左心疾病相关肺高血压课件.ppt

1、左心疾病相关性肺高血压左心疾病相关性肺高血压Pulmonary hypertension due to left heart disease 吉林大学白求恩第一医院吉林大学白求恩第一医院 张尉华张尉华2019.06.13武汉左心疾病相关肺高血压p左心收缩功能不全p左心舒张功能不全p瓣膜疾病p先天性/获得性左心室流入道/流出道梗阻和先天性心肌病pLHD是PH的常见病因之一，占全部PH的首位，约半数被超声筛查出的PH为LHD相关PH。pPH也是LHD常见而又重要的合并症之一。pPH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。流 行 病 学p心力衰竭p左心收缩功能不全（缺血性心

2、肌病、扩张型心肌病等）p左心舒张功能不全（高血压病、缩窄性心包炎、限制性心肌病等）p瓣膜病变p二尖瓣狭窄和关闭不全p主动脉瓣狭窄和关闭不全p先天性/获得性左心室流入道/流出道狭窄 病 因p毛细血管后PHp以不同程度的肺淤血和肺水肿为主要特点p肺毛细血管楔压增高(PCWP15 mm Hg)p“被动性PH”“不匹配的PH”p具有一定的可逆性与波动性p具体机制尚完全不清楚病理生理及可能机制不匹配的PH:根据跨肺压（TPG）判定;提示肺高血压的压力不仅来自于肺静脉，也来自肺动脉本身。ESC/ERS G U ID ELIN ESG ui del i nes f or the di agnosi s an

3、d treatm entofpul m onary hypertensi onT he T ask Force f or the D i agnosi s and T reatm ent ofPul m onaryH ypertensi on ofthe European Soci ety ofC ardi ol ogy(ESC)andthe European Respi ratory Soci ety(ERS),endorsed by theInternati onalSoci ety ofH eart and Lung T ranspl antati on(ISH LT)A uthors/

4、T ask Force M em bers:N azzareno G al i e (C hairperson)(Ital y)*;M ari us M.H oeper(G erm any);M arc H um bert(France);A damT orbi cki(Pol and);Jean-Luc V achi ery(France);Joan A l bert B arbera(Spai n);M auri ce Beghetti(Sw i tzerl and);PaulC orri s(U K);Sean G ai ne(Irel and);J.Si m on G i bbs(U

5、K);M i guelA ngelG om ez-Sanchez(Spai n);G ui ll aum e Jondeau(France);W al ter K l epetko(A ustri a)C hri sti an O pi tz(G erm any);A ndrew Peacock(U K);Lew i s Rubi n(U SA);M i chaelZel l w eger(Sw i tzerl and);G eral d Si m onneau(France)ESC C om m i ttee f or Practi ce G ui deli nes(C PG):A l ec

6、 V ahani an(C hairperson)(France);A ngel o A uri cchio(Sw i tzerl and);Jeroen B ax(T he N etherlands);C l audio C econi(Ital y);V eroni ca D ean(France);G erasi m osFi l i ppatos(G reece);C hri sti an Funck-Brentano(France);Ri chard H obbs(U K);Peter K earney(Irel and);T heresa M cD onagh(U K);K ei

7、th M cG regor(France);Bogdan A.Popescu(Rom ani a);Zel j ko Rei ner(C roati a);U do Sechtem(G erm any);Per A nton Si rnes(N orw ay);M i chalTendera(Pol and);Panos V ardas(G reece);Petr W i di m sky(C zech Republ i c)D ocum ent Revi ew ers:U do Sechtem(C PG Revi ew C oordi nator)(G erm any);N aw w ar

8、A lA ttar(France);Fel i ci ta A ndreotti(Ital y);M i chaelA scherm ann(C zech Republ i c);Ri ccardo A steggi ano(Ital y);Ray B enza(U SA);Rol fB erger(T he N etherl ands);D am i en Bonnet(France);M ari on D el croi x(Bel gi um);Luke H ow ard(U K);A nastasi a N K i tsi ou(G reece);Irene Lang(A ustri

9、a);A l do M aggioni(Ital y);Jens Eri k N i el sen-K udsk(D enm ark);M yung Park(U SA);Pasqual e Perrone-Fi l ardi(Ital y);Suzanna Pri ce(U K);M ari a Teresa Subi rana D om enech(Spai n);A nton V onk-N oordegraaf(T he N etherl ands);Jose Lui s Zam orano(Spai n)T he di scl osure f orm s ofal lthe auth

10、ors and revi ew ers are avai l abl e on the ESC w ebsi te w w w.escardi o.org/gui del i nesIM PO RT A N T N O T E:Si nce the ori gi nalpubl i cati on ofthese G ui del i nes,the drug si taxentan has been w i thdraw n f rom the m arketdue to l i ver toxi ci ty.Si taxentan w asw i thdraw n i n D ecem b

11、er 2010(f or f urther i nf orm ati on pl ease see EurH eartJ2011;32:386 387and on the ESC w ebsi te http:/w w w.escardi o.org/gui del i nes-surveys/esc-gui del i nes/Pages/pul m onary-arteri al-hypertensi on.aspx).T he i nstances w here si taxentan appears i n thi s docum ent have been hi ghl i ghte

12、d i n yel l ow.T abl e ofC ontentsAbbrevi ati ons and acronym s.2494Pream bl e.24951.I ntroducti on.24962.D efini ti ons.24973.Cl i ni calcl assi ficati on ofpul m onary hypertensi on.24984.Pathol ogy ofpul m onary hypertensi on.24995.Pathobi ol ogy ofpul m onary hypertensi on.24996.G eneti cs,epi d

13、em i ol ogy,and ri sk f actors ofpul m onaryhypertensi on.25007.Pul m onary arteri alhypertensi on(group 1).25017.1 D i agnosi s.25027.1.1 Cl i ni calpresentati on.25027.1.2 El ectrocardi ogram.25027.1.3 Chestradi ograph.2502*Correspondi ng author.I nsti tute of Cardi ol ogy,Bol ogna Uni versi t y H

14、 ospi t al,Vi a M assarenti,9,40138 Bol ogna,I tal y.Tel:39 051 349 858,Fax:39 051 344 859,Em ai l:nazzareno.gal i e uni bo.i tThe contentofthese European Soci etyofCardi ol ogy(ESC)G ui del i nes hasbeen publ i shed f orpersonaland educati onaluse onl y.N o com m erci aluse i sauthori zed.N o parto

15、ftheESC G ui del i nesm aybe transl ated orreproduced i n any f orm w i thoutw ri tten perm i ssi on f rom the ESC.Perm i ssi on can be obtai ned upon subm i ssi on ofaw ri tten requestto O xf ordU ni versi ty Press,the publ i sher ofthe European HeartJ ournaland the party authori zed to handl e suc

16、h perm i ssi ons on behal fofthe ESC.D i scl ai m er.The ESC G ui del i nes representthe vi ew s ofthe ESC and w ere arri ved ataf ter caref ulconsi derati on ofthe avai l abl e evi dence atthe ti m e they w ere w ri tten.H eal thprof essi onal s are encouraged to take them f ul l y i nto accountw h

17、en exerci si ng thei rcl i ni calj udgem ent.The gui del i nesdo not,how ever,overri de the i ndi vi dualresponsi bi l i ty ofheal thprof essi onal s to m ake appropri ate deci si ons i n the ci rcum stances ofthe i ndi vi dualpati ents,i n consul tati on w i th thatpati ent,and w here appropri ate

18、and necessary the pati entsguardi an or carer.I ti s al so the heal th prof essi onal s responsi bi l i ty to veri f y the rul es and regul ati ons appl i cabl e to drugsand devi ces atthe ti m e ofprescri pti on.&The European Soci ety ofCardi ol ogy 2009.Al lri ghts reserved.For perm i ssi ons pl e

19、ase em ai l:j ournal s.perm i ssions oxf ordj ournal s.org.European H eartJ ournal(2009)30,2493 2537doi:10.1093/eurheartj/ehp297“被动性PH”“不匹配的PH”血流动力学特征为肺毛细血管楔压增高(15 mm Hg)和肺血管阻力逐渐增强,后期可有跨肺压升高。不同病因导致PH的发病率72-79左心衰患者存有不同程度的PH这些患者大多为左心室收缩功能不全（EF下降），其余为左心室充盈受损和(或)舒张功能障碍（EF保留）。不同病因导致PH的发病率二尖瓣病变PH的常见原因62二尖瓣狭窄患者sPAP50 mm Hg，33患者sPAP为50-79 mmHg，6患者sPAP80 mm Hg。不同病因导致PH的发病率在主动脉瓣狭窄和(或)关闭不全情况下，PH发生率并不如二尖瓣疾病常见，发生率达429，主要由于左心室舒张未期压增高和严重舒张功能不全。右心导管检查是诊断PH的唯一标准mPAP25mmHg；mPAWP15mmHg评估TPG，RAP，PVR，CO诊断舒张性心衰的金标准快速补液试验和运动试验适应证：怀疑LHD相关PH，PCWP12mmHg）患者谢谢！