Pulmonale Hypertonie assoziiert mit Linksherzerkrankungen (Gruppe 2)

Kai Helge Schmidt; Olympia Bikou; Rüdiger Blindt; Leonhard Bruch; Ralf Felgendreher; Wolfgang Hohenforst-Schmidt; Stephan Holt; Dennis Ladage; Elena Pfeuffer-Jovic; Andreas Rieth; Alexander Schmeisser; Katharina Schnitzler; Stefan Stadler; Regina Steringer-Mascherbauer; Athiththan Yogeswaran; Wolfgang M. Kuebler

doi:10.1055/a-2145-4792

Pneumologie, Inhaltsverzeichnis

Pneumologie 2023; 77(11): 926-936
DOI: 10.1055/a-2145-4792

Übersicht

Pulmonale Hypertonie assoziiert mit Linksherzerkrankungen (Gruppe 2)

Pulmonary hypertension associated with left heart disease (group 2)

Kai Helge Schmidt

¹Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland

²Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin Mainz, Mainz, Deutschland

,

Olympia Bikou

³Medizinische Klinik und Poliklinik I, Klinikum der Universität München, München, Deutschland

,

Rüdiger Blindt

⁴Kardio Bremen, Rotes Kreuz Krankenhaus Bremen, Bremen, Deutschland

,

Leonhard Bruch

⁵Klinik für Innere Medizin und Kardiologie, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland

,

Ralf Felgendreher

⁶Innere Medizin, Marienhospital Arnsberg, Arnsberg, Deutschland

,

Wolfgang Hohenforst-Schmidt

⁷Lungenzentrum Bamberg, Klinikum am Bruderwald Bamberg, Bamberg, Deutschland

,

Stephan Holt

⁸Praxis am Steintor, Recklinghausen, Recklinghausen, Deutschland

,

Dennis Ladage

⁹Klinik für Pneumologie, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Deutschland

,

Elena Pfeuffer-Jovic

¹⁰Klinikum Würzburg Mitte, Standort Missioklinik Würzburg, Würzburg, Deutschland

,

Andreas Rieth

¹¹Abteilung für Kardiologie, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Deutschland

,

Alexander Schmeisser

¹²Zentrum für Innere Medizin, Universitätsklinik für Kardiologie und Angiologie Magdeburg, Magdeburg, Deutschland

,

Katharina Schnitzler

¹Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland

,

Stefan Stadler

¹³Klinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland

,

Regina Steringer-Mascherbauer

¹⁴Interne 2, Ordensklinikum Linz, Linz, Österreich

,

Athiththan Yogeswaran

¹⁵Department of Internal Medicine, Member of the German Center for Lung Research, Universities of Giessen and Marburg Lung Center, Justus-Liebig-University Giessen, Giessen, Deutschland

,

Wolfgang M. Kuebler

¹⁶Institute of Physiology, Charité – Universitätsmedizin Berlin, Berlin, Deutschland

› Institutsangaben

Abstract

Zusammenfassung

Die pulmonale Hypertonie in Verbindung mit Linksherzerkrankungen (PH-LHD) bildet in der klinischen Klassifikation die Gruppe 2 der pulmonalen Hypertonie ab. Hämodynamisch zählt zu dieser Gruppe die isoliert postkapilläre pulmonale Hypertonie (IpcPH) und die gemischt post- und präkapilläre pulmonale Hypertonie (CpcPH). Die PH-LHD ist durch einen mPAP > 20 mmHg und einen PAWP > 15 mmHg definiert, zur Differenzierung zwischen IpcPH und CpcPH wird der pulmonalvaskuläre Widerstand (PVR) mit dem Grenzwert von 2 Wood Units (WU) herangezogen. Ein PVR von größer 5 WU weist auf eine dominierende präkapilläre Komponente hin. Die PH-LHD ist die häufigste Form der pulmonalen Hypertonie, ursächlich führend ist die Linksherzinsuffizienz mit erhaltener (HFpEF) oder reduzierter Ejektionsfraktion (HFmrEF, HFrEF), Herzklappenerkrankungen und seltener angeborene Herzfehler. Das Vorhandensein eines pulmonalen Hypertonus geht im gesamten Spektrum der Linksherzerkrankungen mit einer erhöhten Symptomlast und schlechterem Outcome einher. Eine besondere Herausforderung stellt die Differenzierung zwischen der pulmonalen Hypertonie der Gruppe 1 mit kardialen Komorbiditäten und der PH-LHD, besonders infolge der HFpEF dar. Therapeutisch kann zum jetzigen Zeitpunkt noch keine generelle Empfehlung für den Einsatz von PDE-5-Inhibitoren bei HFpEF-assoziierter CpcPH gegeben werden. Für die Anwendung von PAH-Medikamenten bei der IpcPH gibt es aktuell keine belastbare Rationale, ebenso wird die Therapie mit Endothelin-Rezeptor-Antagonisten oder Prostazyklin-Analoga bei allen Formen der PH-LHD nicht empfohlen.

Abstract

Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD.

Schlüsselwörter

pulmonale Hypertonie assoziiert mit Linksherzerkrankung - isoliert postkapilläre pulmonale Hypertonie - gemischt post- und präkapilläre Pulmonale Hypertonie - kardiale Komorbiditäten - Herzinsuffizienz mit erhaltener Ejektionsfraktion

Keywords

pulmonary hypertension associated with left heart disease - isolated post-capillary pulmonary hypertension - combined post- and pre-capillary pulmonary hypertension - cardiac comorbidities - heart failure with preserved ejection fraction

Volltext

Referenzen

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