慢性阻塞性肺疾病合并肺动脉高压： 表型分型、无创诊断与精准干预新进展

Chronic Obstructive Pulmonary Disease Complicated with Pulmonary Hypertension: New Advances in Phenotyping, Noninvasive Diagnosis and Precise Intervention

摘要: 慢性阻塞性肺疾病(COPD)合并肺动脉高压(PH)是临床上最常见的肺高血压亚型之一。这类患者的肺血管会逐渐重构，右心负担加重，最终心功能失代偿，导致急性加重次数增多、住院更频繁、死亡风险也更高。近五年来，COPD合并肺动脉高压(COPD-PH)的研究重点逐步集中于四个方面：表型精准分型、无创多模态诊断、新型生物标志物联合预测、靶向分层干预。本文从临床实际出发，总结了血管优势型、肺实质优势型及混合型三种表型在病理、影像、预后及治疗上的区别；梳理了心脏彩超、胸部CT定量、动脉血气及肺功能这些无创检查的价值；归纳了心功能、炎症、凝血及营养相关标志物的预测能力；深入解析缺氧–炎症–凝血轴分子交互机制；系统梳理各类肺血管靶向药物临床试验结局与失败机制；最后围绕危险因素控制、基础治疗、肺血管靶向药物及右心保护，提出了个体化的干预建议，希望能帮助临床医生更早识别COPD-PH、做好危险分层并规范化治疗。

Abstract: Chronic obstructive pulmonary disease (COPD) complicated with pulmonary hypertension (PH) is the most common Group 3 pulmonary hypertension. It is characterized by progressive pulmonary vascular remodeling and increased right heart load,which significantly exacerbates acute exacerbations, hospitalizations,and mortality. In recent years, studies on COPD-PH have focused on phenotype stratification, noninvasive multimodal diagnosis, biomarker combination prediction, and precise targeted intervention. This review summarizes the three major phenotypes, compares noninvasive diagnostic methods, and describes related biomarkers. We further elucidate the molecular mechanisms of hypoxia-inflammation-coagulation network interactions and systematically analyze clinical trials and failure causes of pulmonary vascular targeted drugs. Finally, we propose a stratified treatment strategy to provide evidence for early identification, risk stratification, and standardized management of COPD-PH.