Coronary insufficiency I24.8

The physiologist H. Rein (Remmele 1999) first coined the term coronary insufficiency in 1931 (Roskamm 2013). Büchner introduced it into the pathological anatomy in 1935 (Roskamm 1984). Note: Acute coronary insufficiency is also called unstable angina pectoris (Barmeyer 2020).

Coronary insufficiency describes a pathophysiological condition concerning the blood flow in the coronary arteries (Unger 1995). It is the disproportion between the heart's demand for oxygen and the supply of blood and thus of oxygen (Herold 2019).

In the literature there are different classifications.

A distinction is made between the following different types of coronary insufficiency:

• Primary: These are pathological changes in the coronary vessels themselves that cause coronary insufficiency.
• Secondary: These are extracardial, extracorporeal and extracorporeal factors.
• Absolute: The blood supply to the heart muscle is qualitatively or quantitatively insufficient.
• Relative: The heart muscle has a disproportionately high oxygen demand.
• Temporary or "passagere coronary insufficiency": The disproportion between oxygen demand and oxygen supply occurs only temporarily.
• Persistent coronary insufficiency, also known as "permanent coronary insufficiency": the disproportion between oxygen demand and oxygen supply is permanent and leads to necrobiosis of the affected heart muscle.
• Acute: The imbalance occurs suddenly, often as a seizure.
• Chronic: The imbalance exists over a long period of time, but is compatible with the survival of the heart muscles.
• Chronic recurrent: In the chronic recurrent form, conditions of acute coronary insufficiency exist, but they are not permanent, but rather recurrent.
• Diffuse: In diffuse coronary insufficiency, the entire heart muscle is affected.
• Circumscripts: Only the supply area of a certain coronary artery or a certain branch of the coronary arteries is affected.
• Microcirculatory: Several neighbouring blood capillaries fail to function and the microcirculation is severely impaired. This causes hypoxidotic changes in the affected myocardium. A distinction is made between primary and secondary microcirculatory coronary insufficiency:
  • Primary microcirculatory: In this case, the loss of function is caused by pathological changes in the blood capillaries.
  • Secondary or associated: The general damage to the myocardium caused by a noxious agent. The hypoxidotic changes caused are reversible (Roskamm 1984).

The following types of coronary insufficiency are distinguished:

• symptomatic form (unstable angina pectoris)
  • initial form (corresponds to de novo angina pectoris)
  • crescendo form
  • Resting Angina pectoris (corresponds to the angina decubitus or spontaneous form)
  • vasospastic angina pectoris (also known as variant angina or Prinzmetal angina)
• asymptomatic form (silent myocardial ischemia)
  • total asymptomatic ischemia
  • mixed form (asymptomatic or symptomatic angina)
• sudden cardiac death (Barmeyer 2020)

A distinction is also made between 3 different stages of coronary insufficiency:

• Ischemia
• lesion
• Necrosis

Both the ischemia and the lesion are reversible, but the necrosis is irreversible (Unger 1995).

The causes of coronary insufficiency can be a reduced supply of oxygen on the one hand and an increased demand for oxygen on the other. A reduced supply can be caused by morphological changes in the coronary arteries and by functional factors such as atherosclerosis in the coronary vessels (Herold 2019)

Arteriosclerosis is the main cause with > 95% (Unger 1995).

• inflammatory diseases of the coronary vessels
• Embolisms in the coronary area
• congenital deformities
• traumatic injuries
• Coronary spasms
• Coronary Stenoses
• Formation of collaterals
• increased heart weight
• increased heart rate (causes a critical shortening of the diastole)
• Increase in myocardial wall tension due to e.g. dilatation, hypertrophy etc.
• Increase in contractility
• severe anemia
• acute blood loss
• Reduced oxygen content in the air we breathe, e.g. during stays at high altitude
• Loss of lung tissue e.g. in the case of embolism, pneumothorax etc.
• Poisoning e.g. with carbon monoxide (Lapp 2014, Remmele 1999).

An increased demand for O2 exists, for example, in the case of:

• Increase in the catecholamine level, e.g. due to stress, serious illness, etc.
• Thyrotoxicosis
• Myocarditis
• Stress on the heart due to arterial hypertension
• Heart valve defect (Remmele 1999)

Clinically, coronary insufficiency is manifested by angina pectoris or myocardial infarction(Unger 1995).

In the foreground is the treatment of the respective underlying disease.

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