Nuklearkardiologische Methoden zur Prognosebeurteilung und Risikostratifizierung bei koronarer Herzkrankheit

 

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Zusammenfassung

Die Aussagen der Myokardperfusions-SPECT bei Patienten mit vermuteter oder bekannter koronarer Herzkrankheit und stabiler Symptomatik enthalten neben der diagnostischen Wertigkeit auch eine prognostische Information. Sie gestatten eine Abschätzung der zukünftigen kardialen Ereignisrate weitgehend unabhängig von anderen klinischen Parametern. Ein Normalbefund in der Belastungs-Myokardperfusions-SPECT ist unabhängig von anamnestischen, klinischen und ergometrischen Daten bei Patienten aller Risikogruppen mit einer guten Prognose verbunden, die sich nicht von der Prognose der durchschnittlichen Normalbevölkerung unterscheidet. Mit zunehmendem Ausmaß von Perfusionsdefekten und Funktionsstörungen in der herzphasengetriggert akquirierten Myokardperfusions-SPECT steigt das Risiko zukünftiger kardialer Ereignisse und somit der Zugewinn durch eine invasive Therapiestrategie an. Mit der Myokardperfusions-SPECT als „Gatekeeper” für die Überweisung zur Koronarangiographie gelingt eine effiziente Risikostratifizierung von Patienten mit vermuteter oder chronischer koronarer Herzerkrankung. Bei schwerer koronarer Herzerkrankung und eingeschränkter linksventrikulärer Funktion erlaubt eine Vitalitätsdiagnostik mit nuklearkardiologischen Verfahren eine präoperative Vorhersage, ob durch Revaskularisationsmaßnahmen eine funktionelle Erholung und Verbesserung der kardialen Prognose zu erzielen ist. Bei fehlendem Vitalitätsnachweis führt die Revaskularisation nicht zu einer Verbesserung von Funktion und Prognose und kann zugunsten einer konservativen Strategie vermieden werden.

Abstract

Myocardial perfusion imaging in patients with suspected or known coronary artery disease and stable symptoms enables not only accurate diagnosis of disease but also entails prognostic value. Myocardial perfusion SPECT contributes to assessment of future cardiac events independently of other clinical parameters. A normal stress myocardial perfusion scan is associated with a favorable prognosis in all pre-test risk subsets similar to that of the general population independent of history, symptoms, and exercise electrocardiography test variables. Cardiac risk and benefit from invasive therapeutic strategies increase in relation to the severity of the abnormality of perfusion and function assessed by gated myocardial perfusion SPECT. Thus, stress myocardial perfusion imaging may serve as a gatekeeper for referral to coronary angiography enabling effective risk stratification in patients with suspected or documented coronary artery disease. In severe coronary artery disease accompanied by left ventricular dysfunction preoperative prediction of reversibility of functional impairment and improvement in survival after revascularization can be achieved by viability testing using nuclear cardiology. Absence of viability is associated with no significant difference in functional and survival outcomes, irrespective of treatment strategy. Therefore, unnecessary revascularization can be avoided in cases with absent evidence of viability.

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Dr. med. Bernd Nowak

Klinik für Nuklearmedizin · Universitätsklinikum der RWTH Aachen

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52074 Aachen

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