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Diagnostik der pulmonalen Hypertonie

Diagnostics in pulmonary hypertension

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Zusammenfassung

Häufig ergibt sich der klinische Verdacht einer pulmonalen Hypertonie bei einer ungeklärten Belastungsdyspnoe oder aufgrund zufällig angefertigter Untersuchungen mit Zeichen der Rechtsherzinsuffizienz. Die Kenntnis der Venedig-Klassifikation ist für das systematische diagnostische Vorgehen zur exakten Klassenzuordnung entscheidend. Zu den Basisuntersuchungen zählen EKG, Röntgenthoraxaufnahme, Lungenfunktionsuntersuchung und die Echokardiographie, die die wichtigste nicht-invasive Untersuchung zur ätiologischen Abklärung und Verlaufsbeurteilung darstellt, aber auch zur Screeningdiagnostik dient. Echokardiographische Kriterien einer pulmonalen Hypertonie sind ein hypertrophierter und dilatierter rechter Ventrikel, eine paradoxe Septumbewegung, ein dilatierter rechter Vorhof und eine erweitere untere Hohlvene. Mittels Dopplerechokardiographie kann bei Trikuspidalinsuffizienz der systolische rechtsventrikuläre und pulmonal-arterielle Druck bestimmt werden. Eine CT des Thorax dient zum Ausschluss von Lungenembolien und interstitiellen Lungenerkrankungen. Die kardiale MRT gewinnt zunehmende Bedeutung in der Beurteilung der rechtsventrikulären Morphologie, Funktion und Hämodynamik. Zur Beurteilung des Schweregrads, aber auch als Verlaufsparameter, dient der 6-Minuten-Gehtest. Die Spiroergometrie objektiviert den Schweregrad, die Prognoseeinschätzung und dient zur Verlaufsbeurteilung. Zur definitiven Diagnosestellung wird die Rechtsherzkatheteruntersuchung einschließlich einer pharmakologischen Testung einer „Teilreversibilität“ der pulmonal-vaskulären Druckerhöhung eingesetzt.

Abstract

Commonly, pulmonary hypertension is clinically suspected because of unexplained exertional dyspnoea or as a chance finding in clinical examination revealing signs of right heart failure. The systematic diagnostic approach and exact classification is based on the Venice classification. Basic investigations include ECG, chest radiograph, lung function studies and echocardiography. Echocardiography is the most important investigation for the diagnosis of pulmonary hypertension. It also serves as non invasive control during treatment and as the main screening test for pulmonary hypertension. Echocardiographic criteria of pulmonary hypertension are a dilated and hypertrophied right ventricle, paradoxic septum movement, a dilated right atrium, and a distended inferior Vena cava. Using Doppler echocardiography, the right ventricular and thus pulmonary arterial systolic pressure can be determined from the tricuspid regurgitant jet velocity. CT of the chest serves to exclude pulmonary embolism and interstitial lung disorders. Cardiac MRI is increasingly being used for analysis of right ventricular morphology, function and haemdynamics. The 6 minute walk test and cardiopulmonary exercise test are used to assess severity and response to treatment and give prognostic information. For the definite diagnosis of pulmonary hypertension, right heart catheterisation is required for the determination of the pulmonary vascular resistance and pharmacological testing of “reversibility”.

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  1. Klinik für Kardiologie, Pneumologie und Angiologie, Klinikum Esslingen, Hirschlandstraße 97, 73730, Esslingen, Deutschland

    M. Leschke, A. Wädlich, S. Waldenmaier & M. Faehling

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  1. M. Leschke
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  2. A. Wädlich
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  3. S. Waldenmaier
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Correspondence to M. Leschke.

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Leschke, M., Wädlich, A., Waldenmaier, S. et al. Diagnostik der pulmonalen Hypertonie. Internist 50, 1086–1100 (2009). https://doi.org/10.1007/s00108-009-2335-9

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