How is arteriosclerotic heart disease diagnosed

Coronary heart disease (CHD)


Coronary artery disease is the hardening of the coronary arteries caused by atherosclerosis. Atherosclerosis describes the pathological deposition of fats in the blood vessels and represents a form of arteriosclerosis. The most common symptom of coronary heart disease is angina pectoris (chest pain). The risk of rapid progression of atherosclerosis and thus of coronary heart disease can be significantly reduced with relatively simple measures.

What is coronary artery disease (CHD)?

Coronary artery disease is the manifestation of what is known as atherosclerosis in the coronary arteries. It leads to one over numerous causes Circulatory disorder of the heart muscle. This in turn can cause chest pain (angina pectoris) or serious complications such as irregular heartbeat, sudden cardiac death or weak heart muscle. However, the course of the disease can also be clinically silent.


Coronary artery disease: constriction in a coronary artery

Spread of atherosclerosis and coronary artery disease (CHD)

The diseases caused by atherosclerosis are the current ones most common causes of death for men from the age of 40 and for women from the age of 50. The death rate from acute myocardial infarction has indeed decreased due to the possibilities of modern cardiology, but the mortality from chronic circulatory disorders of the heart has increased. The incidence and death of coronary artery disease vary widely from country to country.

Causes and origins

Atherosclerosis can be classified as Calcification of the arterial wall be understood. The arteries are the blood vessels that are exposed to particularly high pressure loads. especially the inner layer the multilayered arterial wall has to adapt to constantly changing conditions. This inner layer is called the endothelium. Without the endothelium, blood circulation would not be possible, as important processes of so-called blood coagulation are regulated by the endothelium, among other things.

The starting point for the development of atherosclerosis is probably always one Damage to the endothelium, the causes of which can be varied.


The human coronary system

Risk factors

Besides hereditary factors are essential

  • High blood pressure,
  • Disorders of lipid metabolism,
  • Obesity,
  • Diabetes mellitus
  • Smoke,
  • unhealthy diet with too much animal fat,
  • as well as other rarer factors that are not yet fully understood in terms of their importance, such as homocysteine ​​or lipoprotein

to call.

Whether a chronic bacterial infection is involved in the development of atherosclerosis has not yet been conclusively proven. In particular, studies involving the use of antibiotics could not demonstrate any radical effect.

Development of the disease

Immigration of the smallest, so-called smooth muscle cells from the media into the intima, as well as specialized transport particles of cholesterol leads to the formation of the so-called atherosclerotic plaque.


Depiction of arteriosclerosis

Inflammatory processes play an important role in this, so increased inflammation markers such as the C-reactive protein indicate an increased risk of mortality in blood sugar patients and are almost always detectable in the blood in the case of acute myocardial infarction.

The composition of atherosclerotic plaque, but above all the ratio of dead cell material (necrosis) in the center of the plaque and connective tissue cover plates, determine the risk of plaque rupture and the development of an acute heart attack.

As a rule, however, atherosclerosis of the coronary arteries (coronary artery disease) progresses slowly, mostly discontinuously, i.e. over and over Growth spurts, which is a reliable prognosis for growth of the disease from angiographic (i.e. Depiction of the coronary vessels with the help of the cardiac catheter) information is difficult.


Coronary artery disease (CHD) symptoms

The most common symptom in coronary heart disease is that Angina pectoris (chest pain), typically as extensive central pain often radiating to the shoulder region or the lower jaw. Often, especially in women, they only show up in coronary artery disease unspecific symptoms such as:

  • Shortness of breath (dyspnoea)
  • Drop in blood pressure (hypotension)
  • increased pulse rate (tachycardia)
  • Paleness
  • Sweating
  • nausea
  • Upper abdominal pain
  • anxiety

In coronary artery disease, the symptoms can also be completely absent. One then speaks of silent myocardial ischemia. This occurs particularly in the elderly and diabetics.

At the onset of coronary artery disease, symptoms only appear if the The heart's need for oxygen increases is e.g. during physical exertion, emotional stress (sadness and joy), overactive thyroid gland or also when the oxygen content of the blood is low, such as anemia (anemia).

Coronary artery disease (CHD) diagnosis

The medical history of the patient provides important information about the presence of coronary artery disease. Here the doctor asks about the known risk factors and the patient's exact symptoms.

Laboratory examination

Pronounced circulatory disorders of the heart muscle lead to a Cardiac muscle cell death. Specific enzymes are released from these disintegrated cells, which can then be detected in the blood serum. This includes troponin, the detection of which is particularly specific.

Resting ECG and stress ECG

With the help of an EKG, a reduced blood flow to the heart at rest or under stress can be indicated by changes in the electrocardiogram.

Echocardiography

Echocardiography and stress echocardiography examinations can reveal wall movement disorders of the left ventricle as a result of a circulatory disorder of the heart that already exists at rest or that only occurs under stress.

Further diagnostic aids

Further examination methods to discover a reduced blood supply to the heart muscle are myocardial scintigraphy and magnetic resonance imaging (MRI) of the heart. These examinations can also be carried out at rest and under stress.


Computed tomography of the heart showing the coronary vessels and parts of the left and right ventricles

Computed tomography (CT) of the heart is mainly used to detect or exclude calcium deposits in the area of ​​the coronary vessels. The main importance of this method currently lies in its high negative predictive value. This means a high level of security for a patient in whom the examination does not show any calcium or age-related and gender-related low values.

If these non-invasive examination methods make the suspicion of coronary heart disease probable or cannot be ruled out with certainty, the follow-up invasive examination of the coronary arterieswho have favourited Coronary Angiography.

During this examination, contrast agent is injected directly into the coronary arteries via a catheter. This allows constrictions or occlusions to be reliably diagnosed. In suitable cases, an expansion (PTCA) or re-opening (recanalization) to treat the affected coronary artery can be carried out in the same examination.

Coronary artery disease (CHD) therapy

The treatment strategy for patients with coronary artery disease depends on the clinical appearance and the stage of the disease.

Medication

Complaint-free or clinically stable patients, i.e. complaint intensity and characteristics that have remained constant over years medicinal can be treated safely and usually with good success. The effect is best documented for the group of so-called nitrates, which in an acute attack cause rapid symptom relief via a vasodilator effect, as well as for ß-blockers, especially for patients who have survived myocardial infarction. All patients with proven CHD should be treated with aspirin (acetylsalicylic acid) and fat-lowering drugs (preferably with statins), as a reduction in overall mortality has been proven through regular use.

Cardiac catheterization

The need for a cardiac catheter examination always arises in coronary artery disease if, despite drug treatment, the Discomfort increaseeither in intensity or more frequently. Whether a non-invasive examination has to be carried out beforehand depends on the so-called pre-test probability, which results from the symptoms, the age and the sex of the patient.


For example, a male patient with typical symptoms and advanced age can be advised immediately to have a cardiac catheter examination if an improvement in the prognosis is to be expected through revascularizing, i.e. blood circulation-enhancing measures and thus justifies the risk of a cardiac catheter examination (very rare complications are strokes, vascular injuries or bleeding at the puncture site , mostly right groin region).


Scheme of a stent implantation (PCI) for the treatment of critical vascular narrowing due to advanced atherosclerosis

Expansion of the vessels using PTCA and bypass surgery

If during the cardiac catheter examination in the angiography, i.e. representation of the coronary arteries with contrast medium, a strong vascular constriction in a significant vascular region can be detected usually in the same session immediately after the diagnosis can be treated by balloon dilatation (PTCA). As a rule (> 90%), however, the implantation of a stent (vascular support) is then necessary in order to ensure lasting success of the treatment. In addition to simple metal stents, so-called drug-coated stents are already in use in routine clinical practice, which have significantly reduced the re-narrowing rate of old metal stents.

However, PTCA is not the appropriate treatment method for all findings. In particular for so-called main trunk stenoses or complex involvement of several vascular regions (especially in people with blood sugar), bypass surgery can be advantageous, especially with regard to the need for repeated vasodilator measures.

With identical mortality rates for both therapy methods, the available data from the large comparative studies show one significantly lower stroke rate in favor of PTCA.

Adjustment to the patient's personal situation

Due to the Complexity of Findings and of the possible alternative therapy options, the patient has to be included in the therapy planning more and more frequently, whereby, in the case of non-urgent treatment indications, sufficient space should always be allowed for a period of reflection or consultation with the relatives.

In an acute heart attack, there is one reopening as soon as possible the closed vessel is the all-important therapeutic goal. The best results are achieved if the infarct vessel is reopened within the first 90 minutes after the onset of the complaint, if possible with the help of interventional procedures, i.e. cardiac catheters and PTCA.

Medicinal measures to dissolve blood clots (lysis therapy) are only relevant if invasive catheter therapy cannot be carried out on time for logistical reasons. With today's density of specialized clinics with left heart catheter measuring stations, this is rarely the case in Germany.

Can you prevent coronary artery disease (CHD)?

Using relatively simple measures, the risk of rapid progression of atherosclerosis in the coronary arteries and thus of coronary artery disease can be reduced significantly reduce.

A controlled one physical training has been proven to help significantly reduce the risk of cardiovascular diseases. This applies to people of normal weight as well as to those who are overweight and diabetics. Favorable influences on blood pressure and blood sugar have been well documented. It is less about top athletic performance than about regular endurance performances such as cycling, jogging or swimming.

In addition to the Smoking cessation represents a Change of diet Another important step to prevent the progression of atherosclerosis and its catastrophic consequences such as acute heart attack. The so-called Mediterranean food, which is characterized by high-calorie, high-fiber and low-fat food. It is also rich in so-called unsaturated omega-3 fatty acids, which are said to have vascular protective properties.

Studies also show that Vegetarians are less likely to be affected by cardiovascular disease are, but it has not been conclusively clarified whether this is due to a generally healthier way of life or whether it is actually due to the fact that meat is avoided. Vegans, on the other hand, do not benefit because they lack important substances to protect the vessels.

Preventive drug measures for coronary artery disease are essentially aimed at treating a high blood pressure disease or blood sugar disease. The need to influence blood lipids depends on the initial values ​​and the individual risk constellation.

Authors:
Dr. med. F. Hennersdorf
Prof. Dr. med. Gerd Peter Meyer
Dr. med. C. Diefenbach