Diagnostik der koronaren Herzkrankheit – aktueller Stand der CT

Zusammenfassung

Kontinuierliche technische Innovationen der CT-Technologie sorgen in den letzten Jahren für eine immer bessere klinische Einsatzfähigkeit der Modalität. Die 16- und-64-Zeiler-CT-Generation hat die nicht-invasive CT-Koronarangiografie mit hoher Übereinstimmung zur invasiven Katheterangiografie etabliert. Es wurde jedoch berechtigte Kritik zur hohen Röntgendosisexposition geäußert. Das Problem ist derzeit im Fokus der technischen Entwicklung. Durch geschickte Kombination aus modifizierten Rekonstruktionsverfahren und neuer Detektortechnologie lassen sich die erforderlichen Dosisexpositionen um 80% senken. Damit ist die Methode für die klinische Routine einsetzbar. Symptomatische Patienten mit mittlerer Vortestwahrscheinlichkeit für eine KHK sind bereits als geeignet für eine primäre CT-Koronarangiografie identifiziert worden. In einer mittlerweile unüberschaubaren Fülle von Publikationen werden Einsatzgebiete in der Primärdiagnostik der KHK, bei der schnellen Abklärung von Bypassgefäßen und von Koronaranomalien definiert. Weitere Möglichkeiten ergeben sich für den Einsatz bei unklarem Thoraxschmerz und für die simultane Erfassung von Morphologie (Koronararterien) und Funktion (Perfusion). Interessant wird in diesem Zusammenhang die wissenschaftliche Evaluation der rein CT-basierten Perfusionsbildgebung. Möglicherweise ist dann eine weitere Modalität wie das SPECT zur Akquisition von Perfusionsdatensätzen gar nicht erforderlich.

Abstract

Continuous technical innovations during the last years have established cardiac CT as a modality for noninvasive coronary angiography in clinical routine. 64 detector row generations and beyond have shown high diagnostic accuracy for obstructive stenosis detection in comparison to the standard of reference catheterization angiography. But the high radiation dose exposure associated with helical cardiac CT acquisition has sparked increasing concern in the medical community. The issue has been addressed with the newest releases of technology. Dose reduction by 80% and more is achieved with modified scan techniques rendering the method suitable for clinical routine. Symptomatic patients with an intermediate pre-test probability have been identified as the most suitable candidates for CT coronary angiography. Other appropriate indications include the rapid assessment of bypass grafts and suspected coronary anomalies. CT coronary angiography has been shown to be cost effective for the evaluation of patients with acute chest pain in the emergency department. But CT is able to provide more than coronary morphology, initial feasibility testing has shown that CT first-pass myocardial imaging can visualize perfusion defects with adenosine induced vasodilatation. Coronary morphology and functional perfusion studies have been shown to be complementary providing incremental diagnostic value over either technique alone. In the next few years a lot of comparison trials will establish the best suitable perfusion method (SPECT, MRI or CT) for hybrid imaging with CT coronary angiography.

Schlüsselwörter

koronare Herzerkrankung - Computertomografie - Koronarangiografie

Key words

coronary artery disease - computed tomography - coronary angiography

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