Konservative Therapie des chronischen Koronarsyndroms

Nach wie vor bildet die konservative Therapie das Fundament in der Behandlung des chronischen Koronarsyndroms. Die aktuellen ESC-Leitlinien betonen die Bedeutung einer individualisierten Therapie, die sich an den Pathomechanismen und den spezifischen Bedürfnissen der Patienten orientiert. Die komplexe Pathophysiologie des CCS unterstreicht die Bedeutung eines umfassenden Therapieansatzes, der konservative und interventionelle Maßnahmen integriert.

Abstract

CCS management, based on the 2024 ESC Guidelines, a cornerstone of contemporary cardiology, aims to prevent cardiovascular events, alleviate symptoms, and enhance quality of life through conservative and invasive strategies. Non-invasive approaches, encompassing patient education, lifestyle interventions, and optimized pharmacological treatments, have demonstrated significant benefits in prognosis and quality of life. The guidelines advocate for a patient-centered approach, tailoring therapies to pathophysiological mechanisms, comorbidities, and individual needs. Pharmacological strategies integrate antithrombotic, lipid-lowering, RAAS-blocking, anti-inflammatory, and antidiabetic agents for event prevention, alongside antianginal medications for symptom relief. Invasive interventions remain essential for high-risk patients with obstructive coronary artery disease (e.g., left main disease, three-vessel disease, or proximal LAD involvement) or refractory angina despite optimal medical therapy. However, the growing efficacy of medical management increasingly challenges the incremental benefits of early revascularization. The guidelines also highlight underdiagnosed conditions such as ANOCA (Angina with Non-Obstructive Coronary Arteries) and INOCA (Ischemia with Non-Obstructive Coronary Arteries). Recognizing diverse endotypes, including microvascular dysfunction and vasospastic angina, enables precise and individualized therapeutic approaches. Conservative therapy remains the foundation of CCS management, demanding a holistic, multidisciplinary, and patient-centered approach to optimize outcomes and improve quality of life.

Kernaussagen

• Die konservative Therapie bildet das Fundament der CCS-Behandlung. Sie verbessert nachweislich Prognose und Lebensqualität, was den zusätzlichen Nutzen einer frühen interventionellen Strategie zunehmend schwerer belegbar macht. Bestimmte Hochrisiko-Patienten mit obstruktiver KHK profitieren jedoch weiterhin von einer frühen Revaskularisation. Bei persistierender Angina pectoris trotz OMT bleibt die invasive Therapie die bevorzugte Option.

• Eine strukturierte Patientenschulung ist essenziell für nachhaltige Lebensstil-Interventionen und eine langfristige Therapie-Adhärenz. Rauchstopp, Gewichtsreduktion und regelmäßige Bewegung senken das kardiovaskuläre Risiko signifikant und verbessern die Lebensqualität der Patienten.

• Die medikamentöse CCS-Therapie folgt einem patientenzentrierten Ansatz. Sie berücksichtigt Pathomechanismen, Komorbiditäten und individuelle Bedürfnisse. Während Antianginosa primär Symptome lindern, dienen antithrombotische, lipidsenkende, RAAS-blockierende, anti-inflammatorische und antidiabetische Medikamente der Ereignisprävention.

• Zentrale Therapieziele der Sekundärprävention bei KHK sind: LDL-C <55mg/dl (Reduktion >50% des Ausgangswerts), HbA1c <7% und ein systolischer Blutdruck von 120–129mmHg, sofern die Therapie gut vertragen wird.

• ANOCA und INOCA verdeutlichen die Notwendigkeit, über flusslimitierende Koronarstenosen hinauszudenken. Patienten mit diesen Krankheitsbildern haben eine eingeschränkte Prognose und profitieren von einer differenzierten Diagnostik sowie individualisierten Therapie-Ansätzen.

Schlüsselwörter

chronisches Koronarsyndrom - koronare Herzerkrankung - Therapie - lipidsenkend - antithrombotisch - antianginös - Mikrozirkulationsstörung - ANOCA - INOCA

Keywords

chronic coronary syndrome - coronary artery disease - therapy - lipid-lowering - antithrombotic - antianginal - microvascular disease - ANOCA - INOCA

Publikationsverlauf

Artikel online veröffentlicht:
06. Mai 2025

• Literatur

• 1 Deutsche Herzstiftung e.V. 35. Deutscher Herzbericht – Update. 2024 Zugriff am 12. Februar 2025 unter: https://epaper.herzstiftung.de/#0
• 2 Vrints C, Andreotti F, Koskinas KC. et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45: 3415-3537
• 3 Alexander Y, Osto E, Schmidt-Trucksäss A. et al. Endothelial function in cardiovascular medicine: a consensus paper of the European Society of Cardiology Working Groups on Atherosclerosis and Vascular Biology, Aorta and Peripheral Vascular Diseases, Coronary Pathophysiology and Microcirculation, and Thrombosis. Cardiovasc Res 2021; 117: 29-42
• 4 Maron DJ, Hochman JS, Reynolds HR. et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020; 382: 1395-1407
• 5 Navarese EP, Lansky AJ, Kereiakes DJ. et al. Cardiac mortality in patients randomised to elective coronary revascularisation plus medical therapy or medical therapy alone: a systematic review and meta-analysis. Eur Heart J 2021; 42: 4638-4651
• 6 Mileva N, Nagumo S, Mizukami T. et al. Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11
• 7 Ford TJ, Stanley B, Good R. et al. Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: The CorMicA Trial. J Am Coll Cardiol 2018; 72: 2841-2855
• 8 Dorresteijn JA, Visseren F. The SMART Risk Score. The SMART Risk Score is a tool to estimate 10-year risk for recurrent vascular events in patients with manifest cardiovascular disease (26.08.2021). Zugriff am 12. Februar 2025 unter: https://www.escardio.org/Education/ESC-Prevention-of-CVD-Programme/Risk-assessment/SMART-Risk-Score
• 9 Critchley J, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database Syst Rev 2004; CD003041
• 10 Khan SS, Ning H, Wilkins JT. et al. Association of Body Mass Index With Lifetime Risk of Cardiovascular Disease and Compression of Morbidity. JAMA Cardiol 2018; 3: 280-287
• 11 Pack QR, Rodriguez-Escudero JP, Thomas RJ. et al. The prognostic importance of weight loss in coronary artery disease: a systematic review and meta-analysis. Mayo Clin Proc 2014; 89: 1368-1377
• 12 Ferrari R, Pavasini R, Camici PG. et al. Anti-anginal drugs-beliefs and evidence: systematic review covering 50 years of medical treatment. Eur Heart J 2019; 40: 190-194
• 13 Sorbets E, Steg PG, Young R. et al. β-blockers, calcium antagonists, and mortality in stable coronary artery disease: an international cohort study. Eur Heart J 2019; 40: 1399-1407
• 14 Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324: 71-86
• 15 Ference BA, Ginsberg HN, Graham I. et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel. Eur Heart J 2017; 38: 2459-2472
• 16 McMurray JJV, Packer M, Desai AS. et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014; 371: 993-1004
• 17 McGuire DK, Shih WJ, Cosentino F. et al. Association of SGLT2 Inhibitors With Cardiovascular and Kidney Outcomes in Patients With Type 2 Diabetes: A Meta-analysis. JAMA Cardiol 2021; 6: 148-158
• 18 Kristensen SL, Rørth R, Jhund PS. et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet Diabetes Endocrinol 2019; 7: 776-785
• 19 Lincoff AM, Brown-Frandsen K, Colhoun HM. et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. N Engl J Med 2023; 389: 2221-2232
• 20 Tardif JC, Kouz S, Waters DD. et al. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. N Engl J Med 2019; 381: 2497-2505
• 21 Nidorf SM, Fiolet ATL, Mosterd A. et al. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med 2020; 383: 1838-1847
• 22 Jolly SS, d’Entremont MA, Lee SF. et al. Colchicine in Acute Myocardial Infarction. N Engl J Med 2024;
• 23 Jespersen L, Hvelplund A, Abildstrøm SZ. et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012; 33: 734-744
• 24 Kunadian V, Chieffo A, Camici PG. et al. An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology & Microcirculation Endorsed by Coronary Vasomotor Disorders International Study Group. Eur Heart J 2020; 41: 3504-3520
• 25 Ong P, Safdar B, Seitz A. et al. Diagnosis of coronary microvascular dysfunction in the clinic. Cardiovasc Res 2020; 116: 841-855