Cor pulmonale: diagnosis

Instrumental research with a pulmonary heart:

Electrocardiography

ECG signs of chronic pulmonary heart by Widhmky

Direct ECG-signs (due to the increased mass of the right ventricle):

• RV1 > 7 mm;
• RV1 / SV1 > 1;
• RV1 + RV5 > 10.5 mm;
• time of activation of the right ventricle in V1 0.03-0.05 ";
• incomplete blockage of the right leg of the bundle of Guiss and late RV1 > 15 mm;
• signs of right ventricular overload in V1-V2;
• the presence of QRV1 with the exclusion of focal myocardial damage.

Indirect ECG signs (appear at an early stage, often due to changes in the position of the heart):

• RV5 < 5 mm;
• SV5 > 5 mm;
• RV5 / SV5 < 1.0;
• incomplete block of right bundle branch and late RV1 < 10 mm;
• complete blockage of the right bundle butt and late RV1 < 15 mm;
• index (RV5 / SV5) / (RV1 / SV1) < 10;
• negative teeth T 1-5;
• SV1 < 2 mm;
• P pulmonale > 2 mm;
• deviation of the electric axis of the heart to the right (a > + 110 °);
• S-type ECG;
• P / Qv avR > 1.0.

[1], [2], [3], [4], [5], [6], [7], [8]

Criteria for myocardial hypertrophy of the right ventricle

Sokolov-Lyon (1947)

1. RV1 > 7 mm;
2. SV1 < l.0;
3. SV5-6 > 7 mm;
4. RV1 + SV5-6 > 10.5 mm;
5. RV5-6 < 5 mm;
6. R / SV5-6 < 5 mm;
7. (R / SV5) / (R / SV1) < 0.4;
8. R avR > 5 mm;
9. R / SV1 > 1.0;
10. the deviation of the electric axis of the heart to the right is greater than + 110 °;
11. activation time of the right ventricle in V1-2 0.04-0.07 ";
12. decrease and inversion of TV1-2 at R > 5 mm;
13. decrease ST avL and inversion T avL or T avR.

[9], [10], [11], [12], [13], [14], [15]

Rheoraphasia of the chest

Determine the value of pressure in the pulmonary artery can be using a "pulmonary" rheogram according to the formula:

Systolic pressure in the pulmonary artery = 702 * T - 52.8 (mm Hg)

Diastolic pressure in the pulmonary artery = 345.4 * T - 26.7 (mm Hg)

T - period of right ventricular tension; its duration is equal to the interval from the ECG wave before the rise of the rheogram wave.

Echocardiography with a pulmonary heart

The echocardiographic method has the following possibilities for a chronic pulmonary heart:

• visualization of the right heart with confirmation of their hypertrophy;
• identification of signs of pulmonary hypertension;
• a quantitative assessment of pulmonary hypertension;
• determination of the main parameters of central hemodynamics.

EchoCG reveals the following signs of right ventricular hypertrophy:

• an increase in the thickness of the wall of the ventricle (in the norm 2-3 mm, an average of 2.4 mm);
• expansion of the right ventricle cavity (cavity size in terms of the body surface) (mean values of right ventricular index 0.9 cm / m ² ).

Other echocardiographic signs of pulmonary hypertension:

• a decrease in the "a" wave in the visualization of the pulmonary artery valve, the mechanism of which is associated with the partial opening of the pulmonary artery valve during atrial systole (normally, the amplitude of the "a" wave is 2-7 mm). This amplitude depends on the gradient of diastolic pressure in the right ventricle - pulmonary artery. Amplitude of wave "a" of 2 mm or less is a reliable sign of pulmonary hypertension;
• change in configuration and decrease in the rate of diastolic decline;
• an increase in the rate of opening of the valve of the pulmonary artery and a relatively easy detection of it;
• W-shaped motion of the crescent valves of the pulmonary artery in systole;
• an increase in the diameter of the right branch of the pulmonary artery (more than 17.9 mm).

[16], [17], [18], [19]

Chest X-ray

X-ray signs of a chronic pulmonary heart are:

• an increase in the right ventricle and atrium;
• bulging cone and pulmonary artery trunk;
• significant expansion of the basal vessels with a peripheral vascular depletion;
• "Chopping off" the roots of the lungs;
• an increase in the diameter of the descending branch of the pulmonary artery (determined on a computer tomogram - 19 mm or more);
• an increase in the Moore index - the percentage ratio of the diameter of the pulmonary artery to half the diameter of the chest; the latter is determined from the x-ray in the anterior-posterior projection at the level of the right dome of the diaphragm. With pulmonary hypertension, the index increases.

Normally, the Moore index at the age of 16-18 years = 28 ± 1.8%; 19-21 year = 28.5 ± 2.1%; 22-50 years = 30 ± 0.8%.

• an increase in the distance between the branches of the pulmonary artery (in norm it is equal to 7-10.5 cm).

[20], [21]

Radionuclide ventriculography with pulmonary heart

Radionuclide ventriculography allows you to visually inspect the heart chambers and the main vessels. The study is performed on a scintillation gamma camera using 99mTc. In favor of pulmonary hypertension, a decrease in the right ventricular ejection fraction, especially in a sample with physical exertion, speaks.

Examination of the function of external respiration with a pulmonary heart

Changes due to the underlying disease are found; chronic obstructive bronchitis leads to the development of obstructive respiratory failure (< FVC, < MVL, < MSV); with severe emphysema, a restrictive type of respiratory failure develops (< VCL, < МОД).

[22], [23], [24], [25], [26], [27]

Laboratory data for pulmonary heart disease

The chronic pulmonary heart is characterized by erythrocytosis, high hemoglobin content, delayed ESR, increased tendency to coagulation. With an exacerbation of chronic bronchitis, leukocytosis and an increase in ESR are possible.

The program for examination with a pulmonary heart

1. Common blood tests, urine tests.
2. Biochemical blood test: total protein, protein fractions, sialic acids, fibrin, seromucoid.
3. ECG.
4. Echocardiography.
5. X-ray of the heart and lungs.
6. Spirography.

Example of the formulation of the diagnosis

Chronic purulent obstructive bronchitis in the phase of exacerbation. Diffuse pneumosclerosis. Emphysema of the lungs. DN II of Art. Chronic compensated pulmonary heart.

[28], [29], [30], [31], [32]