Cor pulmonale

Cor pulmonale: description

Cor pulmonale (Cor = heart, pulmonary = assigned to the lungs) refers to a heart in which the right ventricle is greatly enlarged and its task, oxygen-poor blood from the body to pump into the lungs, can not properly meet. The second part of the name indicates the cause of the cardiac enlargement – it is located in the lungs: increased flow resistance in the pulmonary arteries causes the right ventricle to work harder to pump the oxygenated blood flowing from the body into the pulmonary circulation.

In response, the muscle wall of the ventricle thickens first. If the resistance continues to increase, the chamber is enlarged by the backflow of blood and the structure of the muscle fibers is disturbed. The ventricle literally empties. It develops a so-called right heart failure and finally a cor pulmonale – a condition that is irreversible.

Acute cor pulmonale

A cor pulmonale can arise in different ways. The so-called acute cor pulmonale develops quite suddenly, it is triggered by an increase in pressure in the pulmonary circulation – for example, when a clot (thrombus) blocks part of the pulmonary circulation. The result is a sudden overload of the right heart.

Chronic cor pulmonale

A chronic cor pulmonale develops gradually. The trigger can be various lung diseases that have one thing in common: they increase the pressure in the pulmonary circulation. As a result, blood that is pumped from the right heart into the lungs partially flows back. The additional cardiac load leads to an additional load on the right ventricle. The heart muscle has to work harder to overcome the increased resistance and is increasing more and more. The tight structure of the muscle cells is disturbed, connective tissue stores.

As a result of these changes, the pumping power of the right ventricle continues to decrease, resulting in a so-called right heart failure.

Diseases that lead to the development of chronic cor pulmonale include COPD (chronic obstructive pulmonary disease), pulmonary emphysema (hyperinflation of the lung with reduced oxygen exchange), long-term inflammation of the bronchi, which are associated with constrictions, and pulmonary fibrosis (increased formation of connective tissue in the lung).

Cor pulmonale: symptoms

Since a chronic cor pulmonale develops over years, the symptoms are still low at the beginning of the disease. With increasing weakness of the right ventricle (right heart failure) but typical symptoms occur. Thus, the blood accumulates in the right atrium and the veins of the large systemic circulation. The pressure causes fluid to pass from the blood vessels into the tissue, causing water retention between the cells and in the connective tissue (edema), especially in the area of ​​the lower legs and ankles, and on the back of the foot.

Also in the organs, the blood accumulates, which in particular greatly increase the liver (hepatomegaly) and spleen (splenomegaly). At the same time the bile drainage can be disturbed, the dye retained in the liver (bilirubin) can lead to a yellowish discoloration of the skin and conjunctiva of the eye (jaundice). If tissue water collects in the free abdominal area, doctors talk about ascites or ascites.

Oxygen deficiency throughout the body

Due to the reduced pumping capacity of the right heart into the pulmonary circulation, less oxygen-rich blood also reaches the left ventricle – and thus into the body. This results in a lack of oxygen, which can eventually discolor skin and mucous membranes bluish (cyanosis). In addition, patients with a cor pulmonale suffer from shortness of breath, which initially becomes noticeable only under heavy physical stress, later even at rest. The jugular veins can become visible through the back pressure on the heart. Other symptoms include hoarseness, cough, sometimes with bloody sputum, and a feeling of pressure in the chest.

Patients with cor pulmonale are physically less resilient and faster exhausted. In the advanced stage, physical overload can lead to collapse and loss of consciousness.

Acute cor pulmonale means danger to life

In the case of an acutely occurring cor pulonale, there is a particular risk that those affected may die from a sudden cardiac death. The trigger of the acute form is usually a severe pulmonary embolism, that is, a blood clot that has migrated to the lungs obstructs a portion of the pulmonary arteries. As a result, no more blood can flow into the relevant part of the lung. The back pressure loads the right ventricle so much that it can fail.

Cor pulmonale: causes and risk factors

A chronic cor pulmonale develops as a result of an increase in pressure in the lungs or in the pulmonary arteries. It is also known as pulmonary arterial hypertension. By damaging the lung tissue and the pulmonary vessels, less oxygen-poor blood can be taken from the right heart into the lungs so that it backs up. As a result, the right ventricle, which is connected upstream of the lung, heavily loaded. It thickens its muscle wall, expands and is only reduced in clinically manifest cor pulmonale. The cause of this is usually chronic lung disease, most notably COPD.

COPD is mainly caused by smoking. The pollutants often cause recurrent irritation and inflammation of the respiratory tract. Typical is a chronic cough, which is later associated with tough expectoration and shortness of breath. In the further course of the disease, the smallest bronchi and alveoli are damaged, and the dividing walls between the alveoli are destroyed. Instead of the smallest alveoli, large blisters form, leading to over-distension of the lungs, the so-called pulmonary emphysema, which is another possible cause of the pulmonary corpus.

Also diseases with an increased formation of connective tissue in the lung, the so-called pulmonary fibrosis, can lead to cor pulmonale. As a result, the lung tissue loses elasticity, which in turn results in a complicated gas exchange. Examples of diseases that can lead to pulmonary fibrosis are sarcoidosis, tuberculosis, silicosis or asbestosis.

Also, a difficulty in breathing from the outside can lead to a cor pulmonale, such as a spinal curvature (kyphoscoliosis), in which the lungs is concentrated and the pressure in their blood vessels increases. ,

Causes of acute cor pulmonale

The acute cor pulmonale usually arises as a result of a vascular occlusion of the pulmonary artery (pulmonary embolism) and occurs quite suddenly. Responsible for this is usually a blood clot from the leg veins or the pelvis, which settles in the lungs. As a result of the occlusion, the pressure in the still functioning pulmonary arteries increases sharply, the blood accumulates back to the right ventricle. At the same time, the flow of oxygen-rich blood to the left ventricle is so low that it can not pump enough blood into the systemic circulation. In a large (fulminant) pulmonary embolism, the circulation can completely collapse – in the worst case, the heart stops working.

Other causes of an acute cor pulmonale may be a severe asthma attack (status asthmaticus) or a so-called tension pneumothorax (collapse of a lung by the ingress of air into the gap between lung and thorax). Signs of this are severe respiratory distress, rapid heartbeat, sweating and restlessness to death anxiety.

Cor pulmonale: examinations and diagnosis

At the beginning of the treatment is a detailed medical history. The doctor asks for complaints, habits and previous illnesses, including in the family of the person affected. From this he can often already derive a concrete suspicion of illness and get an overview of possible risk factors or triggers for a cor pulmonale. He will probably want to ask for cigarette smoking, cough and expectoration, shortness of breath, recurrent respiratory tract infections or and the physical capacity and experience, or even a heart disease is known.

Inspection and physical examination

Even the external observation of the patient (inspection) can already give initial indications of the presence of a cor pulmonale. Thus, the affected persons often show a bluish discoloration of the lips and fingertips, the end members of the fingers can be distended to so-called drumstick fingers and the fingernails to “clock glass nails” arched. All of these are signs of a lack of oxygen in the body. Edema on the dorsum, ankle joints and over the tibia are also possible indications of a cor pulmonale.

In the foreground of the physical examination is the interception of heart and lung sounds with the stethoscope. This can be used to determine whether the air can flow freely into and out of the lungs, whether secretions accumulate in the bronchi and whether the heart works regularly and effectively. A cor pulmonale, for example, often produces typical sounds on certain heart valves. By palpating the liver, the doctor can determine if the organ is enlarged by congestion. Venous congestion is often directly visible in the area of ​​the upper body and neck. An important sign of water retention in the tissue is the formation of dents on external pressure. Thus, constrictions often appear on the lower legs due to the cuffs of socks or stockings; after pressure with the finger, a visible dent remains for several minutes.

Hints from the laboratory

When examining the blood in the laboratory, there are also some typical indications for a cor pulmonale. On the one hand, the number of oxygen-carrying red blood cells (erythrocytes) is increased because the body tries to compensate in this way for the worse gas exchange in the lungs. Nevertheless, the oxygen content in arterial blood is often lower than normal. If the blood accumulates in the large veins, the liver is almost always affected as well. Therefore, the so-called liver enzymes or transaminases (GOT, GPT, gamma-GT) are usually elevated in cor pulmonale.

X-ray and further apparatus examinations

The diagnostic apparatus gives further indications of a cor pulmonale. For example, the chest X-ray (thorax) often shows a widening of the right heart’s shadow due to the right heart strain. By ultrasonography of the heart (echocardiography), the doctor can measure the enlargement of the right heart and detect the increased pressure in the pulmonary artery and leaks in the heart valves. Also, an enlarged liver can be demonstrated by ultrasound examination (sonography).

Another firm element of investigation for suspected cor pulmonale is the electrocardiogram (ECG). It shows how the electrical arousal of the heart takes place – the prerequisite for the contraction of the heart muscle. In the case of cor pulmonale, typical changes occur due to the stretching of the right ventricle. Pulmonary function tests are also important for the diagnosis because a cor pulmonale always emanates from the lungs. In spirometry, for example, the patient blows with full force into a small measuring tube, via which the lung volume and air flow are determined. Plethysmography is also a commonly used method for testing lung function.

Elaborate, but very precise, are cardiac catheter examinations, with which the pressures in the right heart and the large vessels can be determined and correlated. Typically, the catheter is advanced from the inguinal vein into the large vena cava into the right atrium and then across the right ventricle into the pulmonary artery. If there is a suspicion of pulmonary embolism (the most common cause of acute cor pulmonale), a contrast agent can be injected into the pulmonary artery using the cardiac catheter. If the diagnosis is confirmed, the clot can in many cases be broken up or smashed by special medication or mechanical measures via the catheter (recanalization of the pulmonary artery).

Cor pulmonale: treatment

In the treatment of chronic cor pulmonale, it is first important to treat the underlying disease. Since cor pulmonale is in most cases based on chronic obstructive pulmonary disease (caused mainly by smoking), the most important therapy step is immediate smoking cessation.

An oxygen therapy, usually as a long-term treatment, significantly improves the resilience and quality of life of patients. Physical protection and dehydrating medications relieve the overstretched right ventricle.

Certain medications may also reduce pressure in the pulmonary arteries directly or by treatment of the triggers. Thus, prostacyclin or endothelin receptor antagonists directly expand the pulmonary vessels, while, for example, bronchospasmolytics and expectorant drugs reduce the hyperinflation of the lungs. This also increases the resistance in the blood vessels. Corticosteroids can also be used for severe respiratory infections; severe bacterial infections sometimes require the use of an antibiotic.

In addition, treatment of cardiac insufficiency is required for chronic cor pulmonale. In addition to low-salt diet and dehydrating medications, experts also recommend the use of digitalis, especially if certain forms of cardiac arrhythmias are present. A bloodletting can also be used as a therapy. The controlled blood loss leads to a dilution of the blood in the body. This improves its flow properties and the heart is relieved.

If these therapies are not enough to improve their quality of life, lung or heart-lung transplantation may also be considered.

Emergency therapy for acute cor pulmonale

Acute cor pulmonale is a medical emergency that needs to be quickly identified and treated. In addition to the absolutely necessary oxygen supply and soothing and pain-relieving medicines, the doctors try to relieve the heart in the short term by fast-acting drugs. If, as in most cases, an embolism of the pulmonary arteries is responsible for the acute cor pulmonale, the obstructed vessel can in many cases be reopened mechanically or through medication (recanalization).

Cor pulmonale: disease course and prognosis

Chronic cor pulmonale is a progressive disease that, if left untreated, leads to death within a few years. Those affected experience an increasing reduction in their quality of life through a sharp decline in physical performance, shortness of breath, chronic cough, and prolonged fatigue and fatigue.

If the disease has already led to organ changes in the lungs and heart, they are no longer reversible. However, the use of various medications, combined with long-term oxygen therapy, can significantly improve the quality of life and delay or even prevent progression of the disease. Important is an early start of therapy and an immediate smoking cessation in smokers.

If medication therapy does not work or if the quality of life is severely impaired, patients will remain with it Cor pulmonale as a last resort only a heart-lung transplantation.