Die neue Definition und Klassifikation der pulmonalen Hypertonie

Zusammenfassung

In der Neufassung der ESC/ERS-Leitlinien 2022 zur pulmonalen Hypertonie (PH) kam es zu wesentlichen Änderungen in der hämodynamischen Definition sowie zu einer weiteren Verfeinerung in der Klassifikation des Lungenhochdrucks.

Als bedeutende Neuerung gilt die Einführung eines neuen Grenzwerts des mittleren pulmonalarteriellen Druckes (mPAP) für die Definition der PH. Eine PH wird nun durch eine Erhöhung des mPAP > 20 mmHg, ermittelt durch Rechtsherzkatheter, definiert. Des Weiteren wurde der Grenzwert des pulmonalen Gefäßwiderstands (PVR) zur Definition einer präkapillären PH verringert. Eine präkapilläre PH liegt nun bereits ab einem PVR > 2 WU und einem pulmonalarteriellen Verschlussdruck (PAWP) ≤ 15 mmHg vor. Die zunehmende Evidenz für die klinische Relevanz der pulmonalen Belastungshämodynamik führte schließlich auch zur Wiederaufnahme des Belastungs-PH-Terminus in die Leitlinien. Die Belastungs-PH wird als Verhältnis zum Herzzeitvolumen (CO) über einen pathologischen mPAP/CO-Slope > 3 mmHg/L/min definiert. In der Klassifikation werden weiterhin fünf Gruppen unterschieden: die pulmonalarterielle Hypertonie (Gruppe 1), PH assoziiert mit Linksherzerkrankungen (Gruppe 2), PH assoziiert mit Lungenerkrankungen und/oder Hypoxie (Gruppe 3), PH assoziiert mit pulmonalarterieller Obstruktion (Gruppe 4) und PH mit unklaren und/oder multifaktoriellen Mechanismen (Gruppe 5).

In der folgenden Leitlinienübersetzung soll auf die Neuerungen eingegangen, deren Hintergründe näher beleuchtet und mögliche Schwierigkeiten in ihrer klinischen Anwendung diskutiert werden.

Abstract

In the recent ESC/ERS guidelines on the diagnosis and management of pulmonary hypertension (PH) several important changes have been made in respect of the definition and classification of PH.

The mPAP cut-off for defining PH was lowered. PH is now defined by an mPAP > 20 mmHg assessed by right heart catheterization. Moreover, the PVR threshold for defining precapillary PH was lowered. Precapillary PH is now defined by a PVR > 2 WU and a pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg. Furthermore, the increasing evidence for the clinical relevance of pulmonary exercise hemodynamics led to the reintroduction of exercise pulmonary hypertension (EPH) [1]. EPH is characterized by a mPAP/CO-slope > 3 mmHg/L/min during exercise testing. In the classification of PH five groups are distinguished: Pulmonary arterial hypertension (group 1), PH associated with left heart disease (group 2), PH associated with lung diseases and/or hypoxia (Group 3), PH associated with pulmonary artery obstructions (group 4) and PH with unclear and/or multi-factorial mechanisms (group 5).

In the following guideline-translation we focus on novel aspects regarding the definition and classification of PH and to provide additional background information.

Schlüsselwörter

pulmonale Hypertonie - Definition - Klassifikation

Keywords

pulmonary hypertension - definition - classification

Publikationsverlauf

Artikel online veröffentlicht:
14. November 2023

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