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Der Klinikarzt 2017; 46(08): 382-388
DOI: 10.1055/s-0043-116605
Schwerpunkt
© Georg Thieme Verlag Stuttgart · New York

Pulmonale Hypertonie bei Linksherzerkrankungen

Klassifikation, Diagnostik und Therapie
Christian Opitz
1   Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK-Kliniken Berlin
,
Andreas Rieth
2   Abteilung Kardiologie, Kerckhoff-Klinik, Bad Nauheim
,
Stephan Rosenkranz
3   Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln
4   Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln
› Author Affiliations
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Publication History

Publication Date:
24 August 2017 (online)

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Zusammenfassung

Die pulmonale Hypertonie (PH) bei Linksherzerkrankungen ist die weitaus häufigste Form der PH. Nach der hämodynamischen Definition liegt hierbei eine post-kapilläre PH vor (PAPmean ≥ 25 mmHg, PAWP > 15 mmHg). Die Schwere einer PH sowie die Einschränkung der rechtsventrikulären Funktion haben erhebliche Bedeutung für die Prognose von Patienten mit systolischer (Heart Failure with reduced Ejection Fraction, HFrEF) oder diastolischer (Heart Failure with preserved Ejection Fraction, HFpEF) Herzinsuffizienz und/oder linksseitigen Klappenerkrankungen. Die pathophysiologische Sequenz besteht in einer Rückwärtsübertragung pathologisch erhöhter Füllungsdrucke im linken Herzen über die pulmonale Zirkulation bis zum rechten Herzen. Im Vordergrund der Therapie stehen daher eine leitliniengerechte Behandlung der Linksherzerkrankung und die Optimierung des Volumenstatus. Gezielte PH-Medikamente sind primär nicht indiziert. Zeigen sich jedoch trotz Entwässerung eine ausgeprägte PH und eine Rechtsherzbelastung, so sollte eine detaillierte Abklärung inklusive exakter hämodynamischer Charakterisierung erfolgen. Die ESC/ERS-Leitlinien differenzieren unter Berücksichtigung des diastolischen Druckgradienten (DPG) und des pulmonal vaskulären Widerstandes (PVR) zwischen isoliert post-kapillärer PH (Ipc-PH) und kombiniert post- und prä-kapillärer PH (Cpc-PH). Während bei Ipc-PH kein therapeutisches Target in der pulmonalen Zirkulation besteht, kann bei Cpc-PH mit erhöhtem PVR und DPG ein Therapieversuch mit gezielten PH-Medikamenten gerechtfertigt sein. Jedoch liegen für diese Form der PH nur präliminäre Daten vor, und kontrollierte Studien sind notwendig.

 

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