Pulmonale Hypertonie assoziiert mit Linksherzerkrankungen (Gruppe 2)

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

Publication History

Article published online:
14 November 2023

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