Cor pulmonale

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A cor pulmonale (so-called pulmonary heart) is used when the right ventricle has expanded and expanded significantly, but the reason for this is not in the heart but in the lungs. The cause of the cor pulmonale is an increased resistance in the pulmonary circulation, against which the heart works for a long time. Mostly respiratory diseases are responsible for this. Read more about the causes, symptoms and treatment of cor pulmonale.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. I26I27

Cor pulmonale: description

Cor pulmonale (Cor = heart, pulmonale = assigned to the lungs) is a heart in which the right ventricle is greatly expanded and can no longer properly perform its task of pumping oxygen-poor blood from the body into the lungs. The second part of the name of the disease refers to the cause of the dilation of the heart - it is in the lungs: an increased flow resistance in the pulmonary arteries means that the right ventricle has to work harder to pump the oxygen-poor blood flowing out of the body into the pulmonary circulation.

In response to this, the muscle wall of the heart chamber first thickens. If the resistance increases further, the chamber enlarges due to the backflow of blood and the structure of the muscle fibers is disturbed. The heart chamber literally wears out. A so-called right heart weakness develops and finally a cor pulmonale - a condition that cannot be reversed.

Acute cor pulmonale

A cor pulmonale can develop in different ways. The so-called acute cor pulmonale develops 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

Chronic cor pulmonale develops gradually. It can be triggered by various lung diseases that have one thing in common: They increase the pressure in the pulmonary circulation. This causes some of the blood that is pumped into the lungs by the right heart to flow back again. The additional stress on the heart leads to an additional stress on the right ventricle. The heart muscle has to work harder to overcome the increased resistance and grows more and more. The tight structure of the muscle cells is disturbed and connective tissue is deposited.

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 a chronic cor pulmonale include COPD (chronic obstructive pulmonary disease), pulmonary emphysema (overinflation of the lungs with reduced oxygen exchange), long-term inflammation of the bronchi, which is associated with constrictions, and pulmonary fibrosis (increased formation connective tissue in the lungs).

Cor pulmonale: symptoms

Since a chronic cor pulmonale develops over years, the symptoms at the beginning of the disease are still minor. With increasing weakness of the right ventricle (right heart failure), however, typical complaints arise. So the blood backs up into the right atrium and the veins of the great body circulation. The pressure causes fluid from the blood vessels to transfer into the tissue, causing water to be retained 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.

The blood also accumulates in the organs, which in particular greatly enlarges the liver (hepatomegaly) and spleen (splenomegaly). At the same time, the outflow of bile can be disturbed, the pigment retained in the liver (bilirubin) can lead to a yellowish discoloration of the skin and the conjunctiva of the eye (jaundice). If tissue water collects in the free abdominal cavity, doctors speak of ascites or ascites.

Lack of oxygen 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 ultimately discolour the skin and mucous membranes bluish (cyanosis). In addition, patients with a cor pulmonale suffer from shortness of breath, which is initially only noticeable during intense physical exertion and later even at rest. The neck veins can visibly protrude through the back pressure on the heart. Other symptoms are hoarseness, cough, sometimes with bloody sputum, and a feeling of pressure in the chest.

Patients with cor pulmonale are less physically resilient and exhausted more quickly. In the advanced stage, physical overload can lead to collapse and unconsciousness.

Acute cor pulmonale means danger to life

In the case of an acute cor pulonale, there is a particular risk that those affected will die of sudden cardiac death. The acute form is usually triggered by a severe pulmonary embolism, i.e. a blood clot that has migrated into the lungs blocks part of the pulmonary arteries. This prevents blood from flowing into that part of the lungs. 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. One also speaks of pulmonary arterial hypertension. Damage to the lung tissue and the pulmonary vessels means that less oxygen-deficient blood can be absorbed from the right heart into the lungs, so that it backs up. As a result, the right ventricle, which is upstream of the lungs, is heavily stressed. It thickens its muscle wall, expands and is only less efficient in the case of clinically manifest cor pulmonale. The cause for this is usually chronic lung diseases, especially COPD.

The main cause of COPD is smoking. The pollutants often cause recurring irritation and inflammation of the airways. A chronic cough is typical, which is later accompanied by tough expectoration and shortness of breath. In the further course of the disease, the smallest bronchi and alveoli are damaged, and the partition walls between the alveoli are destroyed. Instead of the smallest alveoli, large blisters form, leading to overinflation of the lungs, known as pulmonary emphysema, which is another possible cause of the cor pulmonale.

Diseases with an increased formation of connective tissue in the lungs, the so-called pulmonary fibrosis, can also lead to cor pulmonale. As a result, the lung tissue loses its elasticity, which in turn makes gas exchange more difficult. Examples of diseases that can lead to pulmonary fibrosis are sarcoid, tuberculosis, silicosis or asbestosis.

External respiratory obstructions can also lead to cor pulmonale, for example in the case of a curvature of the spine (kyphoscoliosis), in which the lungs are constricted and the pressure in their blood vessels increases. .

Causes of an acute cor pulmonale

The acute cor pulmonale usually arises as a result of a vascular occlusion of the pulmonary artery (pulmonary embolism) and occurs very suddenly. This is usually due to a blood clot from the leg veins or the pelvis that lodges in the lungs. As a result of the occlusion, the pressure in the pulmonary arteries that are still functioning increases sharply, and the blood backs up to the right ventricle. At the same time, the flow of oxygen-rich blood to the left ventricle is so low that it can no longer pump enough blood into the body's circulation.In the case of a large (fulminant) pulmonary embolism, the circulation can collapse completely - in the worst case, the heart stops working.

Other causes of an acute cor pulmonale can be a severe asthma attack (status asthmaticus) or a so-called tension pneumothorax (collapse of a lung due to air entering the gap between the lungs and the chest). Signs of this are severe shortness of breath, palpitations, sweating and restlessness up to fear of death.

Cor pulmonale: examinations and diagnosis

At the beginning of the treatment there is a detailed anamnesis. The doctor asks about symptoms, lifestyle habits and previous illnesses, including those in the family of the person concerned. From this he can often derive a specific suspicion of illness and get an overview of possible risk factors or triggers for cor pulmonale. He will probably ask about cigarette consumption, cough and sputum condition, shortness of breath, recurring respiratory tract infections or and physical resilience and also want to find out, or a heart disease is already known.

Inspection and physical examination

The external examination of the patient (inspection) can also provide initial indications of the presence of a cor pulmonale. Those affected often show a bluish discoloration of the lips and fingertips, the end links of the fingers can become so-called drumstick fingers and the fingernails can be arched into "watch glass nails". These are all signs of a lack of oxygen in the body. Edema on the dorsum of the foot, the ankles and above the shinbones are also possible indications of a cor pulmonale.

The focus of the physical examination is listening to heart and lung sounds with the stethoscope. This makes it possible to determine whether the air can flow freely into and out of the lungs, whether secretion is accumulating in the bronchi and whether the heart is working regularly and effectively. With a cor pulmonale, for example, typical noises are often produced by certain heart valves. By palpating the liver, the doctor can determine whether the organ is enlarged due to congestion. Venous congestion is often directly visible in the area of ​​the upper body and neck. An important sign of water accumulation in the fabric is the formation of dents under pressure from the outside. The lower legs often show constrictions due to the cuffs of stockings or socks, after pressure with the finger a visible dent remains for several minutes.

Notes from the laboratory

When examining the blood in the laboratory, there are also some typical indications of cor pulmonale. On the one hand, the number of oxygen-transporting red blood cells (erythrocytes) is increased because the body tries to compensate for the poor gas exchange in the lungs in this way. Even so, the oxygen levels in the arterial blood are often lower than normal. If the blood builds up in the large veins, the liver is almost always affected. Therefore, the so-called liver values ​​or transaminases (GOT, GPT, Gamma-GT) are usually elevated in Cor pulmonale.

X-ray and other apparatus-based examinations

Apparatus diagnostics provide further evidence of cor pulmonale. X-rays of the chest (thorax) often show a widening of the right heart shadow as a result of the stress on the right heart. Using an ultrasound examination of the heart (echocardiography), the doctor can measure the enlargement of the right heart and detect the increased pressure in the pulmonary artery as well as leaks in the heart valves. An enlarged liver can also be detected with the aid of an ultrasound examination (sonography).

Another fixed component of the examination when cor pulmonale is suspected is the electrocardiogram (EKG). It shows how the electrical excitation of the heart works - the prerequisite for the contraction of the heart muscle. In the cor pulmonale, the stretching of the right ventricle causes typical changes. Since a cor pulmonale always originates in the lungs, lung function tests are also important for the diagnosis: in spirometry, for example, the patient blows with full force into a small measuring tube, which is used to determine the lung volume and air flow. Plethysmography is also a frequently used method to test lung function.

Cardiac catheter examinations, with which the pressures in the right heart and the large vessels can be determined and put in relation to one another, are more complex, but very precise. Typically, the catheter is advanced from the inguinal vein into the great vena cava into the right atrium and then through the right ventricle to the pulmonary artery. If pulmonary embolism is suspected (the most common trigger of acute cor pulmonale), a contrast medium for special X-rays can be injected into the pulmonary artery using the cardiac catheter. If the diagnosis is confirmed, in many cases the clot can be dissolved or smashed through the catheter using special medication or mechanical measures (recanalization of the pulmonary artery).

Cor pulmonale: treatment

When treating chronic cor pulmonale, it is first important to treat the underlying disease. Since in most cases the cor pulmonale is based on a chronic obstructive pulmonary disease (triggered primarily by smoking), the most important therapeutic step is to stop smoking immediately.

Oxygen therapy, usually as a long-term treatment, significantly improves the patient's resilience and quality of life. Physical rest and dehydrating medication relieve the overstretched right ventricle.

Certain drugs can also reduce pressure in the pulmonary arteries, either directly or by treating the triggers. Prostacyclines or endothelin receptor antagonists expand the pulmonary vessels directly, while bronchospasmolytics and expectorant drugs, for example, reduce the inflation of the lungs. This also increases the resistance in the blood vessels. In the case of severe inflammation of the airways, corticosteroids can also be used; severe bacterial infections sometimes require the use of an antibiotic.

In addition, treatment of cardiac insufficiency is necessary in chronic cor pulmonale. In addition to a low-salt diet and dehydrating medication, experts also recommend taking digitalis, especially if certain forms of cardiac arrhythmia are present. Bloodletting can also be used as a therapy. The controlled blood loss leads to a thinning of the blood in the body. This improves its flow properties and the heart is relieved.

If the therapies mentioned are not sufficient to maintain the quality of life of those affected, a lung or heart-lung transplant can also be considered.

Emergency therapy for acute cor pulmonale

Acute cor pulmonale is a medical emergency that needs to be recognized and treated quickly. In addition to the essential oxygen supply and calming and pain relieving medication, doctors try to relieve the heart for a short period of time with fast-acting medication. If - as in most cases - an embolism of the pulmonary arteries is responsible for the acute cor pulmonale, the blocked vessel can in many cases be reopened mechanically or with 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 due to a sharp decline in physical performance, shortness of breath, chronic coughing and persistent exhaustion and tiredness.

If the disease has already led to changes in organs in the lungs and heart, these can no longer be reversed. However, the use of various drugs combined with long-term oxygen therapy can significantly improve the quality of life and delay or even prevent the progression of the disease. It is important to start therapy early and, for smokers, to stop smoking immediately.

If drug therapy does not work or if quality of life is severely impaired, the only alternative for patients with cor pulmonale is a heart-lung transplant.

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