Pulmonary Hypertension in Left Heart...

Stephan Rosenkranz

Klinik III für Innere Medizin

Zentrum für Molekulare Medizin (ZMMK)

Herzzentrum der Universität zu Köln

[email protected]

Pulmonary Hypertension in

Left Heart Disorders

European Society of Cardiology (ESC)

Zürich Heart House

Cardiology Update 2011ESC Update Programme

Davos, Switzerland, February 16, 2011

ESC/ERS Guidelines 2009

Galiè et al., Eur Heart J 2009; 30: 2493-2537

Cardio-Pulmonary Interaction

Cardio-Pulmonary Interaction

heterogeneous

poorly defined

highly variable

condition

Who are these patients?

Updated Clinical Classification of

Pulmonary Hypertension (Dana Point, 2009)

4th World Symposium PAH; Dana Point, CA Feb 11-14, 2008

Simonneau-G et al.; JACC 2009; 54(Suppl. S): S43-S54

Cologne Consensus Conference 2010:

Classification of PH due to Left Heart Disease

Rosenkranz et al., DMW 2010;135(Suppl3): S102-S114; Int J Cardiol 2011 (in press)

Heart Failure with reduced left ventricular Ejection Fraction (EF ≤50%)*

Ischemic Cardiomyopathy (ICM)

Dilative Cardiomyopathy (DCM)

Heart Failure with preserved left ventricular Ejection Fraction (EF >50%)*

Valvular Left Heart Disease

Hypertensive Heart Disease

Coronary Heart Disease

Diabetic Cardiomyopathy

Hypertrophic Cardiomyopathy

Restrictive Cardiomyopathy

Constrictive Pericarditis

Aortic Valve Stenosis

Aortic Valve Insufficiency

Mitral Valve Stenosis

Mitral Valve Insufficiency

Persistent / residual PH after correction of valular heart disease

Atrial fibrillation

Other rhythm disorders

Cor triatriatum

Myxoma or left atrial thrombus

Other causes

LVEF ≥40% LVEF <40%

Moller et al. Am J Cardiol 2005; 96: 199-203

Survival of Patients After Acute Myocardial

Infarction Stratified by RVSP

Überleben bei Herzinsuffizienz:

Bedeutung von PH und RV-Funktion

Normal PAP (PAPm <20 mm Hg)

High PAP (PAPm >20 mmHg)Low RVEF (<35%)

n=379

Months402010 50 60

–0.2

0.0

0.2

0.4

0.6

Cu

mu

lati

ve p

rop

ort

ion

su

rviv

ing

0.8

1.0

0 30 70

Low RVEF (<35%)

Ghio S, et al. J Am Coll Cardiol 2001;37:183–188

Epidemiology and Prognostic Impact

of PH in Diastolic Heart Failure

Lam et al., JACC 2009; 53: 1119-1126

HFpEF: PASP > 35 mmHg present in 83% (median PASP 48 mmHg)

PVH does not fully account for the severity of PH in HFpEF

Prevalence Survival

LV Diastolic Dysfunction in Elderly Hypertensives:

Results of the APROS-diadys Study

Zanchetti A et al, J Hypertens, 2007

Prevalence of Diastolic Heart Failure

25.8 %

ECHO

2545 Patients > 65 Years with Systemic

Hypertension without Systolic HF

(LVEF > 45 %)

LV Diastolic Dysfunction in Elderly Hypertensives:

Results of the APROS-diadys Study

2545 Patients > 65 Years with Systemic

Hypertension without Systolic HF

(LVEF > 45 %)

Zanchetti A et al, J Hypertens, 2007

Prävalenz der diastolischen Herzinsuffizienz

25.8 %

ECHO

Prevalence of left ventricular diastolic dysfunction

in a general population

Kuznetsova T et al. Circ Heart Fail 2009; 2: 105-112

(n = 539, mean age 52,5 years)

27.3%

How to Diagnose Diastolic Heart Failure

(HFNEF)

Paulus et al., ESC Consensus Statement, Eur Heart J 2007

Pre- versus postcapillary PH

PAH vs. PVH: PCWP vs. LVEDP

3.926 Patienten

Halpern-SC, Taichman-DB, Chest 2009; 136: 37-43

RHC: Pressure Curves

The PCWP Controversy

The technical quality of PCWP tracing

should be perfect

(31% technically inadequate)

Morris A et al. Crit Care Med 1984

The correct interpretation mandatory

(50% misinterpreted). Crit Care Med 1997;25:213 and 2002;30:1197

Threshold of PCWP - Normal LVEDP

Braunwald E: Heart Diseases, 2005

O´Rourke RA: Hurst´s The heart, 2008

Harrison´s principles of internal medicine, 2008

Lapp H, Krakau I: Das Herzkatheterbuch, 2008

Standard Textbooks of Cardiology

LVEDP 6 – 12 mmHg

Normal Values for LVEDP (Cardiology World)

and PCWP (PAH World)

Rosenkranz et al., DMW 2010; 135(Suppl 3): S102-S114

Right Heart Catheter (RHC)

PCWP PAP

TPG

Pulmonary Hemodynamics in Left Heart Disease:

Pulmonary Circulation

PAPm LAP

15

8

normal

TPG = 7 mmHg

25

PAPm LAP

15

8

normal

TPG = 7 mmHg

40



PAPm LAP

15

8

normal

TPG = 7 mmHg

precapillary PH

TPG = 32 mmHg

40



PAPm LAP

15

8

normal

TPG = 7 mmHg

elevated

filling pressure20



PAPm LAP

15

8

normal

TPG = 7 mmHg

20



elevated

filling pressure

PAPm LAP

15

8

normal

TPG = 7 mmHg

20

30„passive“



elevated

filling pressure

postcapillary PH

LAP > 15 mmHg

PAPm LAP

15

8

normal

TPG = 7 mmHg

20

Protective

Pulmonary Vasoconstriction

30„passive“



elevated

filling pressure

postcapillary PH

LAP > 15 mmHg

PAPm LAP

15

8

normal

TPG = 7 mmHg

20

30

55



elevated

filling pressure

postcapillary PH

LAP > 15 mmHg

PAPm LAP

15

8

normal

TPG = 7 mmHg

20

30

55



elevated

filling pressure

postcapillary PH

LAP > 15 mmHg

Precapillary

Component

TPG = 35 mmHg

„reactive“

„out of proportion“

PH in Left Heart Failure:

Pathophysiology


Delgado, Rev Esp Cardiol 2010; 63: 334-345

LHI + PH LHI - PH


Pathophysiology

PAPm LAP

15

8

normal

TPG = 7 mmHg

20

30

55



elevated

filling pressure

postcapillary PH

LAP > 15 mmHg

Precapillary

Component

TPG = 35 mmHg

„reactive“


PAPm LAP

15

8

normal

TPG = 7 mmHg

20

30

55 VARIABLE



elevated

filling pressure

Volume load

Heart Failure Treatment

Correction of Valvular Disease

postcapillary PH

LAP > 15 mmHg

Precapillary

Component

TPG = 35 mmHg

„reactive“


PAPm LAP

15

8

normal

TPG = 7 mmHg

postcapillary PH

LAP > 15 mmHg20

30

Precapillary

Component

TPG = 35 mmHg

55 VARIABLEVolume load

Heart Failure Treatment

Correction of Valvular Disease

„reactive“




elevated

filling pressure

Pulmonary Hemodynamics in Left Heart Disease

Impact of Volume Load

70 year-old patient

Diastolic Heart Failure

Body weight 80 kg

70 year-old patient

6 days later

Body weight now 73 kg

PAPm 51 mmHg

PAPm

mmHg

10

20

30

40

50

60

30

21

PAPm 24 mmHg

PAPm

mmHg

10

20

30

40

50

60

13

11

PCWP TPG PCWP TPG

Redfield M, Mayo Clinic, 2007

Hemodynamic Monitoring during Physical Exercise

and Sexual Intercourse in Patients with CHF and PH

Chronical Device, IHM, Medtronic Inc.

Cremers B et al, Am J Med, 2002

53-y.o. patient; ICM; EF 25%

20

40

60

80

100

120

140

11:50 PM 11:52 PM 11:54 PM 11:56 PM 11:58 PM 12:00 AM 12:02 AM

0

5

10

15

20

25HEART RATE (bpm) ACTIVITY (counts)

20

40

60

80

100

120

140

12:57 PM 12:58 PM 12:59 PM 1:00 PM 1:00 PM 1:01 PM 1:02 PM

0

5

10

15

20

25

HEART RATE (bpm) ACTIVITY (counts)

Exercise (brisk walking)

Sexual Intercourse

11:50 PM 11:52 PM 11:54 PM 11:56 PM 11:58 PM 12:00 AM 12:02 AM

0

20

40

60

80

100

120

PRESSURE (mmHg)

ePADP

RVSP

RVDP

0

20

40

60

80

100

120

12:57 PM 12:58 PM 12:59 PM 1:00 PM 1:00 PM 1:01 PM 1:02 PM

RVSP

ePADPRVDP

0

20

40

60

80

0

20

40

60

80

100

67-y.o. patient; DHF

40 Watt

PAP = 85/40/55 mmHg

RAP = 28 mmHg

Baseline

0

20

40

60

80

0

20

40

60

80

100

PAP = 45/20/28 mmHg

RAP = 9 mmHg

Diagnostic Tests in PH Group 2 ?

Proper

classification

pre- vs. postcapillary

PH

VOLUME

CHALLENGE

Differentiation

vasoconstriction /

vascular

remodeling

VASOREACTIVITY

TESTING

Costard-Jackle A, Fowler MB, JACC 1992Oudiz RJ, Clin Chest Med 2007

Pulmonary

hemodynamics

during

exercise

EXERCISE

TEST

Treatment of PH in

Left Heart Disease?

Systolic HF: Standard Treatment

Medical Treatment:

• ACE-Inhibitors / AT1R-Blockers / Beta-Blockers

• Diuretics

• Digitalis

• Aldosterone Antagonists

Interventional / surgical Treatment:

• CRT (may reduce PH, but PH ↓ effectiveness)

– QRS > 120 ms (50% SHF)

• LVAD (Bridge-to-Transplant)

• HTX (limited)

Heart Failure Treatment may improve PH

But: PH frequent despite maximal Treatment

Targeted PAH Therapies in Heart Failure

• Calcium Channel Blockers

– SHF – No Benefit

– DHF – Potential Benefit – “Need for RCT”

• PDE 5-Inhibitors

– Small RCT and Experimental Data – efficacious?

– Potential Benefit in SHF and DHF – “Need for RCT”

– RELAX Trial ongoing (Sildenafil)

• Endothelin-Receptor-Antagonists

– SHF – No Benefit in multiple Studies

– Potential Benefit in DHF – “Need for RCT”

– Sitaxsentan – DHF Trial stopped

• Epoprostenol

– SHF – Increased Mortality !! (FIRST Trial)

– DHF – No Data

PAH/PH in Left Heart Disease:

Transpulmonary Gradient (TPG)

Volume loadinitial Sildenafil Mean change p value*

Hemodynamics

PAPsyst (mmHg) 84.3 ± 5.7 60.2 ± 11.5 -24.1 ± 7.1 <0.05

PAPmean (mmHg) 52.5 ± 2.5 37.2 ± 5.5 -15.3 ± 4.4 <0.05

PCWP# (mmHg) 27.5 ± 2.4 21.3 ± 3.6 -6.2 ± 4.4 n.s.

TPG (mmHg) 25.2 ± 3.2 15.8 ± 4.2 -9.4 ± 2.2 <0.05

HZV (ml/min) 3.4 ± 0.6 3.7 ± 0.4 +0.3 ± 0.1 n.s.

PVR (Wood units) 10.2 ± 3.0 3.9 ± 0.7 -6.3 ± 2.8 <0.05

RAP (mmHg) 17.0 ± 1.2 13.5 ± 1.8 -3.5 ± 1.9 n.s.

Echocardiography

RVEDD (mm) 41.0 ± 2.4 41.3 ± 3.9 +0.3 ± 3.6 n.s.

RA area (cm2) 30.5 ± 4.1 28.3 ± 4.0 -2.2 ± 2.3 n.s.

LVEF (%) 36.8 ± 5.3 40.6 ± 8.8 + 3.8 ± 5.6 n.s.

TAPSE (mm) 12.7 ± 1.5 15.8 ± 0.9 +3.2 ± 1.4 <0.05

Serum markers

NTproBNP (ng/dl) 7123 ± 1835 3201 ± 504 -3922 ± 2099 <0.05

Exercise tolerance

6MWD (m) 212 ± 75 336 ± 62 +124 ± 65 <0.05

Dumitrescu & Rosenkranz, 2010 (submitted)

Volume loadinitial Sildenafil Mean change p value*

Hemodynamics

PAPsyst (mmHg) 84.3 ± 5.7 60.2 ± 11.5 -24.1 ± 7.1 <0.05

PAPmean (mmHg) 52.5 ± 2.5 37.2 ± 5.5 -15.3 ± 4.4 <0.05

PCWP# (mmHg) 27.5 ± 2.4 21.3 ± 3.6 -6.2 ± 4.4 n.s.

TPG (mmHg) 25.2 ± 3.2 15.8 ± 4.2 -9.4 ± 2.2 <0.05

HZV (ml/min) 3.4 ± 0.6 3.7 ± 0.4 +0.3 ± 0.1 n.s.

PVR (Wood units) 10.2 ± 3.0 3.9 ± 0.7 -6.3 ± 2.8 <0.05

RAP (mmHg) 17.0 ± 1.2 13.5 ± 1.8 -3.5 ± 1.9 n.s.

Echocardiography

RVEDD (mm) 41.0 ± 2.4 41.3 ± 3.9 +0.3 ± 3.6 n.s.

RA area (cm2) 30.5 ± 4.1 28.3 ± 4.0 -2.2 ± 2.3 n.s.

LVEF (%) 36.8 ± 5.3 40.6 ± 8.8 + 3.8 ± 5.6 n.s.

TAPSE (mm) 12.7 ± 1.5 15.8 ± 0.9 +3.2 ± 1.4 <0.05

Serum markers

NTproBNP (ng/dl) 7123 ± 1835 3201 ± 504 -3922 ± 2099 <0.05

Exercise tolerance

6MWD (m) 212 ± 75 336 ± 62 +124 ± 65 <0.05

Dumitrescu & Rosenkranz, 2010 (submitted)

PAH/PH in Left Heart Disease:

Transpulmonary Gradient (TPG)

Abraham et al., Lancet 2011; published on-line February 10, 2011

CHAMPION Trial: Wireless Pulmonary Artery

Hemodynamic Monitoring in Heart Failure

Randomized, controlled trial (Left HF, NYHA III; n=550)

HF-related hospitalizations @ 6 monthsWireless implantable hemodynamic

monitoring system (W-IHM)

Specific Recommendations of the Working Group regarding Treatment of PH

associated with Left Heart Disease:

Potential Use of Targeted PAH Therapies in PH and elevated PCWP:

- pronounced precapillary component foregrounded to the disease

- Requirement: complete diagnostics including RHC and LHC.

Patients must fullfill the following criteria:

1. Invasively confirmed PH, which markedly exceeds the extent usual seen in left

heart disease (markedly elevated TPG / PVR);

2. no treatable cause of heart failure (CAD, valvular disease);

3. Guideline-based, evidence-based treatment for heart failure for a reasonable

period of time (> 3-6 months) and at the anticipated target doses;

4. Exclusion of other causes of PH and of CTEPH.

Primary Goal: Inclusion in clinical trials (e.g., LEPHT, CAESAR)

Cologne Consensus Conference 2010


….. a long way to go

Thank you!

PH in Left Heart Disorders

Doppler / Gewebe-Doppler

IVCT IVRT

Systole

E„ A„

RV LV

St

Tissue Doppler Imaging (TDI)

MK: E/E´

LAP/PCP

TK: E/E´

RAP

TDI-MPI

RV-Fkt.

STK

MK: E/ADT

LA-Größe

Olmsted County, MI

EFFECT data base,

Ontario, Canada

Survival in Systolic versus


Diastolic HF: Ready for Treatment?

1990 2010

Diuretics X X

BP Control X X

Revascularization X X

BB/ACEI/ARB/CCB (?) X X

HR in A-Fib X X

Guidelines only Expert Opinion

ESC HF Guidelines, Eur Heart J, 2008

Diastolic HF: Clinical Trials

AT1-Antagonist (Candesartan):

CHARM-Preserved: Yusuf et al., Lancet 2003

ACE Inhibitor (Perindopril):

PEP-CHF: Cleland et al., Eur Heart J 2006

I-Preserve: Massie et al., NEJM 2008

AT1-Antagonist (Irbesartan):

Diastolic HF: Ready for Treatment?

1990 2010

Diuretics X X

BP Control X X

Revascularization X X

BB/ACEI/ARB/CCB (?) X X

HR in A-Fib X X

Guidelines only Expert Opinion

Chatterjee K: Western Journal of Medicine: 1990

ESC HF Guidelines, Eur Heart J, 2008

Olmsted County, MI

EFFECT data base,

Ontario, Canada

Survival in Systolic versus


Diastolic Dysfunction and Heart Failure

Clinical Signs of Heart Failure

Hypertrophy, Compliance , Relaxation

Preserved LV Ejection Fraction (≥50%)

Ursache für die Symptomatik bei

diastolischer Herzinsuffizienz

Chattopadhyay-S, et al.

Circ Heart Fail 2009; in press

HFpEF

Kurt-M, et al.

Circ Cardiovasc Imaging 2009; 2: 10-15

Reduzierte LA(S) strain

Erhöhte LA-Steifigkeit

Gestörte LA-FunktionEingeschränkte

Diastolische Reserve

DSE: mitral annular velocity

Reduced Ea, increased E/Ea

PAH/PH bei Linksherzerkrankungen:

Transpulmonaler Gradient (TPG)

PCWP PAP

PVH PAHP(A)H / LHI

PCWP PAP PCWP PAP

20 41/17/31

TPG 1126 74/40/54

TPG 2811 96/30/53

TPG 42

Belastungsinduzierte pulmonale Hypertonie

bei Herzinsuffizienz

*Butler JACC 1999; Tumminello Eur Heart J 2007

Systolische versus diastolische Herzinsuffizienz ?PAP unter Belastung in Relation zu PAP in Ruhe ?

Differenzierung zwischen PAH und

diastolischer Herzinsuffizienz

Diagnosen:

• Hypertensive Herzerkrankung

• Diastolische Herzinsuffizienz

• Pulmonal venöse Hypertonie

Diagnosen:

• Pulmonal arterielle Hypertonie

• Leichte diastolische Dysfunktion des linken Ventrikels

• Arterielle Hypertonie

Leitsymptom „Dyspnoe“

PAH HFpEF

ESC/ERS-Leitlinien: Therapie der Non-PAH PH?

Was ist „out-of proportion PH“?

Bei Linksherzinsuffizienz TPG > 12 mmHg?

Wann ist die PH „zweite Erkrankung“

Dann PAH bei Herzinsuffizienz?

Galiè N et al; Eur Heart J 2009;30:2493-2537

Indikation Empfehlung

Therapie der PH bei Linksherzerkrankungen

mit PAH-spezifischen Medikamenten?III - C

PAPm 48 mmHg

PAPm 38 mmHg

0

10

20

30

40

50

Baseline

PCWP TPG

0

10

20

30

40

50

Baseline

PCWP TPG

Pulmonale Hypertonie bei Linksherzerkrankungen:

Patienten mit postkapillärer PH

Patient 1 - NYHA III55 Jahre, DCM, LVEF 25%

6MWD 320 m

Patientin 2 - NYHA III75 J, HPT, VHF, LVEF 55%, NIDDM,

Adipositas, 6MWD 270 m

PAPm 48 mmHg

PAPm 38 mmHg

0

10

20

30

40

50

Baseline

PCWP TPG

0

10

20

30

40

50

Baseline

PCWP TPG




6MWD 320 m



Optimierte Herzinsuffizienz-

Therapie nach den aktuellen

Leitlinien

PAPm 48 mmHg

PAPm 38 mmHg

0

10

20

30

40

50

Baseline

PCWP TPG

0

10

20

30

40

50

Baseline

PCWP TPG




6MWD 320 m



Optimale Blutdruckeinstellung

Frequenz/Rhythmuskontrolle

Diuretika, Gewichtsreduktion

Optimale Diabetestherapie

Optimierte Herzinsuffizienz-

Therapie nach den aktuellen

Leitlinien

PAPm 37 mmHg

PAPm 29 mmHg

0

10

20

30

40

50

Baseline 6 Monate

PCWP TPG

0

10

20

30

40

50

Baseline 6 Monate

PCWP TPG


Hämodynamik nach 6 Monaten


6MWD 320 m

Patientin 2 - NYHA II75 J, HPT, VHF, LVEF 55%, NIDDM,


Häufige Diagnosen bei dem Leitsymptom

„Dyspnoe“ in der kardiologischen Praxis

Systolic Heart Failure

Coronary Heart Disease


Valvular Heart Disease

DYSPNEA

Epidemiologie der PH und der

Linksherzinsuffizienz

Prävalenz PAH: 15-50 / Mio. Einwohner

Prävalenz IPAH: 6-12 / Mio. Einwohner

DCM: 360 / Mio. Einwohner

ICM: 3000-4500 / Mio. Einwohner

Pulmonal arterielle Hypertonie:

Systolische Herzinsuffizienz:

Diastolische Herzinsuffizienz:

~ 250.000-450.000

Prävalenz unklar – hohe Dunkelziffer

Deutschland

~ 1000

~ 4000

???

~ 50.000

ca. 50% aller Patienten mit Herzinsuffizienz

Epidemiologie der PH bei systolischer

und diastolischer Linksherzinsuffizienz

• Allgemeinbevölkerung (>45 Jahre; n=1417)

2.04% PASP ≥ 40; 0.07% PASP ≥ 60assoziiert mit Alter, PVH (LAvol; E/E’)

• Systolische Herzinsuffizienz (EF<40%; n=1462)

55% PASP ≥ 40; 16% PASP ≥ 60assoziiert mit PVH (LAvol; E/E’) und MI, nicht mit EF

• Diastolische Herzinsuffizienz (EF>50%, n=240)

68% PASP ≥ 40; 20% PASP ≥ 60assoziiert mit PVH (LAvol; E/E’)

Maggie Redfield, JACC 2009; 53: 1119-1126

HFpEF: PASP > 35 mmHg present in 83% (median PASP 48 mmHg)

PVH does not fully account for the severity of PH in HFpEF

Rechtsherzkatheter-Untersuchung

PCWP PAP

Diastolische Herzinsuffizienz und PH

M Redfield, Mayo Clinic, 2008

KLINISCH:

• Alter > 65 Jahre

• Adipositas

• Arterielle Hypertonie

• KHK

• Diabetes mellitus

• Vorhofflimmern

ECHOKARDIOGRAPHIE:

• Erhöhter SBP

• LA-Vergrößerung

• LV-Hypertrophie

• Erhöhte Füllungsdrucke

Diastolische Dysfunktion II-III°

FOLLOW-UP:

• Verbesserung durch Diuretika

• Starker SBP-Anstieg bei Belastung

• Rö-Thorax: Zeichen für CHF

KLINISCH:

• Alter < 45 Jahre

• Niedriger SBP

• Keine kardiovaskulären Erkrankungen

– Hypertension

– KHK

– Diabetes mellitus

– Vorhofflimmern

ECHOKARDIOGRAPHIE:

• Kein erhöhter SBP

• Keine LA-Vergrößerung

• Keine LV-Hypertrophie

• Niedrige Füllungsdrucke

Diastolische Dysfunktion ≤ I°

FOLLOW-UP:

• Keine Verbesserung durch Diuretika

• Normaler SBP-Anstieg unter Belastung

• Rö-Thorax: Keine Zeichen für CHF

DHF wahrscheinlich DHF unwahrscheinlich

Ist die Entstehung einer PH bei

Herzinsuffizienz nur passiv bedingt?


Bei Linksherzinsuffizienz ist die Entstehung einer PH in vielen Fällen durch die Erhöhung des PCWP bedingt……..

Ist die Entstehung einer PH bei

Herzinsuffizienz nur passiv bedingt?


Bei Linksherzinsuffizienz ist die Entstehung einer PH in vielen Fällen durch die Erhöhung des PCWP bedingt……..

….aber nicht in allen Fällen

PH bei Linksherzinsuffizienz:Interaktionen linkes Herz – Lungenstrombahn – rechtes Herz

POSTKAPILLÄRE PH

LVEDP

LAP

PCP

PAP


LVEDP

LAP

PCP

PAP Vasokonstriktion

Remodeling

POSTKAPILLÄRE PH


PRÄKAPILLÄRE

KOMPONENTE

LVEDP

LAP

PCP


Remodeling

POSTKAPILLÄRE PH


PRÄKAPILLÄRE

KOMPONENTE

LVEDP

LAP

PCP


Remodeling

POSTKAPILLÄRE PH

RECHTSHERZINSUFFIZIENZ VERMINDERTE FÜLLUNG LINKS

Zeit (Monate bis Jahre)

CHF

Kra

nk

he

its

pro

gre

ss

ion

PH bei Linksherzinsuffizienz:

Bedeutung der RV-Funktion?


CHF

Kra

nk

he

its

pro

gre

ss

ion

PAP

PVR?




CHF

Rechtsherz-

insuffizienz

Kra

nk

he

its

pro

gre

ss

ion

PAP

PVR?






CHF

Rechtsherz-

insuffizienz

Kra

nk

he

its

pro

gre

ss

ion

Jugularvenenstauung

Periphere Ödeme

Hepatomegalie

Ascites

Hypoxie

PAP

PVR?

Cappola TP et al, Circulation 2002; 105:1663-1668

Pulmonale Hämodynamik und Prognose

• 1134 Pat. mit neu diagnostizierter Kardiomyopathie• PAPmean 25±11, PCWP 17±9, PVR 2,2±1,6

• Follow-up 4,4 Jahre

PH ist bei SHF und DHF mit erhöhter Sterblichkeit assoziiert

Diagnostik und Behandlung der PH bei HF erscheint wichtig

Therapie der pulmonal arteriellen Hypertonie:

Problematik der Datenlage

Prostanoide ERA PDE5i

Primärer Studienendpunkt: 6-min-Gehstrecke

Kurze Beobachtungsdauer (12-16 Wochen)

BREATHE 1-Studie(Rubin et al., NEJM 2002)

SUPER 1-Studie(Galiè et al., NEJM 2005)

AIR-Studie(Olschewski et al., NEJM 2002)

E/E‘ lat = 16,8

Echokardiographie:

Diastolische LV-Dysfunktion


Pathophysiology


Cologne Consensus Conference 2010

Rosenkranz et al., DMW 2010;135(Suppl3): S102-S114

Pulmonary Hypertension in Left Heart...

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