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Introduction
Introduction Chronic pulmonary heart disease: refers to the increase of pulmonary circulation resistance caused by chronic diseases of the lungs, thoracic or pulmonary arteries, resulting in pulmonary hypertension and right ventricular hypertrophy, and finally heart disease of right heart failure, referred to as pulmonary heart disease. Its clinical features include coughing, coughing, palpitations after exercise, difficulty in breathing, edema of lower extremities, X-ray showing emphysema, branching of pulmonary artery, and echocardiography showing enlargement of right atrium or right ventricle. The course of the disease is slow to develop. First, patients have a long history of chronic cough, cough or asthma. They gradually develop fatigue and difficulty in breathing. Secondly, palpitations, dyspnea and purpura gradually appear. Especially in the case of acute respiratory infection, the ventilatory disorder is further aggravated. This causes hypoxia and carbon dioxide retention and leads to respiratory failure and heart failure. The disease is more common in China. According to statistics in recent years, the average prevalence of pulmonary heart disease is 0.41%-0.47%. The age of the disease is more than 40 years old, and the prevalence rate increases with age. Acute attacks are more common in winter and spring. Acute respiratory infections are often the cause of acute attacks, often leading to lung and heart failure, and high mortality.
Cause
Cause
1. The cause of chronic pulmonary heart disease:
According to different parts of the primary disease, it can be divided into three categories:
1), bronchi, lung disease
Intermittent emphysema with chronic bronchitis is the most common, accounting for 80%-90%, followed by bronchial asthma, bronchiectasis, severe tuberculosis, pneumoconiosis, chronic diffuse pulmonary interstitial fibrosis, sarcoidosis, allergic alveolar Inflammation, eosinophilic granuloma, etc.
2) Thoracic dyskinesia
Less common, severe posterior spine, scoliosis, spinal tuberculosis, rheumatoid arthritis, extensive pleural adhesions, and severe thoracic or spinal deformities caused by thoracic formation, as well as neuromuscular disorders such as polio, can cause chest vestibules Limited mobility, lung compression, bronchial distortion or deformation, resulting in limited lung function, poor airway drainage, repeated lung infection, emphysema, or fibrosis, hypoxia, pulmonary vasoconstriction, stenosis, making resistance Increase, pulmonary hypertension, develop into pulmonary heart disease.
3), pulmonary vascular disease
Very rare. Allergic granulmatosis involving the pulmonary artery, extensive or recurrent multiple pulmonary embolism and pulmonary arteritis, and unexplained primary pulmonary hypertension can cause pulmonary arteriolar stenosis and obstruction It causes an increase in pulmonary vascular resistance, pulmonary hypertension and right ventricular load, and develops into pulmonary heart disease.
2. The pathogenesis of chronic pulmonary heart disease:
Changes in lung function and structure, repeated airway infections and hypoxemia, leading to a series of changes in humoral factors and pulmonary vasculature, resulting in increased pulmonary vascular resistance, pulmonary hypertension, increased pulmonary circulation resistance, right heart exerts Compensatory function to overcome right pulmonary ventricular hypertrophy by overcoming the resistance to elevated pulmonary arterial pressure. Early pulmonary hypertension; the right ventricle is still compensated, and the end-diastolic pressure is still normal. As the disease progresses, especially during the acute exacerbation period, the pulmonary arterial pressure continues to rise and is severe, exceeding the right ventricular load, right heart decompensation, right heart discharge, and right ventricular end-systolic residual blood volume, end-diastolic Increased pressure causes right ventricular enlargement and right ventricular failure.
Examine
an examination
Related inspection
Ultrasound diagnosis of cardiovascular disease, dynamic electrocardiogram (Holter monitoring), hemoglobin
Arterial blood gas analysis
Pulmonary heart disease may have hypoxemia or hypercapnia in the compensatory phase of lung function. When PaO2 <8kPa (60mmHg), PaCO2>6.66kPa (50mmHg), it is more common in lung disease caused by chronic obstructive pulmonary disease.
2. Blood test
In patients with hypoxic pulmonary heart disease, red blood cells and hemoglobin can be elevated, and the hematocrit is as high as 50% or more. When the infection was combined, the total number of white blood cells increased, neutrophils increased, and nuclear left shift occurred. Serological tests may have changes in renal function or liver function, as well as changes in high potassium, low sodium, low chlorine, low calcium, and low magnesium.
3. Other
Pulmonary function tests are meaningful for early or remission pulmonary heart disease. Bacterial examination of sputum can guide the selection of antibiotics for acute exacerbation of pulmonary heart disease.
4. X-ray inspection
In addition to the characteristics of lung, chest basic diseases and acute lung infection, there may be signs of pulmonary hypertension: 1 The right lower pulmonary artery is dilated, its transverse diameter is 15mm, and the ratio of transverse diameter to tracheal transverse diameter is 1.07. 2 pulmonary artery segment or its height 3mm. 3 The central pulmonary artery is dilated and the peripheral branches are slender, which is in sharp contrast. 4 The conical portion is significantly convex (45° in the right front oblique position) or cone height 7 mm. 5 right ventricular hypertrophy. The above five criteria, with one item, can diagnose pulmonary heart disease.
5. ECG examination
For the right atrium, room hypertrophy changes, such as the right axis of the electric axis, the frontal average electrical axis +90 °, severe clockwise transposition (V5: R / S 1), Rv1 + Sv5 1.05mV, aVR QR type and pulmonary type P wave. The right bundle branch block and low voltage pattern can also be seen as a reference condition for the diagnosis of pulmonary heart disease. At V1, V2 even extends to V3, and there is a QS wave that resembles the old myocardial infarction pattern.
Diagnosis
Differential diagnosis
1. Identification with coronary heart disease: coronary heart disease and pulmonary heart disease are more common in middle-aged and above, heart enlargement, arrhythmia and heart failure can occur, the heart murmur is not obvious, pulmonary heart disease ECG has similar myocardial infarction pattern, resulting in diagnosis Difficulties. Identification points:
1 patients with pulmonary heart disease often have chronic bronchitis, emphysema history and signs, and no typical angina or myocardial infarction.
2 Pulmonary heart disease ECG ST-T wave changes are not obvious, similar to myocardial infarction pattern occurs in the acute exacerbation of pulmonary heart disease, with the improvement of the condition, these patterns can disappear, pulmonary heart disease can also appear a variety of arrhythmia, more after the incentive is removed Normal, short-term and variability is characteristic. Coronary heart disease often has atrial fibrillation and various conduction block, which is constant and long-lasting compared with pulmonary heart disease.
Pulmonary heart disease with coronary heart disease is difficult to diagnose, and often missed diagnosis, foreign reports of pulmonary heart disease with coronary heart disease misdiagnosis rate of 8% to 38%, missed diagnosis of 12% to 26%. Because the symptoms overlap each other when the two are combined, the diagnostic criteria for pulmonary heart disease or coronary heart disease cannot be applied. The following comprehensive clinical diagnosis should be combined. The following points support the diagnosis of pulmonary heart disease with coronary heart disease:
(1) due to long-term hypoxia and emphysema: typical angina symptoms are less, such as pre-cardiac discomfort, chest tightness increased, taking nitroglycerin 3 ~ 5min relieved.
(2) The second sound of the aortic valve is larger than the second sound of the pulmonary valve: the apical systolic murmur of the apex 2/6 or above indicates the dysfunction of the papillary muscle.
(3) X-ray showed that the left and right chambers were enlarged: the aortic arch was distorted, prolonged, calcified, and the heart was enlarged. The shape was aortic, aortic-mitral valve and left ventricular large.
(4) ECG changes: myocardial infarction pattern can exclude patients with myocardial infarction, complete left bundle branch block, left anterior block and / or double bundle branch block, left ventricular hypertrophy or strain can be excluded Blood pressure, two to three degrees of atrioventricular block, the power axis is severe left-sided (high blood pressure.
(5) Echocardiogram showed a decrease in the amplitude of the posterior wall of the left ventricle: the difference in the diameter of the left ventricular end-systolic phase.
2. Identification with Rheumatic Heart Disease: Rheumatic heart disease mitral stenosis can cause pulmonary hypertension, right heart involvement, myocardial contraction in heart failure is not easy to hear typical murmur, easy to be confused with pulmonary heart disease. The tricuspid valve of the pulmonary heart disease is relatively closed, and the heart is turned in the direction of the clock. In the original mitral valve area, 2/6~3/6 grade vocal murmurs can be heard, and the pulmonary valve regurgitation has a diastolic murmur in the pulmonary valve area. Right ventricular hypertrophy and pulmonary hypertension are easily mistaken for rheumatic heart disease. Identification points:
(1) Pulmonary heart disease is more common in middle-aged and above, but more common in rheumatic heart disease.
(2) Pulmonary heart disease has a history of respiratory diseases for many years, respiratory function is reduced, heart failure often occurs on the basis of respiratory failure, rheumatic heart disease often has a history of rheumatism, rheumatism and fatigue are often the cause of heart failure.
(3) Pulmonary heart disease murmur is enhanced after heart failure, while rheumatic heart disease can be weakened.
(4) Pulmonary heart disease often shows right heart failure, and rheumatic heart disease often shows left heart failure.
(5) X-ray changes: pulmonary heart disease is mainly caused by right ventricle, and rheumatic heart disease is mainly mitral valve heart changes.
(6) Blood gas analysis: Pulmonary heart disease often has a decrease in PaO2 or an increase in PaCO2, and rheumatic heart disease can be normal.
(7) Electrocardiogram: Pulmonary heart disease has pulmonary P wave and right ventricular hypertrophy, while rheumatic heart disease has mitral P wave.
3. Identification with constrictive pericarditis: constrictive pericarditis is insidious, clinical manifestations of palpitations, shortness of breath, cyanosis, jugular vein engorgement, hepatomegaly, ascites, electrocardiogram, low voltage and pulmonary heart disease, but no chronic bronchus In the history of inflammation, the pulse pressure becomes smaller, the X-ray is straightened, the heart beats weakly or disappears, and the pericardial calcification is seen, and there is no emphysema and pulmonary hypertension, which can be differentiated from pulmonary heart disease.
4. Identification with primary cardiomyopathy: Primary cardiomyopathy, heart enlargement, weak heart sound, atrioventricular valve relative dysplasia and right heart failure caused by hepatomegaly, ascites, lower extremity edema and pulmonary heart disease. Pulmonary heart disease has a history of chronic respiratory infection and signs of emphysema, X-ray has changes in pulmonary hypertension, electrocardiogram has right axis deviation and clockwise transposition, while cardiomyopathy is characterized by extensive myocardial damage, echocardiographic findings "large ventricle" , small opening", blood gas changes are not obvious, there may be mild hypoxemia.
