左心疾病相关肺动脉高压的临床诊治进展

Left heart disease-associated pulmonary hypertension: advances in its diagnosis and treatment

摘要:

左心疾病（LHD）不仅是导致心力衰竭的临床常见疾病, 也是临床常见的导致肺动脉高压（PH）的病因之一。临床流行病学研究提示, LHD相关PH是PH最常见疾病类型之一, PH是LHD患者预后重要的预测因素之一, 合并PH的LHD患者预后不良。超声心动图检查是目前临床常用的筛查LHD相关PH的无创性检查方法, 同时对于LHD相关PH患者的基础疾病的诊断与病情评估也具有重要作用。LHD相关PH患者典型的血流动力学改变特点为毛细血管后PH。对于疑似LHD相关PH患者进行包括肺毛细血管楔压(PCWP)、肺动脉压力（PAP）、肺血管阻力（PVR）以及跨肺压梯度（mPAP－mPCWP）等血流动力学参数的血流动力学评估, 具有重要的临床诊断、鉴别诊断、疾病评估和治疗决策作用。LHD相关PH的治疗首先应进行LHD基础疾病的优化治疗。虽然缺乏大型临床试验和循证医学的证据支持, 治疗动脉型肺动脉高压有效的PH靶向治疗药物也被初步应用于部分LHD相关PH患者的治疗。LHD相关PH研究领域可能是目前及今后PH研究领域的热点和难点之一, 也可能是目前及今后心力衰竭研究领域的热点之一。

Abstract:

Left heart disease (LHD) is one of the most common causes of heart failure. Pulmonary hypertension (PH) is a common hemodynamic finding in patients with LHD and is usually associated with increased morbidity and mortality. LHD-assoicated PH is one of the most common types. Doppler echocardiography remains the most useful noninvasive tool for assessing the presence of PH in patients with LHD, and for diagnosis and assessment of LHD. Typical hemodynamic finding in LHD-associated PH is pre-capillary PH. Hemodynamic parameters, including pulmonary capillary wedge pressure, pulmonary artery pressure, pulmonary vascular resistance and transpulmonary pressure gradient (for example mPAP–mPCWP), are all valuable in diagnosis, differential diagnosis, assessment, and effective treatment of LHD-associated PH. Most importantly, the underlying cause of LHD should be treated firstly. Drugs with proven efficacy in pulmonary arterial hypertension are being increasingly used in LHD-associated PH, despite the virtual absence of supporting evidence from clinical trials. LHD-associated PH may be the hot and difficult point in the future researches on PH, as well as heart failure.