Consenso ecuatoriano de hipertensión pulmonar
DOI:
https://doi.org/10.47464/MetroCiencia/vol33/2/2025/73-116Palabras clave:
hipertensión pulmonar, hipertensión arterial pulmonar, consenso, cardiologíaResumen
Este documento de consenso, desarrollado por la Sociedad Ecuatoriana de Cardiología, establece un marco integral para el diagnóstico y tratamiento de la hipertensión pulmonar (HP). La HP se define hemodinámicamente por una presión arterial pulmonar media (PAPm) superior a 20 mmHg, medida mediante cateterismo cardíaco derecho (CCD). Es fundamental diferenciar el compromiso pre y poscapilar utilizando parámetros como la presión en cuña pulmonar (PCP) y la resistencia vascular pulmonar (RVP). Una PCP > 15 mmHg indica un origen en las cavidades izquierdas del corazón (poscapilar), mientras que una RVP > 2 UW sugiere una enfermedad vascular pulmonar (precapilar). La clasificación de la HP, basada en los criterios de la OMS, es crucial para un tratamiento adecuado y se divide en cinco grupos principales:
Grupo 1: Hipertensión arterial pulmonar (HAP), que incluye formas idiopáticas y hereditarias.
Grupo 2: HP asociada a enfermedad cardíaca izquierda, la causa más común.
Grupo 3: HP debida a enfermedades pulmonares crónicas y/o hipoxia, como la EPOC.
Grupo 4: HP tromboembólica crónica (HPTEC), causada por obstrucciones arteriales.
Grupo 5: HP con mecanismos poco claros o multifactoriales.
El diagnóstico sigue un algoritmo escalonado que comienza con la historia clínica y el examen físico ante síntomas como la disnea de esfuerzo. Los pasos iniciales incluyen estudios no invasivos como electrocardiograma, radiografía de tórax y análisis de sangre (incluyendo BNP/NT-proBNP). La ecocardiografía es la herramienta no invasiva clave para evaluar la probabilidad de HP. Pruebas adicionales como la tomografía computarizada (TC) y la gammagrafía de ventilación/perfusión (V/Q) ayudan a identificar causas subyacentes, como la HPTEC. Sin embargo, el diagnóstico definitivo y la caracterización hemodinámica requieren un cateterismo cardíaco derecho, considerado el estándar de oro. El manejo de la HP comienza con medidas generales, incluyendo actividad física supervisada y rehabilitación cardiopulmonar para pacientes estables. El tratamiento de soporte puede incluir diuréticos para la sobrecarga de volumen, oxigenoterapia para la hipoxemia y vacunación. El embarazo está asociado con un alto riesgo de mortalidad y generalmente se desaconseja en pacientes con HAP de riesgo intermedio o alto. El tratamiento farmacológico depende del grupo de HP. Para el Grupo 1 (HAP), la terapia se dirige a tres vías moleculares: la de la endotelina (antagonistas de receptores de endotelina como ambrisentán, macitentán), la del óxido nítrico (inhibidores de la PDE-5 como sildenafilo, o estimuladores de la guanilato ciclasa como riociguat) y la de la prostaciclina (análogos como epoprostenol, o agonistas como selexipag). La estratificación del riesgo es fundamental para guiar la terapia, y la combinación de fármacos desde el inicio es la estrategia recomendada para pacientes de riesgo intermedio o alto. Para los otros grupos, el tratamiento se centra en la causa subyacente. En el Grupo 2, se debe optimizar el manejo de la cardiopatía izquierda, ya que las terapias específicas para la HAP han demostrado ser perjudiciales. En el Grupo 3, el enfoque es tratar la enfermedad pulmonar de base y corregir la hipoxemia. Para el Grupo 4, el tratamiento de elección es la endarterectomía pulmonar (EAP) para trombos accesibles quirúrgicamente, mientras que el riociguat está indicado para pacientes no operables. La anticoagulación crónica es fundamental en este grupo.
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Derechos de autor 2025 María Elisa Acosta De la Vega, María Alejandra Alvarado Cuadros, Carlos Alomía Arévalo, Joffre Arequipa Herrera, María Daniela Carpio Toro, Enrique Carrera Estupiñán, Alex Fernando Castro Mejía, Jeanneth Alexandra Cedeño Quincha, César Chávez Rodriguez, María Gabriela Cobo Jaramillo, Patricia Cortez Flores, Nohelia Estrada Meza, César Delgado Viteri, Lucía Gordillo Tobar, Alejandra García, Edison Fernando Gualpa Álvarez, Luis Guerrero, Rodrigo Hoyos Paladines, Valeria López Izquierdo, Grace Loza Erazo, Bosco Fabián Mendoza Cedeño, Geovanny Mera Bravo, Claudia Liliana Moreno Díaz, Mariana Eugenia Morocho Minchala, Andrés Navarro Lecaro, Guillermo Estuardo Novoa Uquillas, Tanya Padilla Molina, Edwin Iván Páez Mendoza, César Augusto Prócel Ramírez, Daniel Polo Morales, Long Freddy Pow Chon, Wendy Tatiana Quintana Hermosa, David Alejandro Puga Bermudez, Liliana Carolina Rodríguez Chisaguano, Javier Arístides Rodríguez Herrera, A, A, Mario Rubio Neira, Tony Sacan Morán, Diana Isabel Salazar Chamba, Sussety Salazar Álvarez, Vladimir Ernesto Ullauri Solórzano, Álvaro Daniel Villacres López, Vanessa Viteri Terán, María Teresa Zúñiga Infantas
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