1975年第一次世界卫生组织(WHO)肺动脉高压会议将肺动脉高压分为“原发性”和“继发性”两类,1998年根据病理学和血流动力学特点分为5大类,到2003年肺动脉高压现代5分类框架基本确立并维持至今。2015年欧洲心脏学会(ESC)与欧洲呼吸学会(ERS)以WHO的分类为基础,考虑病因或发病机制、病理与病理生理学特点,对肺动脉高压分类进行了更新(表2-11-1),具有指导制订治疗方案的作用,获得国内外学者认可。
表2-11-1 2015年ESC与ERS修订的肺动脉高压分类
1.动脉性肺动脉高压(pulmonary arterial hypertension,PAH) 1.1 特发性(idiopathic) 1.2 遗传性(heritable) 1.2.1 BMPR2基因突变(BMPR2 mutation) 1.2.2 其他突变(other mutations) 1.3 药物所致和毒物所致肺动脉高压(drug-and toxin-induced) 1.4 疾病相关肺动脉高压(associated with) 1.4.1 结缔组织疾病(connective tissue diseases) 1.4.2 HIV感染(human immunodeficiency virus infection) 1.4.3 门静脉脉高压(portal hypertension) 1.4.4 先天性心脏病(congenital heart diseases) 1.4.5 血吸虫病(schistosomiasis) 1'.肺静脉闭塞病和(或)肺毛细血管瘤样增生症[pulmonary veno-occlusive disease(PVOD) and/or pulmonary capillary hemangiomatosis(PCH)] l'.l特发性(idiopathic) 1'.2遗传性(heritable) 1'.2.1 EIF2AK4基因突变(EIF2AK4 mutation) 1'.2.2 其他基因突变(other mutations) 1'.3 药物、毒物和放射线所致(drugs,toxins and radiation induced) 1'.4 疾病相关(associated with) 1'.4.1 结缔组织疾病(connective tissue diseases) 1'.4.2 HIV感染(human immunodeficiency virus infection) 1". 新生儿持续性肺动脉高压(persistent pulmonary hypertension of the newborn) 2.左心疾病所致肺动脉高压(pulmonary hypertension due to lef theart disease) 2.1 左心室收缩性功能不全(lef tventricular systolic dysfunction) 2.2 左心室舒张性功能不全(lef tventricular diastolic dysfunction) 2.3 心脏瓣膜病(valvular disease) 2.4 先天性/获得性左心流入道/流出道梗阻和先天性心肌病(congenital/acquired left heart inflow/outflow tract obstruction and congenital cardiomyopathies) 2.5 先天性/获得性肺静脉狭窄(congenital/acquired pulmonary veins stenosis) 3. 肺部疾病和(或)低氧所致肺动脉高压(pulmonary hypertension due to lung diseases and/or hypoxia) 3.1 慢性阻塞性肺疾病(chronic obstructive pulmonary disease) 3.2 间质性肺疾病(interstitial lung disease) 3.3 其他限制性与阻塞性通气功能障碍并存的肺部疾病(other pulmonary diseases with mixed restrictive and obstructive pattern) 3.4 睡眠呼吸障碍(sleep-disordered breathing) 3.5 肺泡低通气(alveolar hypoventilation disorders) 3.6 长期居住高原环境(chronic exposure to high altitude) 3.7 肺发育异常(developmental lung diseases) 4. 慢性血栓栓塞性肺动脉高压和其他肺动脉阻塞性疾病(chronic thromboembolic pulmonary hypertension and other pulmonary artery obstructions) 4.1 慢性血栓栓塞性肺动脉高压(chronic thromboembolic pulmonary hypertension,CTEPH) 4.2其他肺动脉梗阻性疾病(other pulmonary artery obstructions) 4.2.1 血管肉瘤(angiosarcoma) 4.2.2 其他血管内肿瘤(other intravascular tumors) 4.2.3 动脉炎(arteritis) 4.2.4 先天性肺动脉狭窄(congenital pulmonary arteries stenosis) 4.2.5 寄生虫病(包虫病/棘球蚴病)[parasites(hydatidosis)] 5. 未明和(或)多因素所致肺动脉高压(pulmonary hypertension with unclear and/or multifactoriai mechanisms) 5.1 血液系统疾病:慢性溶血性贫血、骨髓增生异常综合征、脾切除(haematological disorders:chronic haemolytic anaemia,myeloproliferative disorders,splenectomy) 5.2 系统性疾病:结节病、肺组织细胞增多症、淋巴管平滑肌瘤病(systemic disorders,sarcoidosis,pulmonary histiocytosis,lymphangioleiomyomatosis) 5.3 代谢性疾病:糖原贮积症、戈谢病、甲状腺疾病(metabolic disorders:glycogen storage disease,Gaucher disease,thyroid disorders) 5.4 其他:肺肿瘤血栓性微血管病、纤维素性纵隔炎、慢性肾功能不全(接受或未接受透析治疗)、节段性肺动脉高压[others:pulmonary tumoral thrombotic microangiopathy,fibrosing mediastinitis,chronic renal failure(with/without dialysis),segmental pulmonary hypertension] |
动脉性肺动脉高压、肺部疾病或低氧所致肺动脉高压、CTEPH及未明多因素机制所致肺动脉高压都属于毛细血管前性肺动脉高压,血流动力学特征为mPAP≥25mmHg,肺毛细血管楔压(pulmonary capillary wedge pressure,PCWP)或左心室舒张末压<15mmHg。左心疾病所致肺动脉高压属于毛细血管后性肺动脉高压,血流动力学特征为mPAP≥25mmHg,PCWP或左心室舒张末压>15mmHg。肺动脉高压的严重程度应根据症状、6分钟步行距离、脑钠肽前体水平、心脏彩超、血流动力学等进行综合分析,可根据静息状态下mPAP水平分为“轻”(26~35mmHg)、“中”(36~45mmHg)、“重”(>45mmHg)三度。