell CM, Steiner S, Strauer BE (2005) Hypertensive mikrovaskuläre Erkrankung. Herz 30:26–36CrossRefPubMed Schannwell CM, Steiner S, Strauer BE (2005) Hypertensive mikrovaskuläre Erkrankung. Herz 30:26–36CrossRefPubMed
2.
Zurück zum Zitat Granger DN, Rodrigues SF, Yildirim A, Senchenkova EY (2010) Microvascular responses to cardiovascular risk factors. Microcirculation 17:192–205CrossRefPubMedPubMedCentral Granger DN, Rodrigues SF, Yildirim A, Senchenkova EY (2010) Microvascular responses to cardiovascular risk factors. Microcirculation 17:192–205CrossRefPubMedPubMedCentral
3.
Zurück zum Zitat Rosano GM, Collins P, Kaski JC et al (1995) Syndrome X in women is associated with oestrogen deficiency. Eur Heart J 16:610–614PubMed Rosano GM, Collins P, Kaski JC et al (1995) Syndrome X in women is associated with oestrogen deficiency. Eur Heart J 16:610–614PubMed
4.
Zurück zum Zitat Fedele F, Mancone M, Chilian WM et al (2013) Role of genetic polymorphisms of ion channels in the pathophysiology of coronary microvascular dysfunction and ischemic heart disease. Basic Res Cardiol 108:387CrossRefPubMedPubMedCentral Fedele F, Mancone M, Chilian WM et al (2013) Role of genetic polymorphisms of ion channels in the pathophysiology of coronary microvascular dysfunction and ischemic heart disease. Basic Res Cardiol 108:387CrossRefPubMedPubMedCentral
5.
6.
Zurück zum Zitat Crea F, Camici PG, Bairey Merz CN (2014) Coronary microvascular dysfunction: an update. Eur Heart J 35:1101–1111CrossRefPubMed Crea F, Camici PG, Bairey Merz CN (2014) Coronary microvascular dysfunction: an update. Eur Heart J 35:1101–1111CrossRefPubMed
8.
Zurück zum Zitat Jespersen L, Hvelplund A, Abildstrøm SZ et al (2012) Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 33:734–744CrossRefPubMed Jespersen L, Hvelplund A, Abildstrøm SZ et al (2012) Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 33:734–744CrossRefPubMed
9.
Zurück zum Zitat Reis SE, Holubkov R, Smith CAJ et al (2001) Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 141:735–741CrossRefPubMed Reis SE, Holubkov R, Smith CAJ et al (2001) Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 141:735–741CrossRefPubMed
10.
Zurück zum Zitat Ong P, Athanasiadis A, Borgulya G et al (2012) 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 59:655–662CrossRefPubMed Ong P, Athanasiadis A, Borgulya G et al (2012) 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 59:655–662CrossRefPubMed
11.
Zurück zum Zitat Sambuceti G, Parodi O, Marcassa C et al (1993) Alteration in regulation of myocardial blood flow in one-vessel coronary artery disease determined by positron emission tomography. Am J Cardiol 72:538–543CrossRefPubMed Sambuceti G, Parodi O, Marcassa C et al (1993) Alteration in regulation of myocardial blood flow in one-vessel coronary artery disease determined by positron emission tomography. Am J Cardiol 72:538–543CrossRefPubMed
12.
Zurück zum Zitat Pupita G, Maseri A, Kaski JC et al (1990) Myocardial ischemia caused by distal coronary-artery constriction in stable angina pectoris. N Engl J Med 323:514–520CrossRefPubMed Pupita G, Maseri A, Kaski JC et al (1990) Myocardial ischemia caused by distal coronary-artery constriction in stable angina pectoris. N Engl J Med 323:514–520CrossRefPubMed
13.
Zurück zum Zitat Ong P, Athanasiadis A, Perne A et al (2014) Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis. Clin Res Cardiol 103:11–19CrossRefPubMed Ong P, Athanasiadis A, Perne A et al (2014) Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis. Clin Res Cardiol 103:11–19CrossRefPubMed
14.
Zurück zum Zitat Ong P, Athanasiadis A, Mahrholdt H et al (2012) Increased coronary vasoconstrictor response to acetylcholine in women with chest pain and normal coronary arteriograms (cardiac syndrome X). Clin Res Cardiol 101:673–681CrossRefPubMed Ong P, Athanasiadis A, Mahrholdt H et al (2012) Increased coronary vasoconstrictor response to acetylcholine in women with chest pain and normal coronary arteriograms (cardiac syndrome X). Clin Res Cardiol 101:673–681CrossRefPubMed
15.
Zurück zum Zitat Kajander S, Joutsiniemi E, Saraste M et al (2010) Cardiac positron emission tomography/computed tomography imaging accurately detects anatomically and functionally significant coronary artery disease. Circulation 122:603–613CrossRefPubMed Kajander S, Joutsiniemi E, Saraste M et al (2010) Cardiac positron emission tomography/computed tomography imaging accurately detects anatomically and functionally significant coronary artery disease. Circulation 122:603–613CrossRefPubMed
16.
Zurück zum Zitat Achenbach S, Marwan M, Ropers D et al (2010) Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur Heart J 31:340–346CrossRefPubMed Achenbach S, Marwan M, Ropers D et al (2010) Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur Heart J 31:340–346CrossRefPubMed
17.
Zurück zum Zitat 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 34:2949–3003CrossRef 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 34:2949–3003CrossRef
18.
Zurück zum Zitat Galiuto L, Sestito A, Barchetta S et al (2007) Noninvasive evaluation of flow reserve in the left anterior descending coronary artery in patients with cardiac syndrome X. Am J Cardiol 99:1378–1383CrossRefPubMed Galiuto L, Sestito A, Barchetta S et al (2007) Noninvasive evaluation of flow reserve in the left anterior descending coronary artery in patients with cardiac syndrome X. Am J Cardiol 99:1378–1383CrossRefPubMed
19.
Zurück zum Zitat Ong P, Athanasiadis A, Borgulya G et al (2014) Clinical usefulness, angiographic characteristics and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive caucasian patients with unobstructed coronary arteries. Circulation 129:1723–1730CrossRefPubMed Ong P, Athanasiadis A, Borgulya G et al (2014) Clinical usefulness, angiographic characteristics and safety evaluation of intracoronary acetylcholine provocation testing among 921 consecutive caucasian patients with unobstructed coronary arteries. Circulation 129:1723–1730CrossRefPubMed
20.
Zurück zum Zitat Noto TJ Jr, Johnson LW, Krone R et al (1991) Cardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Cathet Cardiovasc Diagn 24:75–83CrossRefPubMed Noto TJ Jr, Johnson LW, Krone R et al (1991) Cardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Cathet Cardiovasc Diagn 24:75–83CrossRefPubMed
21.
Zurück zum Zitat Vermeltfoort IA, Raijmakers PG, Riphagen II et al (2010) Definitions and incidence of cardiac syndrome X: review and analysis of clinical data. Clin Res Cardiol 99:475–481CrossRefPubMedPubMedCentral Vermeltfoort IA, Raijmakers PG, Riphagen II et al (2010) Definitions and incidence of cardiac syndrome X: review and analysis of clinical data. Clin Res Cardiol 99:475–481CrossRefPubMedPubMedCentral
22.
Zurück zum Zitat Pauly DF, Johnson BD, Anderson RD et al (2011) In women with symptoms of cardiac ischemia, nonobstructive coronary arteries, and microvascular dysfunction, angiotensin-converting enzyme inhibition is associated with improved microvascular function: a double-blind randomized study from the National Heart, Lung and Blood Institute Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J 162:678–684CrossRefPubMedPubMedCentral Pauly DF, Johnson BD, Anderson RD et al (2011) In women with symptoms of cardiac ischemia, nonobstructive coronary arteries, and microvascular dysfunction, angiotensin-converting enzyme inhibition is associated with improved microvascular function: a double-blind randomized study from the National Heart, Lung and Blood Institute Women’s Ischemia Syndrome Evaluation (WISE). Am Heart J 162:678–684CrossRefPubMedPubMedCentral
23.
Zurück zum Zitat Kayikcioglu M, Payzin S, Yavuzgil O et al (2003) Benefits of statin treatment in cardiac syndrome-X1. Eur Heart J 24:1999–2005CrossRefPubMed Kayikcioglu M, Payzin S, Yavuzgil O et al (2003) Benefits of statin treatment in cardiac syndrome-X1. Eur Heart J 24:1999–2005CrossRefPubMed
24.
Zurück zum Zitat Lanza GA, Colonna G, Pasceri V, Maseri A (1999) Atenolol versus amlodipine versus isosorbide-5-mononitrate on anginal symptoms in syndrome X. Am J Cardiol 84:854–856CrossRefPubMed Lanza GA, Colonna G, Pasceri V, Maseri A (1999) Atenolol versus amlodipine versus isosorbide-5-mononitrate on anginal symptoms in syndrome X. Am J Cardiol 84:854–856CrossRefPubMed
25.
Zurück zum Zitat Ozçelik F, Altun A, Ozbay G (1999) Antianginal and anti-ischemic effects of nisoldipine and ramipril in patients with syndrome X. Clin Cardiol 22:361–365CrossRefPubMed Ozçelik F, Altun A, Ozbay G (1999) Antianginal and anti-ischemic effects of nisoldipine and ramipril in patients with syndrome X. Clin Cardiol 22:361–365CrossRefPubMed
26.
Zurück zum Zitat Russo G, Di Franco A, Lamendola P et al (2013) Lack of effect of nitrates on exercise stress test results in patients with microvascular angina. Cardiovasc Drugs Ther 27:229–234CrossRefPubMed Russo G, Di Franco A, Lamendola P et al (2013) Lack of effect of nitrates on exercise stress test results in patients with microvascular angina. Cardiovasc Drugs Ther 27:229–234CrossRefPubMed
27.
Zurück zum Zitat Albertsson PA, Emanuelsson H, Milsom I (1996) Beneficial effect of treatment with transdermal estradiol-17-beta on exercise-induced angina and ST segment depression in syndrome X. Int J Cardiol 54:13–20CrossRefPubMed Albertsson PA, Emanuelsson H, Milsom I (1996) Beneficial effect of treatment with transdermal estradiol-17-beta on exercise-induced angina and ST segment depression in syndrome X. Int J Cardiol 54:13–20CrossRefPubMed
28.
Zurück zum Zitat Chen JW, Lee WL, Hsu NW et al (1997) Effects of short-term treatment of nicorandil on exercise-induced myocardial ischemia and abnormal cardiac autonomic activity in microvascular angina. Am J Cardiol 80:32–38CrossRefPubMed Chen JW, Lee WL, Hsu NW et al (1997) Effects of short-term treatment of nicorandil on exercise-induced myocardial ischemia and abnormal cardiac autonomic activity in microvascular angina. Am J Cardiol 80:32–38CrossRefPubMed
29.
Zurück zum Zitat Rogacka D, Guzik P, Wykretowicz A et al (2000) Effects of trimetazidine on clinical symptoms and tolerance of exercise of patients with syndrome X: a preliminary study. Coron Artery Dis 11:171–177CrossRefPubMed Rogacka D, Guzik P, Wykretowicz A et al (2000) Effects of trimetazidine on clinical symptoms and tolerance of exercise of patients with syndrome X: a preliminary study. Coron Artery Dis 11:171–177CrossRefPubMed
30.
Zurück zum Zitat Jadhav S, Ferrell W, Greer IA et al (2006) Effects of metformin on microvascular function and exercise tolerance in women with angina and normal coronary arteries: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 48:956–963CrossRefPubMed Jadhav S, Ferrell W, Greer IA et al (2006) Effects of metformin on microvascular function and exercise tolerance in women with angina and normal coronary arteries: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 48:956–963CrossRefPubMed
31.
Zurück zum Zitat Mehta PK, Goykhman P, Thomson LE et al (2011) Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive coronary artery disease. JACC Cardiovasc Imaging 4:514–522CrossRefPubMed Mehta PK, Goykhman P, Thomson LE et al (2011) Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive coronary artery disease. JACC Cardiovasc Imaging 4:514–522CrossRefPubMed
32.
Zurück zum Zitat Ong P, Konopka N, Mahrholdt H et al (2013) ABSTRACT: P478 – 4‑year follow-up of patients with stable angina, unobstructed coronary arteries and proof of coronary artery spasm: the ACOVA study follow-up. Clin Res Cardiol 102(Suppl 1): doi:10.1007/s00392-013-1100-1 Ong P, Konopka N, Mahrholdt H et al (2013) ABSTRACT: P478 – 4‑year follow-up of patients with stable angina, unobstructed coronary arteries and proof of coronary artery spasm: the ACOVA study follow-up. Clin Res Cardiol 102(Suppl 1): doi:10.1007/s00392-013-1100-1
33.
Zurück zum Zitat Shaw LJ, Merz CN, Pepine CJ et al (2006) The economic burden of angina in women with suspected ischemic heart disease: results from the National Institutes of Health – National Heart, Lung, and Blood Institute – sponsored Women’s Ischemia Syndrome Evaluation. Circulation 114:894–904CrossRefPubMed Shaw LJ, Merz CN, Pepine CJ et al (2006) The economic burden of angina in women with suspected ischemic heart disease: results from the National Institutes of Health – National Heart, Lung, and Blood Institute – sponsored Women’s Ischemia Syndrome Evaluation. Circulation 114:894–904CrossRefPubMed
34.
Zurück zum Zitat Jespersen L, Abildstrøm SZ, Hvelplund A, Prescott E (2013) Persistent angina: highly prevalent and associated with long-term anxiety, depression, low physical functioning, and quality of life in stable angina pectoris. Clin Res Cardiol 102:571–581CrossRefPubMed Jespersen L, Abildstrøm SZ, Hvelplund A, Prescott E (2013) Persistent angina: highly prevalent and associated with long-term anxiety, depression, low physical functioning, and quality of life in stable angina pectoris. Clin Res Cardiol 102:571–581CrossRefPubMed
35.
Zurück zum Zitat Jespersen L, Abildstrøm SZ, Hvelplund A et al (2013) Symptoms of angina pectoris increase the probability of disability pension and premature exit from the workforce even in the absence of obstructive coronary artery disease. Eur Heart J 34:3294–3303CrossRefPubMed Jespersen L, Abildstrøm SZ, Hvelplund A et al (2013) Symptoms of angina pectoris increase the probability of disability pension and premature exit from the workforce even in the absence of obstructive coronary artery disease. Eur Heart J 34:3294–3303CrossRefPubMed
36.
Zurück zum Zitat Lamendola P, Lanza GA, Spinelli A et al (2010) Long-term prognosis of patients with cardiac syndrome X. Int J Cardiol 140:197–199CrossRefPubMed Lamendola P, Lanza GA, Spinelli A et al (2010) Long-term prognosis of patients with cardiac syndrome X. Int J Cardiol 140:197–199CrossRefPubMed
37.
Zurück zum Zitat Halcox JP, Schenke WH, Zalos G et al (2002) Prognostic value of coronary vascular endothelial dysfunction. Circulation 106:653–658CrossRefPubMed Halcox JP, Schenke WH, Zalos G et al (2002) Prognostic value of coronary vascular endothelial dysfunction. Circulation 106:653–658CrossRefPubMed
38.
Zurück zum Zitat Pepine CJ, Anderson RD, Sharaf BL et al (2010) Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women’s Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 55:2825–2832CrossRefPubMedPubMedCentral Pepine CJ, Anderson RD, Sharaf BL et al (2010) Coronary microvascular reactivity to adenosine predicts adverse outcome in women evaluated for suspected ischemia results from the National Heart, Lung and Blood Institute WISE (Women’s Ischemia Syndrome Evaluation) study. J Am Coll Cardiol 55:2825–2832CrossRefPubMedPubMedCentral
39.
Zurück zum Zitat Jespersen L, Hvelplund A, Abildstrøm SZ et al (2012) Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 33:734–744CrossRefPubMed Jespersen L, Hvelplund A, Abildstrøm SZ et al (2012) Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 33:734–744CrossRefPubMed
40.
Zurück zum Zitat Johnson BD, Shaw LJ, Pepine CJ et al (2006) Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women’s Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 27:1408–1415CrossRefPubMed Johnson BD, Shaw LJ, Pepine CJ et al (2006) Persistent chest pain predicts cardiovascular events in women without obstructive coronary artery disease: results from the NIH-NHLBI-sponsored Women’s Ischaemia Syndrome Evaluation (WISE) study. Eur Heart J 27:1408–1415CrossRefPubMed
Metadaten
Titel
Koronare mikrovaskuläre Dysfunktion
Klinik, Diagnose, Therapie
verfasst von
Dr. P. Ong
U. Sechtem
Publikationsdatum
01.06.2016
Verlag
Springer Medizin
Erschienen in
Herz / Ausgabe 4/2016
Print ISSN: 0340-9937
Elektronische ISSN: 1615-6692
DOI
https://doi.org/10.1007/s00059-016-4439-z

Weitere Artikel der Ausgabe 4/2016

Herz 4/2016 Zur Ausgabe

Update Kardiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.