Zusammenfassung
Die Rechtsherzkatheteruntersuchung ist nach wie vor die Goldstandarduntersuchung zur Diagnose einer pulmonalen Hypertonie (PH). Obwohl die Methode seit Jahrzehnten mit wenigen Veränderungen eingesetzt wird, konnten in den letzten Jahren wichtige Herausforderungen identifiziert werden. Diese betreffen in erster Linie die Frühdiagnostik und die Differentialdiagnostik der PH. Im Bereich Frühdiagnostik spielen Belastungsuntersuchungen eine wichtige Rolle. Neue Studien weisen darauf hin, dass die gemeinsame Erhöhung des pulmonalarteriellen Mitteldrucks und des pulmonalen Widerstands bei Belastung eine neue Basis zur Definition einer Belastungs-PH darstellen könnte. Im Bereich Differentialdiagnose stellt sich oft die Frage, ob eine bestehende Herz- oder Lungenerkrankung als Komorbidität oder als Ursache für die PH interpretiert werden soll und wie latente Formen dieser Erkrankungen identifiziert werden können. Die Verwendung der nichtinvasiven diagnostischen Methoden hat in den letzten Jahren zugenommen und in vielen Fragestellungen ergänzen sie erfolgreich die Rechtsherzkatheteruntersuchung. Einfache nichtinvasive Methoden können behilflich sein, Patienten mit sehr wahrscheinlicher und sehr unwahrscheinlicher PH zu identifizieren. Die wichtigste nichtinvasive diagnostische Methode im Bereich PH bleibt die Echokardiographie. Zusätzlich zu klassischen Parametern wurden in aktuellen Studien neue Methoden beschrieben, die eine prognostische Relevanz für die PH nachgewiesen haben. Die Gewebedopplerechokardiographie und die dreidimensionale Echokardiographie sind in der Lage, die rechtsventrikuläre Funktion zuverlässig zu erfassen. Mit der Belastungsechokardiographie können die Belastungshämodynamik und die kontraktile Reserve bestimmt werden. Neue Methoden zur nichtinvasiven Erfassung der pulmonalen Hämodynamik mittels Computertomographie (CT) und Magnetresonanztomographie (MRT) sind sehr vielversprechend und werden in den kommenden Jahren mit großer Wahrscheinlichkeit eine zunehmende Rolle im diagnostischen Algorithmus der PH spielen.
Abstract
Right heart catheterization represents the gold standard examination for the diagnosis of pulmonary hypertension (PH). Although this method has been used for several decades with only minor technical changes, in the last few years some important challenges have been identified. These mainly involve the early diagnosis and the differential diagnosis of PH. In the field of early diagnosis exercise investigations play an increasingly important role. Current studies suggest that the increase of both mean pulmonary arterial pressure and total pulmonary resistance during exercise may provide a new basis for the definition of exercise PH. In the field of differential diagnostics the classification of cardiac and pulmonary diseases as comorbidities or the cause of PH and the identification of the latent forms can represent a major challenge. The importance of novel non-invasive diagnostic methods has increased in recent years and in several questions these add important information to right heart catheterization data. Simple non-invasive methods can help to identify patients with a very likely or a very unlikely PH. The most important non-invasive method for PH remains echocardiography. In addition to classical parameters, novel techniques with prognostic relevance have been established. Tissue Doppler echocardiography and 3-dimensional echocardiography can reliably assess right ventricular function and exercise echocardiography can describe exercise hemodynamics and determine the contractile reserve. Modern imaging methods, including computed tomography (CT) and magnetic resonance imaging (MRI), are very promising in the non-invasive assessment of pulmonary hemodynamics and in upcoming years will most probably play an increasing role in the diagnostic algorithm for PH.
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Einhaltung ethischer Richtlinien
Interessenkonflikt. G. Kovacs hat Honorare von Actelion, GSK, Boehringer Ingelheim, AstraZeneca, Bayer, Pfizer, Novartis, Nycomed und Chiesi erhalten. H. Olschewski gibt Zuschüsse von Actelion sowie Honorare und Beratungstätigkeiten für das Ludwig Boltzmann Institut für Lungengefäßforschung, Bayer, Actelion, Gilead, GSK, Pfizer, AstraZeneca, Boehringer Ingelheim, Almirall, Chiesi und Takeda an.
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Kovacs, G., Olschewski, H. Herausforderungen bei der Diagnostik der pulmonalen Hypertonie. Pneumologe 12, 381–389 (2015). https://doi.org/10.1007/s10405-015-0880-6
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DOI: https://doi.org/10.1007/s10405-015-0880-6
Schlüsselwörter
- Herzkatheteruntersuchung
- Echokardiographie
- Belastung
- Differentialdiagnose
- Nichtinvasive diagnostische Methoden