Aktuelle Definition und Diagnostik der pulmonalen Hypertonie

Zusammenfassung

Die 6. Weltkonferenz für pulmonale Hypertonie (PH) fand vom 27. 2. – 1. 3. 2018 in Nizza statt. Hier wurden die Erkenntnisse auf dem Gebiet der PH der letzten 5 Jahre nach Aufarbeitung und Diskussion über einen längeren Vorbereitungszeitraum von 13 Arbeitsgruppen präsentiert und in der Folge zum Jahreswechsel 2018/2019 publiziert. Einer der seither intensiv diskutierten Vorschläge ist der einer Änderung der hämodynamischen Definition der PH mit Absenkung des Grenzwertes für den mittleren pulmonalarteriellen Druck von ≥ 25 auf > 20 mmHg, gemessen im Rechtsherzkatheter in Ruhe. Zusätzlich wurde der pulmonalvaskuläre Widerstand in die PH-Definition aufgenommen, was die Wichtigkeit der Bestimmung des Herzzeitvolumens während der Rechtsherzkatheteruntersuchung unterstreicht.

Die Rationale sowie mögliche Auswirkungen der neuen PH-Definition, zu welchen zwischenzeitlich bereits neue Publikationen erschienen sind, möchten wir in diesem Übersichtsartikel diskutieren. Ferner ist ein aktueller Überblick zur nicht-invasiven und invasiven Diagnostik der PH enthalten, in welchem auf den Stellenwert der Methoden für Diagnostik, Differenzialdiagnostik und Prognose sowie weitere Neuerungen der 6.  PH-Weltkonferenz eingegangen wird. Ergänzt haben wir einen Abschnitt zum Stellenwert von Belastungsuntersuchungen für das Erkennen und die Verlaufsbeurteilung der PH, welche bei der Diskussion in Nizza und in den nachfolgenden Publikationen zumindest erwähnt, aber nicht ausführlicher besprochen wurden.

Abstract

At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.

In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.

Fazit

Der 6-MWT gilt weiterhin als akzeptierter, submaximaler Belastungstest bei PH-Patienten. Er ist gut standardisiert, kann auch bei schwer eingeschränkten Patienten durchgeführt werden und erlaubt anhand der ermittelten Gehstrecke eine prognostische Beurteilung.

Fazit

Die CPET wird heute meist als maximaler symptomlimitierter Belastungstest durchgeführt und hat einen relevanten Stellenwert bei der Diagnostik (z. B. Differenzierung zwischen prä- vs. postkapilläre Ätiologie oder CTEPH vs. IPAH) und der Verlaufsbeurteilung von PH-Patienten erlangt. Neben der Differenzierung der führenden Ursache der kardiopulmonalen Einschränkung (ventilatorisch, kardio-zirkulatorisch, muskulär) ermöglicht die CPET bei PH-Patienten auch die prognostische Einschätzung, Risikostratifizierung und Beurteilung therapeutischer Akut- und Langzeiteffekte. Die Spiroergometrie kommt zudem zunehmend zur Früherkennung von kardio-zirkulatorischen Störungen zum Einsatz.

Fazit

Die Stressechokardiografie hat in den letzten Jahren eine deutliche Aufwertung im Rahmen der PH-Diagnostik erfahren. Eine auffällige Belastungsreaktion kann mit hoher Sensitivität das Vorliegen einer PH (in Kombination mit anderen Parametern ggf. auch die Differenzierung in prä- und postkapilläre Form) vorhersagen. Die Methode kann ggf. zum Therapiemonitoring eingesetzt und die prognostische Aussagekraft durch Kombination mit anderen nicht-invasiven Parametern verbessert werden.

Publikationsverlauf

Eingereicht: 12. Juni 2020

Angenommen: 14. Juni 2020

Artikel online veröffentlicht:
14. Juli 2020

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