Naeije Robert, Gerges Mario, Vachiery Jean-Luc, Caravita Sergio, Gerges Christian, Lang Irene M
From the Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium (R.N., J.-L.V., S.C.); Department of Internal Medicine II, Division of Cardiology, General Hospital of Vienna (AKH-Wien), Medical University of Vienna, Austria (M.G., C.G., I.M.L.); and Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale S. Luca IRCCS Istituto Auxologico Italiano, Milan, Italy (S.C.).
Circ Heart Fail. 2017 Sep;10(9). doi: 10.1161/CIRCHEARTFAILURE.117.004082.
Increased pulmonary venous pressure secondary to left heart disease is the most common cause of pulmonary hypertension (PH). The diagnosis of PH due to left heart disease relies on a clinical probability assessment followed by the invasive measurements of a mean pulmonary artery pressure (PAP) ≥25 mm Hg and mean wedged PAP (PAWP) >15 mm Hg. A combination of mean PAP and mean PAWP defines postcapillary PH. Postcapillary PH is generally associated with a diastolic pulmonary pressure gradient (diastolic PAP minus mean PAWP) <7 mm Hg, a transpulmonary pressure gradient (mean PAP minus mean PAWP) <12 mm Hg, and pulmonary vascular resistance ≤3 Wood units (WU). This combination of criteria defines isolated postcapillary PH. Postcapillary PH with elevated vascular gradients and pulmonary vascular resistance defines combined post- and precapillary PH (Cpc-PH). Postcapillary PH is associated with a decreased survival in proportion to increased pulmonary vascular gradients, decreased pulmonary arterial compliance, and reduced right ventricular function. The Cpc-PH subcategory occurs in 12% to 13% of patients with PH due to left heart disease. Patients with Cpc-PH have severe PH, with higher diastolic pulmonary pressure gradient, transpulmonary pressure gradient, and pulmonary vascular resistance and more pronounced ventilatory responses to exercise, lower pulmonary arterial compliance, depressed right ventricular ejection fraction, and shorter life expectancy than isolated postcapillary PH. Cpc-PH bears similarities to pulmonary arterial hypertension. Whether Cpc-PH is amenable to therapies targeting the pulmonary circulation remains to be tested by properly designed randomized controlled trials.
继发于左心疾病的肺静脉压力升高是肺动脉高压（PH）最常见的原因。左心疾病所致PH的诊断依赖于临床概率评估，随后进行有创测量，即平均肺动脉压（PAP）≥25 mmHg且平均楔压肺动脉压（PAWP）>15 mmHg。平均PAP和平均PAWP的组合可定义为毛细血管后PH。毛细血管后PH通常与舒张期肺压力梯度（舒张期PAP减去平均PAWP）<7 mmHg、跨肺压力梯度（平均PAP减去平均PAWP）<12 mmHg以及肺血管阻力≤3伍德单位（WU）相关。这些标准的组合可定义为孤立性毛细血管后PH。血管梯度和肺血管阻力升高的毛细血管后PH定义为毛细血管后和毛细血管前联合性PH（Cpc-PH）。毛细血管后PH与生存率降低相关，其程度与肺血管梯度增加、肺动脉顺应性降低及右心室功能减退成正比。Cpc-PH亚类在左心疾病所致PH患者中占12%至13%。与孤立性毛细血管后PH相比，Cpc-PH患者患有严重的PH，具有更高的舒张期肺压力梯度、跨肺压力梯度和肺血管阻力，对运动有更明显的通气反应，肺动脉顺应性更低，右心室射血分数降低，预期寿命更短。Cpc-PH与肺动脉高压有相似之处。Cpc-PH是否适合采用针对肺循环的治疗方法仍有待通过设计合理的随机对照试验来验证。
