Skip to main content
SpringerLink
Log in

Koronare Herzkrankheit – Bedeutung der Ischämiebeseitigung für das Arrhythmieverhalten

Coronary artery disease – relevance of total coronary revascularization on the incidence of malignant arrhythmias

  • ÜBERSICHT
  • Published:
Herzschrittmachertherapie & Elektrophysiologie Aims and scope Submit manuscript

Summary

Myocardial ichemia induces redistribution of different ions (H+, K+, Na+, Ca++) across the cardiomyocyte membrane, as well as the loss of intracellular ATP content. This results in changes in the electrical properties including shortening of the action potential, appearance of delayed afterpotentials, and a modified refractoriness of the cardiomyocyte. These changes may induce or support malignant cardiac arrhythmias. Supersensitivity of sympathetic denervated myocardium may further support the electrical instability of ischemic myocardium.

Virtues of studies indicate that patients with coronary artery disease who develop complex arrhythmias during or after exercise bear a substantially increased risk for sudden cardiac death. Other studies report about arrhythmic stabilization and reduced mortality if patients with reversible myocardial ischemia receive complete revascularization. However, none of these studies is without methodological flaws. Due to the lack of methodologically sound studies in sufficiently large patient cohorts, the question whether complete coronary revascularisation improves the prognosis of patients with coronary artery disease and which strategy (medical, interventional, or surgical) warrants the best outcomes remains open.

Zusammenfassung

Myokardiale Ischämie verursacht massive Veränderungen der transmembranären Ionenflüsse (H+, K+, Na+ und Ca++) sowie eine intrazelluläre ATP-Verarmung des Kardiomyozyten. Die daraus resultierenden Veränderungen der elektrischen Eigenschaften wie eine veränderte Erregbarkeit, Refraktärität und das Auftreten später Nachpotentiale können maligne Rhythmusstörungen verursachen oder unterhalten. Die Übererregbarkeit in sympathisch denervierten Myokardarealen kann die arrhythmogene Instabilität darüber hinaus noch verstärken.

Ischämieinduzierte Kammerarrhythmien sind, dies zeigen zahlreiche, methodisch allerdings nicht uneingeschränkt valide Studien, mit einer schlechten Prognose assoziiert. Patienten mit koronarer Herzkrankheit und relevanter Ischämie sind in erhöhtem Maße vom plötzlichen Herztod bedroht.

Verschiedene Studien geben Hinweise darauf, dass eine Beseitigung der Ischämie zur rhythmogenen Stabilisierung von Koronarpatienten und zur Verbesserung derer Prognose führen kann. Die definitive Beantwortung der Frage ob die Ischämiebeseitigung bei Koronarpatienten deren Prognose verbessert und wann, welche Strategie (medikamentös, interventionell oder operativ) in welchen Patientengruppen die besten Resultate verspricht, bleibt jedoch mangels methodisch hinreichender Studien in größeren Patientenkohorten weiterhin offen.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Literatur

  1. Antman EM, Braunwald E (2005) ST-Elevation myocardial infarction: pathology, pathophysiology, and clinical features. In: Zipes DP, Libby P, Bonow RO, Braunwald E (eds) 7th. Braunwald’s Heart Disease. Elsevier, Philadelphia

  2. Liberthson RR, Nagel EL, Hirschman JC, Nussenfeld SR, Blackbourne BD, Davis JH (1974) Pathophysiologic observations in prehospital ventricular fibrillation and sudden cardiac death. Circulation 49:790–798

    PubMed  CAS  Google Scholar 

  3. Reimer KA, Lowe JE, Rassmussen MM, Jennings RB (1977) The wavefront phenomenon of ischemic cell death. I: Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation 56:786–794

    PubMed  CAS  Google Scholar 

  4. Schaper W (1990) Der aktuelle Stand der experimentellen Herzinfarktforschung. Z Kardiol 79:811–818

    PubMed  CAS  Google Scholar 

  5. Wu J, Zipes DP (2001) Transmural reentry during global acute ischemia and reperfusion in canine ventricular muscle. Am J Physiol 280:H2717–2725

    CAS  Google Scholar 

  6. Takahashi T, Van Dessel P, Lopshire JC, Groh WJ, Miller J, Wu J, Zipes DP (2004) Optical mapping of the functional circuit of ventricular tachycardia in acute myocardial infarction. Heart Rhythm 4:451–459

    Article  Google Scholar 

  7. John SA, Kondo R, Wang SY, Goldhaber JI, Weiss JN (1999) Connexin-43 hemichannels opened by metabolic inhibition. J Biol Chem 274:236–240

    Article  PubMed  CAS  Google Scholar 

  8. Shivkumar K, Deutsch NA, Lamp ST, Khuu K, Goldhaber JI, Weiss JN (1997) Mechanism of hypoxic K loss in rabit ventricle. J Clin Invest 100:1782–1788

    Article  PubMed  CAS  Google Scholar 

  9. Baader AP, Buchler L, Bircher-Lehmann L, Kleber A (2001) Real time, confocal immaging of Ca2+ waves in arterially perfused rat hearts. Cardiovasc Res 53:105–115

    Article  Google Scholar 

  10. Tanaka H, Oyamada M, Tsujii E, Nakajo T, Takamatsu T (2002) Excitation-dependent intracellular Ca2+ waves at the border zone of the cryoinjured rat heart revealed by realtime confocal microscopy. J Mol Cell Cardiol 34:1501–1512

    Article  PubMed  CAS  Google Scholar 

  11. Verkerk AO, Veldkamp MW, Coronel M, Wilders R, van Ginneken AC (2001) Effects of cell-to-cell uncoupling and catecholamins on Purkinje and ventricular action potentials: implications for phase 1b arrhythmias. Cardiovasc Res 51:30–40

    Article  PubMed  CAS  Google Scholar 

  12. Liu Y, Wu CC, Lu LS, Su MJ, Lin CW, Lin SF, Chen LS, Fishbein MC, Chen PS, Lee YT (2003) Sympathetic nerve sprouting, electrical remodelling and increased vulnerability to ventricular fibrillation in hypercholesterolemic rabbits. Circ Res 92:1145–1152

    Article  PubMed  CAS  Google Scholar 

  13. Barber MJ, Mueller TM, Henry DP, Felten SY, Zipes DP (1983) Transmural myocardial infarction in the dog produces sympathectomy in noninfarcted myocardium. Circulation 67:787–796

    PubMed  CAS  Google Scholar 

  14. Warner MR, Wisler PL, Hodges TD, Watanabe AM, Zipes DP (1993) Mechanisms of denervation supersensitivity in regionally denervated canine hearts. Am J Physiol 264:H815–820

    PubMed  CAS  Google Scholar 

  15. Stambler BS, Akosah KO, Mohanty PK, Wood MA, Ellenbogen KA (2004) Myocardial ischemia and induction of sustained ventricular tachyarrhythmias: evaluation using dobitamine stress echocardiography-electrophysiologic testing. J Cardiovasc Electrophysiol 15:908–910

    Article  Google Scholar 

  16. Goldbarg AN, Moran JF, Childers RW, Ricketts HT (1979) Results and correlations of multistage exercise tests in a group of clinicaly normal business executives. Am Heart J 79:194–200

    Article  Google Scholar 

  17. Froehlicher VF, Thomas MD, Pillow C, Lancaster MC (1974) Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 34:770–776

    Article  Google Scholar 

  18. McHenry PL, Morris SN, Kavalier M, Jordan JW (1976) Comparative study of exercise induced ventricular arrhythmias in normal subjects and in patients with coronary artery disease. Am J Cardiol 37:609–616

    Article  PubMed  CAS  Google Scholar 

  19. McHenry PL, Fisch C, Jordan CW, Corya BR (1972) Cardiac arrhythmias observed during maximal treadmill exercise testing in clinically normal men. Am J Cardiol 29:331–336

    Article  PubMed  CAS  Google Scholar 

  20. Crawford M, O’Rourke RA, Ramakrishna N, Henning H, Ross J Jr (1974) Comparative effectiveness of exercise testing and continuous monitoring for detecting arrythmias in patients with previous myocardial infarction. Circulation 50:301–305

    PubMed  CAS  Google Scholar 

  21. Drews S, Drews A, Barmeyer J (1981) Herzrhythmusstörungen unter Ergometerbelastung bei männlichen Infarktpatienten im chronischen Infarktstadium. Herz/Kreisl 11:519–525

    Google Scholar 

  22. Hämäläinen H, Luurila OJ, Kallio V, Hakkila J, Arstila M, Vuori I, Knuts L-R (1989) Prognostic value of an excercise test one year after myocardial infarction. Ann Med 21:447–453

    PubMed  Google Scholar 

  23. Marieb MA, Beller GA, Gibson RS, Lerman BB, Kaul S (1990) Clinical relevance of excercise induced ventricular arrhythmias in suspected coronary artery disease. Am J Cardiol 66:172–178

    Article  PubMed  CAS  Google Scholar 

  24. Jelinek MV, Lown B (1974) Exercise stress testing for exposure of cardiac arrhythmias. Progr Cardiovasc Dis 16:497–522

    Article  CAS  Google Scholar 

  25. Henry RL, Kennedy GT, Crawford MH (1987) Prognostic value of exercise-induced ventricular ectopic activity for mortality after acute myocardial infarction. Am J Cardiol 59:1251–1255

    Article  PubMed  CAS  Google Scholar 

  26. Weld FM, Chu K-L, Bigger JT, Rolnitzky LM (1981) Risk stratification with low-level exercise testing 2 weeks after myocardial infarction. Circulation 64:306–314

    PubMed  CAS  Google Scholar 

  27. Myerburg RJ (2001) Sudden cardiac death: exploring the limits of our knowledge. J Cardiovasc Electrophysiol 12:369

    Article  PubMed  CAS  Google Scholar 

  28. Cuddy TE, Tate RB (2006) Sudden unexpected cardiac death as a function of time since the detection of electrocardiographic and clinical risk factors in apparently healthy men: the Manitoba Follow-Up Study, 1940 to 2004. Can J Cardiol 22:205–211

    PubMed  Google Scholar 

  29. Elhendy A, Chapman S, Porter TR, Windle J (2005) Association of myocardial ischemia with mortality and implantable cardioverter-defibrillator therapy in patients with coronary artery disease at risk of arrhythmic death. J Am Coll Cardiol 46:1721–1726

    Article  PubMed  Google Scholar 

  30. Von Arnim T, for the TIBBS investigators (1995) Medical treatment to reduce total ischemic burden: total ischemic burden bisoprolol study (TIBBS), a multicenter trial comparing bisoprolol and nifedipine. J Am Coll Cardiol 25:231–238

    Article  PubMed  CAS  Google Scholar 

  31. Holmes DR, Davis K, Gersh BJ, Mock MB, Pettinger MD, and the participants of the Coronary Artery Surgery Group (CASS) (1989) Risk factor profiles of patients with sudden cardiac death and death from other cardiac causes: a report from the Coronary Artery Surgery Study (CASS). J Am Coll Cardiol 13:524–530

    PubMed  Google Scholar 

  32. Varnauskas E, and the European Coronary Surgery Study Group (1988) Twelve year follow-up of survival in the randomised European Coronary Surgery Study. N Engl J Med 319:332–337

    Article  PubMed  CAS  Google Scholar 

  33. Varnauskas E, and the European Coronary Surgery Study Group (1985) Survival, myocardial infarction, and employment status in a prospective randomised study of coronary bypass surgery. Circulation 72(Suppl 5):V90–V101

    PubMed  CAS  Google Scholar 

  34. TIME Investigators (2001) Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary-artery disease (TIME): a randomised trial. Lancet 358:951–957

    Article  Google Scholar 

  35. Underwood RD, Axell K, Deshpande S, Sra J, Dhala A, Blanck Z, Biehls M, Li H, Keelan E, Akhtar M, Yazayeri M (1995) Effect of revascularization on arrhythmia recurrence in sudden cardiac death survivors. PACE 18:943

    Google Scholar 

  36. Tresch DD, Wetherbee JN, Siegel R, Troup PJ, Keelan MH, Olinger GN, Brooks HL (1985) Long-term follow up of survivors of prehospital sudden cardiac death treated with coronary bypass surgery. Am Heart J 110:1139–1145

    Article  PubMed  CAS  Google Scholar 

  37. Kehoe R, Tommaso C, Zheutlin T, Meyers S, Mattioni T, Dunnington C, Lesch M (1988) Factors determining programmed stimulation responses and long-term arrhythmic outcome in survivors of ventricular fibrillation with ischemic heart disease. Am Heart J 116:355–363

    Article  PubMed  CAS  Google Scholar 

  38. Every NR, Fahrenbruch CE, Hallstrom AP, Weaver WD, Cobb LA (1992) Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest. J Am Coll Cardiol 19:1435–1439

    PubMed  CAS  Google Scholar 

  39. Wilber DJ, Garan H, Finkelstein D, Kelly E, Newell J, McGovern B, Ruskin JN (1988) Out-of hospital cardiac arrest. Use of electrophysiologic testing in the prediction of long-term outcome. N Engl J Med 318:19–24

    Article  PubMed  CAS  Google Scholar 

  40. Cook JR, Rizo-Patron C, Curtis AB, Gillis AM, Bigger JT Jr, Kutalek SP, Coromilas J, Hofer BI, Powell J, Hallstrom AP (2002) Effect of surgical revascularization in patients with coronary artery disease and ventricular tachycardia or fibrillation in the Antiarrhythmic Versus Implantable Defibrillator (AVID) Registry. Am Heart J 143:821–826

    Article  PubMed  Google Scholar 

  41. Kelly P, Ruskin JN, Vlahakes GJ, Buckley MJ, Freeman CS, Garan H (1990) Surgical coronary revascularization in survivors of prehospital cardiac arrest: its effect on ventricular arrhythmias and long-term survival. J Am Coll Cardiol 15:267–273

    Article  PubMed  CAS  Google Scholar 

  42. Manolis AS, Rastegar H, Estes NA III (1993) Effects of coronary artery bypass surgery on ventricular arrhythmias: results with electrophysiological testing and long-term follow-up. PACE 16:984–991

    PubMed  CAS  Google Scholar 

  43. Vester EG, Strauer BE (1995) Patienten mit malignen Arrhythmien: Verbesserung der Prognose durch Revaskularisation? Herzschr Elektrophysiol 6(Suppl 1):29–41

    Google Scholar 

  44. Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller NL, Sopko G, Pratt C, Deanfield JE, Conti CR (1997) Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomised to initial strategies of medical therapy versus revascularization. Circulation 95:2037–2043

    PubMed  CAS  Google Scholar 

  45. Silber S, Albertsson P, Avilés FF, Camici PG, Colombo A, Hamm C, Jrgensen E, Marco J, Nordrehaug J, Ruzyllo W, Urban P, Sone GW, Wijns W (2005) ESC guidelines for percutaneous coronary interventions. Eur Heart J 26:804–847

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Medizinische Klinik I, Schwerpunkte Kardiologie, Angiologie, Pulmologie und Internistische Intensivmedizin, Krankenhaus Düren gGmbH, Roonstraße 30, 52351, Düren, Germany

    A. Brandt &  D. C. Gulba

Authors
  1. A. Brandt
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. C. Gulba
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to D. C. Gulba.

Additional information

Vortrag in der Sitzung „Primär arrhythmogene Erkrankungen und plötzlicher Herztod“ im Rahmen des Symposiums „Praxis der Klinischen Elektrophysiologie“, Karlsruhe, 18. 3. 2006

Rights and permissions

Reprints and permissions

About this article

Cite this article

Brandt, A., Gulba, D.C. Koronare Herzkrankheit – Bedeutung der Ischämiebeseitigung für das Arrhythmieverhalten. Herzschr. Elektrophys. 17, 211–217 (2006). https://doi.org/10.1007/s00399-006-0535-8

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00399-006-0535-8

Key words

Schlüsselwörter

Search

Navigation