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Pulmonary hypertension in HFpEF and HFrEF: Pathophysiology, diagnosis, treatment approaches

Pulmonale Hypertonie bei HFpEF und HFrEF: Pathophysiologie, Diagnose, Behandlungsansätze

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Abstract

Pulmonary hypertension (PH) is a frequent hemodynamic condition that is highly prevalent in patients with heart failure and reduced (HFrEF) or preserved ejection fraction (HFpEF). Irrespective of left ventricular EF, the presence of PH and right ventricular (RV) dysfunction are highly relevant for morbidity and mortality in patients with heart failure. While elevated left-sided filling pressures and functional mitral regurgitation primarily lead to post-capillary PH, current guidelines and recommendations distinguish between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH), the latter being defined by a pulmonary vascular resistance (PVR) of ≥3 Wood units. Here, we describe the pathophysiology and clinical relevance of these distinct entities, and report on the diagnostic work-up including remote pulmonary artery pressure (PAP) monitoring. Furthermore, we highlight strategies to manage PH and improve RV function in heart failure, which may include optimized management of HFrEF and HFpEF (medical and interventional), sufficient volume control, catheter-based mitral valve repair, and—in selected cases—targeted PH therapy. In this context, we also highlight gaps in evidence and the need for further research.

Zusammenfassung

Pulmonale Hypertonie (PH) ist ein häufiger hämodynamischer Zustand, der sowohl bei Patienten mit Herzinsuffizienz und reduzierter (HFrEF) als auch erhaltener Ejektionsfraktion (HFpEF) prävalent ist. Unabhängig von der linksventrikulären EF sind das Auftreten einer PH und einer rechtsventrikulären (RV-)Dysfunktion für die Morbidität und Mortalität von Patienten mit Herzinsuffizienz hoch relevant. Obgleich erhöhte linksseitige Füllungsdrucke sowie eine funktionelle Mitralklappeninsuffizienz primär zu einer postkapillären PH führen, differenzieren aktuelle Leitlinien und Empfehlungen zwischen isoliert postkapillärer PH (IpcPH) und kombiniert post- und präkapillärer PH (CpcPH). Letztere wird durch einen auf ≥. Wood-Einheiten erhöhten pulmonalvaskulären Widerstand (PVR) definiert. In diesem Artikel werden die Pathophysiologie und klinische Relevanz dieser unterschiedlichen Entitäten sowie die diagnostische Differenzierung inklusive eines Telemonitorings des pulmonalarteriellen Drucks (PAP) beschrieben. Des Weiteren werden Strategien zur Behandlung der PH und Verbesserung der RV-Funktion bei Herzinsuffizienz aufgezeigt, welche ein optimiertes Management von HFrEF und HFpEF (medikamentös und interventionell), eine suffiziente Volumenkontrolle, die kathetergestützte Behandlung einer Mitralklappeninsuffizienz, und – in ausgewählten Fällen – eine gezielte PH-Therapie beinhalten können. In diesem Zusammenhang weisen die Autoren auch auf Evidenzlücken und die Notwendigkeit weiterer Forschungsbemühungen hin.

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Authors and Affiliations

  1. Klinik III für Innere Medizin und Cologne Cardiovascular Research Center (CCRC), Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany

    S. Rosenkranz, T. Kramer & F. Gerhardt

  2. Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK-Kliniken Berlin, Berlin, Germany

    C. Opitz

  3. Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany

    K. M. Olsson & M. M. Hoeper

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  1. S. Rosenkranz
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Correspondence to S. Rosenkranz.

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Conflict of interest

S. Rosenkranz: Remunerations for lectures and/or consultancy from Abbott, Actelion, Arena, Bayer, Ferrer, GSK, MSD, Novartis, Pfizer, and United Therapeutics. Research support to institution from Actelion, Bayer, Novartis, Pfizer, and United Therapeutics. T. Kramer: Remunerations for lectures from Actelion, Bayer, MSD. F. Gerhardt: Remunerations for lectures from Actelion, Bayer, GSK, MSD, and United Therapeutics; grants to institution from Actelion, Bayer, Novartis und United Therapeutics. C. Opitz: No personal fees as potential conflicts of interest. K.M. Olsson: Remunerations for lectures and/or consultancy from Actelion, Bayer, GSK, Pfizer und United Therapeutics. M.M. Hoeper: Honoraria for lectures and/or consulting from Actelion, Bayer, Gilead, GSK, Merck, and Pfizer.

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Rosenkranz, S., Kramer, T., Gerhardt, F. et al. Pulmonary hypertension in HFpEF and HFrEF: Pathophysiology, diagnosis, treatment approaches. Herz 44, 483–490 (2019). https://doi.org/10.1007/s00059-019-4831-6

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