Klinische Klassifikation der pulmonalen Hypertonie und initiale Diagnostik: Empfehlungen der Kölner Konsensus Konferenz 2016

Abstract

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed information about the clinical classification and diagnosis of pulmonary hypertension, and furthermore provide novel recommendations for risk stratification and follow-up assessments. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the clinical classification and initial diagnosis of PH. This article summarizes the results and recommendations of this working group.

Reference Ranges and Determinants of Tricuspid Regurgitation Velocity in Healthy Adults Assessed by Two-Dimensional Doppler-Echocardiography

“…Recent data has shown that the normal PAPm at rest is 14 + 3 mm Hg with an upper limit of normal of approximately 20 mm Hg [2]. In the new joined guidelines of the European societies for respiratory medicine and cardiology for the diagnosis and treatment of PH, transthoracic color-Doppler-echocardiography (TTE) plays a central role in diagnostic work-up [1,3,4]. It should be used to visualize the effects of PH on the heart and to estimate systolic pulmonary artery pressures through continuous wave Doppler measurements.…”

“…In this regard, TRV is a well-established and most widely used TTE parameter for noninvasive determination of pulmonary pressure [7]. However, the cut-off values proposed in the current ESC/ERS guidelines for establishing the probability of PH are more or less arbitrary and have not yet been scientifically evaluated or validated for PH [3,4,8]. Retrospective data from a large cohort of patients with high pre-test probability suggests that in experienced hands determining the systolic pulmonary artery pressure using the TRV and estimated right atrial pressure (RAP) correlated well with the invasively measured values (r = 0.87) and, when the suggested limit (36 mm Hg) was used, it has a specificity of 79% and a sensitivity of 87% to detect PH [9].…”

Pulmonale Hypertonie: Differenzialdiagnostik und therapeutische Konsequenzen

“…Die Diagnostik sollte primär in spezialisierten Expertenzentren durchgeführt werden. In Anlehnung an die ESC/ ERS-Leitlinien empfehlen die Deutschen Fachgesellschaften (DGK, DGP, DGPK) im Rahmen der "Kölner Konsensus-Konferenz" ein strukturiertes Vorgehen [10,11] (▶ Abb. 2).…”

“…Hierbei ist insbesondere die Unterscheidung zwischen prä-und postkapillärer pulmonaler Hypertonie wichtig. Die Kölner Konsensus-Konferenz weist in diesem Zusammenhang auch auf die Bedeutung der Spiroergometrie sowohl in der Früherkennung als auch in der Differenzialdiagnostik der PH hin, da hiermit unter Belastung bereits frühzeitig Zeichen einer pulmonalen Vaskulopathie zu detektieren sind [10,11]. Für Patienten mit neu aufgetretener Symptomatik und Verdacht auf eine relevante pulmonale Hypertonie sollte für die initiale Diagnosestellung ein "Fast-Track-Referral" angeboten werden [12], um eine zügige Therapieeinleitung gewährleisten zu können.…”

“…In der Regel besteht eine präkapilläre pulmonale Hypertonie (PAPm ≥ 25 mmHg, PAWP ≤ 15 mmHg, PVR > 3 WE). Da stattgehabte Lungenembolien bei Patienten mit diagnostizierter CTEPH häufig anamnestisch nicht bekannt sind, müssen Perfusionsdefekte im Rahmen der PH-Diagnostik konsequent diagnostiziert oder ausgeschlossen werden [5,10,11,12]. Hierzu dient die Ventilations-Perfusions-Szintigrafie der Lunge.…”