Das arrhythmogene Risiko von Patienten mit KHK und erhaltener linksventrikulärer Funktion

Zusammenfassung

Patienten mit koronarer Herzkrankheit (KHK) unterliegen einem erhöhten Risiko für ventrikuläre Arrhythmien und plötzlichem Herztod. Eine Verschlechterung der Herzinsuffizienz und der plötzliche Herztod (PHT) sind die überragenden Letalitätsursachen bei Patienten mit KHK und reduzierter Ejektionsfraktion (HFrEF). Eine prophylaktische Versorgung mit einem implantierbaren Kardioverter-Defibrillator (ICD) ist die Therapie der Wahl bei Patienten mit HFrEF. Durch diese leitliniengestützte Therapie kann die Letalität bei entsprechenden Patienten gesenkt werden. Die Mehrheit der Patienten, die einen PHT erleiden, sind jedoch mit der alleinigen Messung der LVEF nicht angemessen erfasst. Tatsächlich weisen sogar mehr als zwei Drittel der Patienten, die arrhythmogen versterben, eine erhaltene LVEF auf. Die vorliegende Arbeit versucht Gruppen innerhalb der Patienten mit KHK und erhaltener linksventrikulärer Funktion zu identifizieren, die einem erhöhten Risiko für den plötzlichen Herztod unterliegen. Zusätzlich werden neue Parameter diskutiert, die in Zukunft die adäquate Risikostratifizierung dieser Patienten verbessern könnten.

Abstract

Patients with coronary artery disease (CAD) are subject to an increased risk for sudden cardiac death (SCD) and ventricular arrhythmias. Worsening heart failure and SCD are the predominant mechanisms of death in patients with CAD and reduced ejection fraction (HFrEF). A prophylactic strategy using implantable cardioverter defibrillator (ICD) therapy in selected patients with HFrEF improves mortality and is guideline-supported. However, the majority of patients who die suddenly are not adequately identified by measuring the LVEF only. Indeed, more than two thirds of all patients who experience SCD, have a preserved ejection fraction. The present paper attempted to identify groups of patients with CAD and preserved left ventricular function, who are especially at risk for sudden cardiac death. Moreover, recent stratification methods are presented which could improve risk stratification in the near future.

Schlüsselwörter

KHK - normale LVEF - Risikostratifizierung - plötzlicher Herztod - ventrikuläre Arrhythmien

Key words

coronary artery disease - preserved LVEF - risk stratification - sudden cardiac death - ventricular arrhythmias

• Literatur

• 1 de Vreede-Swagemakers JJ, Gorgels AP, Dubois-Arbouw WI et al. Out-of-hospital cardiac arrest in the 1990ʼs: a population-based study in the Maastricht area on incidence, characteristics and survival. J Am Coll Cardiol 1997; 30: 1500-1505
• 2 Zipes DP, Wellens HJ. Sudden cardiac death. Circulation 1998; 98: 2334-2351
• 3 Solomon SD, Zelenkofske S, McMurray JJ et al. Sudden death in patients with myocardial infarction and left ventricular dysfunction, heart failure, or both. N Engl J Med 2005; 352: 2581-2588
• 4 Myerburg RJ, Junttila MJ. Sudden cardiac death caused by coronary heart disease. Circulation 2012; 125: 1043-1052
• 5 Gorgels AP, Gijsbers C, de Vreede-Swagemakers J et al. Out-of-hospital cardiac arrest – the relevance of heart failure. The Maastricht Circulatory Arrest Registry. Eur Heart J 2003; 24: 1204-1209
• 6 Christofferson RD, Lehmann KG, Martin GV et al. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 2005; 95: 1088-1091
• 7 Nombela-Franco L, Mitroi CD, Fernández-Lozano I et al. Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study). Circ Arrhythm Electrophysiol 2012; 5: 147-154
• 8 Valenti R, Migliorini A, Signorini U et al. Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. Eur Heart J 2008; 29: 2336-2342
• 9 Aziz S, Stables RH, Grayson AD et al. Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure. Catheter Cardiovasc Interv 2007; 70: 15-20
• 10 Shah PB. Management of coronary chronic total occlusion. Circulation 2011; 123: 1780-1784
• 11 Frommeyer G, Eckardt L. Drug-induced proarrhythmia: risk factors and electrophysiological mechanisms. Nat Rev Cardiol 2016; 13: 36-47
• 12 Wu CS, Tsai YT, Tsai HJ. Antipsychotic drugs and the risk of ventricular arrhythmia and/or sudden cardiac death: a nation-wide case-crossover study. J Am Heart Assoc 2015; 4 pii: e001568
• 13 National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143-3421
• 14 Kurl S, Laaksonen DE, Jae SY et al. Metabolic syndrome and the risk of sudden cardiac death in middle-aged men. Int J Cardiol 2016; 203: 792-797
• 15 Adabag S, Huxley RR, Lopez FL et al. Obesity related risk of sudden cardiac death in the atherosclerosis risk in communities study. Heart 2015; 101: 215-221
• 16 Priori SG, Blomström-Lundqvist C, Mazzanti A et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Rev Esp Cardiol (Engl Ed) 2016; 69: 176
• 17 Adabag S, Rector TS, Anand IS et al. A prediction model for sudden cardiac death in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2014; 16: 1175-1182
• 18 Rijnierse MT, van der Lingen AL, Weiland MT et al. Clinical impact of cardiac magnetic resonance imaging versus echocardiography-guided patient selection for primary prevention implantable cardioverter defibrillator therapy. Am J Cardiol 2015; 116: 406-412
• 19 Haugaa KH, Grenne BL, Eek CH et al. Strain echocardiography improves risk prediction of ventricular arrhythmias after myocardial infarction. JACC Cardiovasc Imaging 2013; 6: 841-850
• 20 Haugaa KH, Smedsrud MK, Steen T et al. Mechanical dispersion assessed by myocardial strain in patients after myocardial infarction for risk prediction of ventricular arrhythmia. JACC Cardiovasc Imaging 2010; 3: 247-256
• 21 Matsuzoe H, Tanaka H, Matsumoto K et al. Left ventricular dyssynergy and dispersion as determinant factors of fatal ventricular arrhythmias in patients with mildly reduced ejection fraction. Eur Heart J Cardiovasc Imaging 2016; 17: 334-342
• 22 Beller GA. Enhanced risk stratification with noninvasive measurement of coronary flow reserve using positron emission tomography. Circulation 2012; 126: 1808-1811