Pulmonary heart disease is a pathology of the right parts of the heart, characterized by an increase (hypertrophy) and dilation (dilation) of the right atrium and ventricle, as well as circulatory insufficiency, developing due to hypertension of the small circulatory circle. The formation disease is facilitated by pathological processes of the bronchopulmonary system, lung vessels, and chest. Clinical manifestations of acute pulmonary heart disease include dyspnea, chest pains, skin cyanosis and tachycardia, psychomotor agitation, hepatomegaly. The examination reveals an increase in the boundaries of the heart to the right, the rhythm of the gallop, pathological pulsation, signs of overload of the right parts of the heart on the ECG. Additionally, chest X-ray, ultrasound of the heart, FRS examination, analysis of the gas composition of the blood are carried out.
The acute form of the pulmonary heart disease develops quickly, in a few minutes, hours or days; chronic – for several months or years. Almost 3% of patients with chronic bronchopulmonary diseases gradually develop a pulmonary heart disease. Pathology significantly aggravates the course of cardiopathology, ranking 4th among the causes of mortality in cardiovascular diseases.
Causes of pulmonary heart disease
The bronchopulmonary form of the pulmonary heart develops with primary lesions of the bronchi and lungs as a result of chronic obstructive bronchitis, bronchial asthma, bronchiolitis, pulmonary emphysema, diffuse pneumosclerosis of various genesis, polycystic lung disease, bronchiectasis, tuberculosis, sarcoidosis, pneumoconiosis, Hammen -Rich syndrome, etc. About 70 bronchopulmonary diseases can cause this form, contributing to the formation of a pulmonary heart in 80% of cases.
The appearance of the thoracodiaphragmatic form of the pulmonary heart is facilitated by primary lesions of the chest, diaphragm, restriction of their mobility, significantly disrupting ventilation and hemodynamics in the lungs. These include diseases that deform the chest (kyphoscoliosis, Bekhterev’s disease, etc.), neuromuscular diseases (polio), pathology of the pleura, diaphragm (after thoracoplasty, pneumosclerosis, paresis of the diaphragm, Pickwick syndrome in obesity, etc.).
The vascular form of the pulmonary heart develops with primary lesions of the pulmonary vessels: primary pulmonary hypertension, pulmonary vasculitis, thromboembolism of the branches of the pulmonary artery (PE), compression of the pulmonary trunk by an aortic aneurysm, atherosclerosis of the pulmonary artery, mediastinal tumors.
The main causes of acute pulmonary heart disease are massive pulmonary embolism, severe asthma attacks, valvular pneumothorax, acute pneumonia. The pulmonary heart of the subacute course develops with repeated PE, cancerous lymphangoitis of the lungs, in cases of chronic hypoventilation associated with polio, botulism, myasthenia gravis.
The mechanism of development
Arterial pulmonary hypertension is of leading importance in the development of the pulmonary heart. At the initial stage, it is also associated with a reflex increase in cardiac output in response to increased respiratory function and tissue hypoxia resulting from respiratory insufficiency. With the vascular form of the pulmonary heart, the resistance to blood flow in the arteries of the small circulatory circle increases mainly due to the organic narrowing of the lumen of the pulmonary vessels when they are blocked by emboli (in the case of thromboembolism), with inflammatory or tumor infiltration of the walls, their lumen overgrowth (in the case of systemic vasculitis). In bronchopulmonary and thoracodiaphragmatic forms of the pulmonary heart, the narrowing of the lumen of the pulmonary vessels occurs due to their microthrombosis, overgrowth of connective tissue or compression in areas of inflammation, tumor process or sclerosis, as well as with a weakening of the ability of the lungs to stretch and collapse of vessels in altered lung segments. But in most cases, the leading role is played by the functional mechanisms of the development of pulmonary arterial hypertension, which are associated with impaired respiratory function, lung ventilation and hypoxia.
Arterial hypertension of the small circulatory circle leads to overload of the right parts of the heart. As the disease develops, there is a shift in the acid-base balance, which may initially be compensated, but later decompensation of disorders may occur. With a pulmonary heart, there is an increase in the size of the right ventricle and hypertrophy of the muscular membrane of large vessels of the small circulatory circle, narrowing of their lumen with further sclerosis. Small vessels are often affected by multiple blood clots. Gradually, dystrophy and necrotic processes develop in the heart muscle.
According to the rate of increase in clinical manifestations, there are several variants of the course of the pulmonary heart: acute (develops in a few hours or days), subacute (develops over weeks and months) and chronic (occurs gradually, over a number of months or years against the background of prolonged respiratory failure).
The process of formation of a chronic pulmonary heart goes through the following stages:
- preclinical – manifested by transient pulmonary hypertension and signs of strenuous work of the right ventricle; revealed only by instrumental examination;
- compensated – characterized by hypertrophy of the right ventricle and stable pulmonary hypertension without circulatory insufficiency;
- decompensated (cardiopulmonary insufficiency) – symptoms of right ventricular insufficiency appear.
There are three etiological forms of the pulmonary heart: bronchopulmonary, thoracodiaphragmatic and vascular.
On the basis of compensation, a chronic pulmonary heart can be compensated or decompensated.
Symptoms of pulmonary heart disease
The clinical picture of the pulmonary heart is characterized by the development of the phenomena of heart failure against the background of pulmonary hypertension. The development of an acute pulmonary heart is characterized by the appearance of sudden pain behind the sternum, sharp shortness of breath; a decrease in blood pressure, up to the development of collapse, cyanosis of the skin, swelling of the cervical veins, increasing tachycardia; progressive enlargement of the liver with pain in the right hypochondrium, psychomotor agitation. Increased pathological pulsations (precardial and epigastric), expansion of the heart border to the right, gallop rhythm in the xiphoid process area, ECG – signs of overload of the right atrium are characteristic.
With massive PE, a shock state develops in a few minutes, pulmonary edema. Acute coronary insufficiency often joins, accompanied by rhythm disturbance, pain syndrome. Sudden death is observed in 30-35% of cases. Subacute pulmonary heart is manifested by sudden moderate pain, shortness of breath and tachycardia, short fainting, hemoptysis, signs of pleuropneumonia.
In the compensation phase of the chronic pulmonary heart, symptoms of the underlying disease are observed with gradual manifestations of hyperfunction, and then hypertrophy of the right parts of the heart, which are usually not clearly expressed. Some patients have pulsation in the upper abdomen caused by an increase in the right ventricle.
At the stage of decompensation, right ventricular failure develops. The main manifestation is shortness of breath, which increases with physical exertion, inhalation of cold air, in a supine position. There are pains in the heart area, cyanosis (warm and cold cyanosis), palpitations, swelling of the cervical veins, persisting on inspiration, liver enlargement, peripheral edema resistant to treatment.
When examining the heart, deafness of heart tones is detected. Blood pressure is normal or low, arterial hypertension is characteristic of congestive heart failure. The symptoms of the pulmonary heart become more pronounced with an exacerbation of the inflammatory process in the lungs. In the late stage, edema increases, liver enlargement progresses (hepatomegaly), neurological disorders appear (dizziness, headaches, apathy, drowsiness) diuresis decreases.
Diagnostic criteria of the pulmonary heart disease consider the presence of diseases – causal factors of the pulmonary heart, pulmonary hypertension, enlargement and dilation of the right ventricle, right ventricular heart failure. Such patients need to consult a pulmonologist and a cardiologist. When examining the patient, attention is paid to signs of respiratory disorders, cyanosis of the skin, pain in the heart area, etc. On the ECG, direct and indirect signs of right ventricular hypertrophy are determined.
According to lung radiography data, there is a unilateral increase in the shadow of the lung root, its increased transparency, high standing of the diaphragm dome from the side of the lesion, bulging of the trunk of the pulmonary artery, an increase in the right parts of the heart. With the help of spirometry, the type and degree of respiratory failure is determined.
Echocardiography determines hypertrophy of the right parts of the heart, pulmonary hypertension. Pulmonary angiography is performed to diagnose PE. When conducting a radioisotope method of studying the circulatory system, changes in cardiac output, blood flow velocity, circulating blood volume, and venous pressure are investigated.
Treatment for pulmonary heart disease
The main therapeutic measures for the pulmonary heart are aimed at active therapy of the underlying disease (pneumothorax, PE, bronchial asthma, etc.). Symptomatic effects include the use of bronchodilators, mucolytics, respiratory analeptics, oxygen therapy. The decompensated course of the pulmonary heart against the background of bronchial obstruction requires constant intake of glucocorticoids (prednisone, etc.).
In order to correct arterial hypertension in patients with chronic pulmonary heart, it is possible to use eufillin (intravenously, orally, rectally), nifedipine in the early stages, and nitrates (isosorbide dinitrate, nitroglycerin) under the control of blood gas composition due to the risk of increased hypoxemia.
With the phenomena of heart failure, the appointment of cardiac glycosides and diuretics is indicated with caution due to the high toxicity of the action of glycosides on the myocardium, especially in conditions of hypoxia and hypokalemia. Correction of hypokalemia is carried out with potassium preparations (asparaginate or potassium chloride). Of diuretics, preference is given to potassium-sparing drugs (triamterene, spironolactone, etc.).
In cases of severe erythrocytosis, bloodletting of 200-250 ml of blood is carried out, followed by intravenous infusion of low-viscosity solutions (rheopoliglyukin, etc.). In the therapy of patients with a pulmonary heart, it is advisable to include the use of prostaglandins powerful endogenous vasodilators, additionally possessing cytoprotective, antiproliferative, antiaggregational effects.
An important place in the therapy of the pulmonary heart is given to endothelin receptor antagonists (bosentan). Endothelin is a powerful vasoconstrictor of endothelial origin, the level of which increases with various forms of pulmonary heart. With the development of acidosis, an intravenous infusion of sodium bicarbonate solution is carried out.
With the phenomena of circulatory insufficiency of the right ventricular type, potassium-sparing diuretics (triamterene, spironolactone, etc.) are prescribed, with left ventricular insufficiency, cardiac glycosides (intravenous corglycone) are used. In order to improve the metabolism of the heart muscle with a pulmonary heart, it is recommended to prescribe meldonium inside, as well as orotate or potassium asparaginate. In the complex therapy of the pulmonary heart, respiratory gymnastics, physical therapy, massage, hyperbaric oxygenation are used.
Prognosis and prevention
In cases of decompensation of the pulmonary heart, the prognosis for working capacity, quality and life expectancy is unsatisfactory. Usually, the ability to work in patients with a pulmonary heart suffers already in the early stages of the disease, which dictates the need for rational employment and solving the issue of assigning a disability group. Early initiation of complex therapy can significantly improve the labor prognosis and increase life expectancy.
Prevention of the pulmonary heart requires prevention, timely and effective treatment of diseases leading to it. First of all, this concerns chronic bronchopulmonary processes, the need to prevent their exacerbations and the development of respiratory failure. To prevent the processes of decompensation of the pulmonary heart, it is recommended to adhere to moderate physical activity.
- Is chronic cor pulmonale an old-age disease?. Jakubowska D, Fiedorowicz J, Klepacki Z, Mroczek H, Pedich W, Stogowski A. Pol Tyg Lek. 1970 Aug 31;25(35):1321-2. link
- Cardiac problems in obstructive respiratory disease–cor pulmonale. Gray FD Jr. Mod Treat. 1969 Mar;6(2):248-60. link
- Concept, principle, and nosological significance of pulmonary heart disease. Herles F. Vnitr Lek. 1969 Jun;15(6):524-7. link
- Cor pulmonale and the cardiac lung. Ivanciuc I. Med Interna (Bucur). 1970 Jul;22(7):783-94. link