Cordul pulmonar

Definitie: Cordul pulmonar reprezinta suferinta inimii drepte indusa de boli acute sau cronice, dar primare, ale vaselor sau tesuturilor pulmonare. Cordul pulmonar este o forma de insuficienta cardiaca in care boala cauzala se afla in afara structurilor inimii, adica in plamin (organul situat ca sens al circulatiei sangvine in fata venticulului drept). Cauze: Bolile care pot produce cordul pulmonar sint extrem de variate, dar se caracterizeaza in mod fundamental prin prezenta in grade variate a doua fenomene: -scaderea ventilatiei alveolelor pulmonare -reducerea spatiului vascular pulmonar Din punct de vedere cauzal, aceste fenomene sint capabile sa produca cordul pulmonar pe cai diferite numai pina in momentul instalarii hipertensiunii din circulatia arteriala pulmonara. Din acel moment, daca factorii cauzali nu sint inlaturati, inima dreapta este din ce in ce mai solicitata de rezistenta ce o are de invins in timpul contractiei si in final devine insuficienta ca si activitate. Scaderea ventilatiei alveolare pulmonare determina scaderea concentratiei oxigenului in singe, cresterea concentratiei bioxidului de carbon si acidoza (scaderea pH-ului sanguin). Acestea, la rindul lor cu cit sint mai accentuate cu atit produc o mai marcata constrictie vasculara la nivelul arterelor mici pulmonare si in acest fel induc cresterea presiunii din artera pulmonara. Se ajunge in final la dilatatea si marirea in volum (hipertrofia) ventriculului drept care, la un moment dat nu mai poate sa satisfaca necesitatile si face ca singele sa stagneze in sens retrograd. Cordul pulmonar acut este determinat in general de obstructia acuta (astuparea) a unui vas pulmonar mare printr-un cheag plecat din teritoriul venos (tromboembolism). Cele mai frecvente cauze de aparitie a acestui accident sint: tromboflebitele acute, fracturile de membre inferioare imobilizate in aparate gipsate, interventiile chirurgicale pe abdomen si micul bazin, infectiile pelviperitoneale de dupa nastere si traumatismele abdominale. BOLILE CE POT PRODUCE CORDUL PULMONAR 1.Boli ale tesutului pulmonar sau ale cailor respiratorii intratoracice: -astmul bronsic -emfizemul pulmonar -infectii pulmonare cronice -fibrozele pulmonare 2. Boli ale custii toracice si pleurei: -deformarile importante ale structurilor toracice osoase -bolili muschilor ce asigura ventilatia -pahipleurite intinse (inflamatii ale foitelor ce invelesc plaminii) 3. Tulburari ale reglarii ventilatiei: -plaminul de altitudine -sindromul de hipoventilatie al obezilor -apnee de somn 4. Boli vasculare pulmonare -hipertensiunea pulmonara primitiva tromboembolismul pulmonar (acut sau cronic) -arteritele pulmonare Tipuri: In functie de modul cum se produce boala, exista doua forme de boala:acuta si cronica. Cordul pulmonar acut este o urgenta medicala majora si semnifica o insuficienta brutala a inimii drepte in timp in forma cronica, insuficienta inimii drepte se produce in timp. Simptome: Modul de manifestare a cordului pulmonar acut este de obicei brusc, iar la unii bolnavi apar o serie de semne si simptome care atrag atentia asupra posibilitatii mobilizarii unor cheaguri ce se opresc in plamini. Astfel, febra de cauza neclara, pulsul accelerat si crizele scurte de sufocare, insotite de anxietate sugereaza tromboembolismul pulmonar, mai ales in contextul cauzal respectiv. Manifestarile clinice ale cordului pulmonar cronic ramin timp indelungat acoperite de simptomatologia bolilor cauzale cu localizare pulmonara. Deoarece deseori bolile cauzale sint cele de tip emfizem pulmonar, bronsita cronica sau astm bronsic, boli in care tulburarile de respiratie (dispneea) sint simptome frecvente se ignora complet diagnosticul de cord pulmonar. Totusi unii bolnavi, care desi s-au obisnuit sa tuseasca in mod cronic sau in episoade acute cu ocazia unor infectii remarca, dupa un timp, ca senzatia de lipsa de aer, anterior intermitenta, devine aproape permanenta si se prezinta la medic din acest motiv. Tulburarile de respiratie (dispneea) nu sint influentate de pozitia corpului, iar bolnavii tolereaza la fel de bine sau la fel de prost atit pozitia culcata cit si pozitia in sezut. Astfel majoritatea bolnavilor sint diagnosticati numai in momentul cind decompensarea cordului este atit de evidenta incit ea nu mai poate fi ignorata. In afara de dificultatile respiratorii (dispneea), mai apar si alte simptome: -conturarea excesiva si congestia venelor gitului (turgescenta venelor jugulare) -cresterea congestiva a ficatului, determinata de stagnarea singelui in circulatia venoasa (hepatomegalie) -umflarea picioarelor (edeme) In mod deosebit bolnavii care sufera de cord pulmonar cronic se caracterizeaza prin: -coloratia albastra inchisa a buzelor, unghiilor si a tuturor zonelor vasculare vizibile prin piele (cianoza). Aceasta coloratie este net mai intensa decit cea a bolnavilor cu insuficienta cardiaca congestiva globala, avind uneori chiar o tenta negricioasa. Diagnostic: Medicul de medicina interna si medicul cardiolog diagnosticheaza boala in functie atit de simptome, examenul clinic cit si de alte analize de laborator suplimentare. Pentru ca toate fenomenele se produc lent si in general fara o exprimare la nivel clinic, numai investigatiile specifice, pot evidentia in fazele de inceput, cresterea semnificativa a presiunii din artera pulmonara. -Numarul de globule rosii creste semnificativ, depasind deseori cifra de 6 milioane/mm3, iar procentul de globule rosii din singele total (hematocritul) trece de 50%. -Creste viscozitatea sangvina -Creste numarul trombocitelor sangvine ce duce la producerea de microcheaguri sangvine(microtrombi) care ingreuneaza si mai mult circulatia pulmonara si accentueaza hipertensiunea din artera pulmonara. Tratament: Insuficienta inimii drepte, acute sau cronice, beneficiaza de tratamente specifice care se aplica sub

strict control medical in spitale. Tratamentul cordului pulmonar cronic decompensat se efectueaza initial numai in spital. Pentru ca tratamentul sa dea bune rezultate, bolnavului ii revine rolul important de a colabora cu medicul. Respectarea cu strictete a prescriptiilor medicale asigura reusita tratamentului. Bolnavii cu diagnosticul de cord pulmonar stabilit, al caror tratament a fost deja initiat in urma unei internari, trebuie sa stie o serie de lucruri ce vizeaza prevenirea recidivelor. Preventie: In primul rind fumatul este interzis cu desavirsire, definitiv si irevocabil, deoarece fiecare tigara fumata produce vasoconstrictie pulmonara, bronhoconstrictie si reduce concentratia de oxigen din singe, crescind-o pe cea de bioxid de carbon. In al doilea rind se recomanda evitarea infectiilor cailor aeriene superioare, precum si prevenirea bolilor pulmonare, bronsitelor acute. Trebuie evitate: frigul, umezeala, contactul cu alti tusitori. Cei cu infectii cronice trebuie sa urmaze tratamente cu antibiotice sau alte medicamente (chimioterapice) in mod intermitent sau continuu, conform indicatiilor medicale. In al treile rind, bolnavii cu crize de spasm bronsic(astm bronsic, bronsita cronica bronhospastica, emfizem pulmonar obstructiv) trebuie sa evite toate circumstantele si toti factorii care au actiune nefavorabila asupra felului cum respira. Recomandari: In cazul in care apare totusi o afectiune infectioasa intercurenta a cailor respiratorii superioare sau inferioare sau se produce o acutizare a unei infectii cronice este necesar ca tratamentul antimicrobian sa fie inceput imediat. Este important de stiut ca numai medicul poate hotari cu ce medicament trebuie urmat tratamentul, autoadministrarea de antibiotice si chimioterapice fiind o greseala grava. Doar medicul este in masura sa decida asupra tipului de medicament si dozelor folosite in functie de caz. Pacientii care au obisnuit sa foloseasca spray-urile medicamentoase antiasmatice necesita o supraveghere medicala mai strinsa si masuri de educatie sanitara sustinute, atragindu-li-se atentia asupra pericolelor la care se expun prin excesul de medicamente bronhodilatatoare. Bolnavii de cord pulmonar cronic au mai frecvent decit populatia generala ulcere gastro-duodenale ignorate care, sub tratamente ce impiedica coagularea singelui, pot singera fara sa dea nici un simptom. Din acest motiv, supravegherea zilnica a scaunului, trebuie sa faca parte din obisnuinta bolnavului aflat in tratament cu anticoagulante, iar la modificarea materiilor fecale sa anunte medicul curant. Aspectul sugestiv de hemoragie este scaunul relativ moale, negru, lucios. Diverse: Datorita raspindirii medicatiei bronhodilatatoare care stimuleaza sistemul nervos simpatic, trebuie cunoscut faptul ca aceasta induce cresterea pulsului si consumului de oxigen, iar la nivel pulmonar mareste cantitatea de singe venos care trece in circulatia arteriala fara sa mai treaca prin etapa schimbului bioxid de carbon-oxigen. Daca bolnavii se afla si sub tratament cu substante digitalice, utilizare abuziva a stimulantelor simpatice risca sa se insoteasca de aritmii cardiace grave. Uneori suferinta cronica a cordului drept determina in mod secundar, prin mecanisme complexe si suferinta cordului sting, moment in care se poate vorbi de instalarea insuficientei cardiace globale. Oprirea unui cheag intr-un vas pulmonar mai mic nu determina in general cordul pulmonar acut, ci produce infarct pulmonar. Repetarea infarctelor pulmonare la intervale scurte poate insa sa duca la instalarea suferintei acute a inimii drepte necesitind o interventie terapeutica rapida.

Cor pulmonale
From Wikipedia, the free encyclopedia

Cor pulmonale

Classification and external resources

ICD-10

I26, I27

ICD-9

415.0

MedlinePlus

000129

MeSH

D011660

Cor pulmonale (Latin cor, heart + New Latin pulmnle, of the lungs) or pulmonary heart disease is enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs (pulmonary hypertension). Chronic cor pulmonale usually results in right ventricular hypertrophy (RVH), whereas acute cor pulmonale usually results in dilatation. Hypertrophy is an adaptive response to a long-term increase in pressure. Individual muscle cells grow larger (in thickness) and change to drive the increased contractile force required to move the blood against greater resistance. Dilatation is a stretching (in length) of the ventricle in response to acute increased pressure, such as when caused by a pulmonary embolism. To be classified as cor pulmonale, the cause must originate in the pulmonary circulation system. Two major causes are vascular changes as a result of tissue damage (e.g. disease, hypoxic injury, chemical agents, etc.), and chronic hypoxic pulmonary vasoconstriction. RVH due to a systemic defect is not classified as cor pulmonale. If left untreated, cor pulmonale can lead to right-heart failure and death.
Contents
[hide]

1 Overview 2 Pathophysiology 3 Causes 4 Symptoms 5 Diagnosis 6 Epidemiology 7 Complications 8 Investigations 9 Treatment 10 Prevention 11 References 12 External links

[edit]Overview

The heart and lung are intricately related. Whenever the heart is affected by disease, the lungs will follow and vice versa. Pulmonary heart disease is by definition a condition when the lungs cause the heart to fail.[1] The heart has two pumping chambers. The left ventricle pumps blood throughout the body. The right ventricle pumps blood to the lungs where it is oxygenated and returned to the left heart for distribution. In normal circumstances, the right heart pumps blood into the lungs without any resistance. The lungs usually have minimal pressure and the right heart easily pumps blood through.[2] However when there is lung disease present, like emphysema, chronic obstructive lung disease (COPD) or pulmonary hypertension- the small blood vessels become very stiff and rigid. The right ventricle is no longer able to push blood into the lungs and eventually fails. This is known as pulmonary heart disease. Pulmonary heart disease is also known as right heart failure or cor pulmonale. The chief cause of right heart failure is the increase in blood pressure in the lungs (pulmonary artery).

[edit]Pathophysiology
There are several mechanisms leading to pulmonary hypertension and cor pulmonale:

Pulmonary vasoconstriction Anatomic changes in vascularization Increased blood viscosity Idiopathic or primary pulmonary hypertension

[edit]Causes

Acute:

Massive pulmonary embolization Exacerbation of chronic cor pulmonale

Chronic:

COPD Primary Pulmonary Hypertension Asthma Recurrent Pulmonary Embolism Loss of lung tissue following trauma or surgery Pierre Robin sequence End stage Pneumoconiosis Sarcoidosis T1-4 Vertebral subluxation Obstructive sleep apnea Altitude sickness

Sickle cell anemia Bronchopulmonary dysplasia (in infants)

[edit]Symptoms
The symptoms of pulmonary heart disease depend on the stage of the disorder. In the early stages, one may have no symptoms but as pulmonary heart disease progresses, most individuals will develop the symptoms like:

Shortness of breath which occurs on exertion but when severe can occur at rest Wheezing Chronic wet cough Swelling of the abdomen with fluid (ascites) Swelling of the ankles and feet (pedal edema) Enlargement or prominent neck and facial veins Raised Jugular Venous Pulse (JVP) Enlargement of the liver Bluish discoloration of face Presence of abnormal heart sounds possible bi-phasic atrial response shown on an EKG due to hypertrophy

[edit]Diagnosis
In many cases, the diagnosis of pulmonary heart disease is not easy as both the lung and heart disease can produce similar symptoms. Most patients undergo an ECG, chest X ray,echocardiogram, CT scan of the chest and a cardiac catheterization. During a cardiac catheterization, a small flexible tube is inserted from the groin and under x ray guidance images of the heart are obtained. Moreover the technique allows measurement of pressures in the lung and heart which provide a clue to the diagnosis.[1]

[edit]Epidemiology
Each year there are about 20,000 deaths and close to 280,000 hospital admissions among individuals who have pulmonary heart disease. The majority of individuals affected by pulmonary heart disease are women less than 65 years of age. Infants who are born with congenital heart disorders (esp. holes in the heart like a VSD) are prone to pulmonary artery disease. While pulmonary heart disease is serious, it is much less common than coronary artery disease.[2]

[edit]Complications
Blood backs up into the systemic venous system, including the hepatic vein. Chronic congestion in the centrilobular region of the liver leads to hypoxia and fatty changes of more peripheralhepatocytes, leading to what is known as nutmeg liver.

[edit]Investigations

Normal heart (left) and right ventricular hypertrophy (right)

Chest X-Ray - Right ventricular hypertrophy, right atrial dilatation, prominent pulmonary artery, peripheral lung fields show reduced vascular markings. Patients of chronic obstructive pulmonary disease show features of hyperinflation which include widened intercostal space, increased translucency of lung and flattened diaphragm.

ECG - Right ventricular hypertrophy - right axis deviation, prominent R wave in lead V1 & inverted T waves in right precordial leads, Large S in Lead I, II and III; Large Q in lead III, Tall Peaked P waves (P pulmonale) in lead II, III and aVF. All the above features are not found in a single patient but different patients show different combination of these findings.

Echocardiogram - Right ventricular dilatation and tricuspid regurgitation is likely

[edit]Treatment
Elimination of the cause is the most important intervention. Smoking must be stopped, exposure to dust, flames, household smoke and to cold weather is avoided. If there is evidence of respiratory infection, it should be treated with appropriate antibiotics after culture and sensitivity. Diuretics for RVF, Inpulmonary embolism, thrombolysis (enzymatic dissolution of the blood clot) is advocated by some authorities if there is dysfunction of the right ventricle, and is otherwise treated with anticoagulants. In COPD, long-term oxygen therapy may improve cor pulmonale. Cor pulmonale may lead to congestive heart failure (CHF), with worsening of respiration due to pulmonary edema, swelling of the legs due to peripheral edema and painful congestive hepatomegaly (enlargement of the liver due to tissue damage as explained in the Complications section. This situation requires diuretics (to decrease strain on the heart), sometimes nitrates (to improve blood flow), phosphodiesterase inhibitors such as sildenafil or tadalafil and occasionally inotropes (to improve heart contractility). CHF is a negative prognostic indicator in cor pulmonale. Oxygen is often required to resolve the shortness of breath. Plus, oxygen to the lungs also helps relax the blood vessels and eases right heart failure. Oxygen is given at the rate of 2 litres per minute. Excess oxygen can be harmful to patients because hypoxia is the main stimulus to respiration. If such hypoxia is suddenly corrected by overflow of oxygen, such stimulus to the respiratory center is suddenly withdrawn

and respiratory arrest occurs. When wheezing is present, majority of the patients require bronchodilators. A variety of drugs have been developed to relax the blood vessels in the lung. Calcium channel blockers are used but only work in a few cases. Other novel medications that need to be inhaled or given intravenously include prostacyclinderivatives. Cases of COPD with chronic corpulmonale present with secondary polycythemia, if severe it may increase the blood viscosity and contribute to pulmonary hypertension. If hematocrit(PCV) is above 60%, then it is better to reduce the red blood cell count by phlebotomies. Mucolytic agents like bromhexine and carbocisteine help bring out excessive bronchial secretions more easily by coughing. All patients with pulmonary heart disease are maintained on blood thinning medications to prevent formation of blood clots. When medical therapy fails, one may require a transplant. However, since the lungs are damaged, both the heart and lungs needs to be transplanted. With a shortage of donors this therapy is only done 10-15 times a year in North America.

[edit]Prevention
While not all lung diseases can be prevented one can reduce the risk of lung disease. This means avoiding or discontinuing smoking. Patients with end stage emphysema or chronic obstructive lung disease always end up with right heart failure. When working in environments where there are chemicals, wear masks to prevent inhalation of dust particles.[3]