Zusammenfassung
Hintergrund
Adipositas ist ein wesentlicher Risikofaktor für eine diastolische Herzinsuffizienz, die sog. Adipositas-Kardiomyopathie.
Diagnostik
Typischerweise findet sich bei normotensiven Patienten mit Adipositas ein verminderter peripherer Widerstand, ein erhöhtes Blutvolumen und eine verstärkte Herzarbeit, sodass Hypertrophie und diastolische Funktionsstörung die Folge sind, die echokardiographisch gut untersucht werden können. Liegt zusätzlich eine arterielle Hypertonie vor, unterscheidet sich die kardiale Geometrie nicht von einem Cor hypertonicum ohne Adipositas. Auch lassen sich die typischen Veränderungen, wie verändertes Blutvolumen und verminderter peripherer Widerstand, dann nicht mehr nachweisen. Ein obstruktives Schlafapnoesyndrom (OSAS) ist überdurchschnittlich häufig bei Adipositas, sodass ein Screening geboten ist. Der Herzinsuffizienzmarker N-terminales Propeptid BNP (NT-ProBNP) ist bei Adipositas aufgrund verminderter Werte nicht evaluiert und hilft differenzialdiagnostisch nur bedingt weiter.
Therapie
Die konservative Gewichtsreduktion ist überaus schwierig und der Nachweis einer Verbesserung der Prognose wurde nicht erbracht. Hingegen kann mit bariatrischen Operationen die kardiovaskuläre Mortalität bei Adipositas gesenkt werden.
Schlussfolgerung
Nicht zuletzt durch die effektive Gewichtsreduktion infolge bariatrischer Operationen und die damit verbundene Verbesserung der Prognose rückt die Therapie der Adipositas immer mehr ins Blickfeld. Neben allen Schwierigkeiten, wie eingeschränkte Untersuchungsbedingungen im Ultraschall, sollte die kardiale Abklärung bei entsprechenden Symptomen unverzüglich und mit den etablierten Standardmethoden erfolgen.
Abstract
Background
Obesity is an important risk factor for the development of heart failure.
Diagnostics
In normotensive obese patients, a reduced peripheral resistance is typically observed and is accompanied by an increased fluid volume and an increase in cardiac work, resulting in hypertrophy and diastolic heart failure, which can be visualized with echocardiography. However, in the presence of arterial hypertension cardiac geometry is not different to hypertensive heart disease without obesity. Furthermore, the typical changes found with obesity, such as reduced peripheral resistance and increased blood volume, are no longer present. Obstructive sleep apnea (OSA) is very common in obesity and warrants screening but levels of the heart failure marker N-terminal pro-brain natriuretic peptide (NT-ProBNP) might be misleading as the values are lower in obesity than in normal weight controls.
Therapy
Body weight reduction is advisable but difficult to achieve and much more difficult to maintain. Furthermore, diet and exercise has not been proven to enhance life expectancy in obesity. However, with bariatric surgery, long-term weight reduction can be achieved and mortality can be reduced.
Conclusions
With effective weight loss and improved clinical outcome after bariatric surgery, treatment of obesity has shifted much more into focus. Regardless of technical challenges in the work-up of obese patients, clinical symptoms suggestive of cardiac disorders warrant prompt investigation with standard techniques following recommendations as established for normal weight patients.
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Interessenkonflikt. D. Weismann, S. Wiedmann, M. Bala, S. Frantz und M. Fassnacht geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Weismann, D., Wiedmann, S., Bala, M. et al. Adipositas und Herzinsuffizienz. Internist 56, 121–126 (2015). https://doi.org/10.1007/s00108-014-3535-5
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DOI: https://doi.org/10.1007/s00108-014-3535-5