Cardiac Causes of Hemoptysis

Hemoptysis, or coughing up blood, can arise from a variety of causes, with cardiac conditions being an important and often overlooked source. Among the cardiac causes of hemoptysis are mitral stenosis, left ventricular heart failure, pulmonary embolism, and several other less common heart-related issues.

What are Cardiac Causes of Hemoptysis?

Mitral Stenosis

Mitral stenosis is one of the most common cardiac causes of massive hemoptysis. This condition involves narrowing of the mitral valve, which impedes the flow of blood from the left atrium into the left ventricle. As a result, blood backs up into the pulmonary veins, leading to increased pressure within the pulmonary vasculature. This elevated pressure can cause capillary rupture, leading to blood leaking into the alveoli of the lungs, which can be coughed up as hemoptysis.
Symptoms associated with mitral stenosis include dyspnea (shortness of breath), crackles in the lungs (heard on auscultation), orthopnea (difficulty breathing while lying down), and signs of volume overload such as swollen ankles or legs due to fluid retention. If left untreated, the condition can progress to pulmonary edema and severe respiratory distress.

Left Ventricular Heart Failure

Left ventricular heart failure is another significant cause of hemoptysis, often due to the development of pulmonary venous hypertension. In this condition, the weakened left ventricle is unable to pump blood efficiently, causing blood to back up in the lungs. This congestion leads to fluid leakage from the capillaries into the alveoli, and in some cases, blood can be present in the sputum.
Patients with left ventricular heart failure may experience symptoms such as shortness of breath, fatigue, pulmonary crackles, and orthopnea. As the condition progresses, patients may also exhibit signs of systemic fluid overload, including peripheral edema and jugular venous distention.

Pulmonary Embolism

Pulmonary embolism (PE) is a serious, often life-threatening condition caused by a blockage in one of the pulmonary arteries, usually due to a blood clot that has traveled from the deep veins in the legs (deep vein thrombosis). Although hemoptysis can occur with PE, it is more common in individuals who have underlying cardiopulmonary disease, such as chronic obstructive pulmonary disease (COPD) or heart failure. The blockage of the pulmonary artery causes increased pressure within the lung vasculature, which can rupture small blood vessels and lead to bleeding.
Symptoms of PE include sudden chest pain, shortness of breath, tachypnea (rapid breathing), cough, and in severe cases, hemoptysis. The diagnosis is often confirmed with imaging studies such as CT pulmonary angiography.

What are Other Cardiac Causes of Hemoptysis?

Right-Sided Infective Endocarditis with Septic Pulmonary Emboli

In cases of right-sided infective endocarditis, septic emboli can travel to the lungs through the right side of the heart. These emboli can cause localized inflammation and tissue damage in the pulmonary arteries, leading to hemoptysis. This is more likely to occur in patients with predisposing factors such as intravenous drug use or structural heart disease.

Aortic Aneurysm with Leakage into the Pulmonary Parenchyma

An aortic aneurysm, particularly one involving the ascending aorta, can erode into the nearby structures, including the pulmonary parenchyma (lung tissue). When this occurs, blood can leak into the lungs and cause hemoptysis. This is a rare but serious cause of bleeding from the respiratory tract, and is often associated with other signs of aortic dissection or rupture.

Pulmonary Artery Aneurysm

A pulmonary artery aneurysm is an uncommon but potentially serious cause of hemoptysis. This occurs when there is a dilation or bulging of the pulmonary artery, which can rupture and cause bleeding into the lungs. In addition to hemoptysis, patients with this condition may present with pleuritic chest pain, dyspnea, or signs of right heart failure.

What are Non-Cardiac Causes of Hemoptysis?

While cardiac causes are significant, there are also numerous non-cardiac causes of hemoptysis that must be considered:

Tuberculosis (TB)

TB is a major infectious cause of hemoptysis, especially in endemic regions. Active pulmonary tuberculosis can lead to cavitary lesions in the lungs, which may rupture into blood vessels, causing bloody sputum.

Bronchiectasis

Bronchiectasis is characterized by permanent dilation of the bronchi, which can lead to chronic infection, inflammation, and local vascular damage, resulting in recurrent hemoptysis.

Lung Abscess

A lung abscess, typically a complication of bacterial infection, can also cause hemoptysis when the infected tissue erodes into blood vessels.

Aspergilloma

Aspergilloma, a fungal ball that grows within pre-existing lung cavities, can result in hemoptysis, particularly in individuals with chronic lung disease.

Pneumonia

Severe pneumonia, especially when complicated by necrotizing infection, can result in the rupture of small blood vessels and hemoptysis.

Diagnosis and Evaluation

The diagnosis of hemoptysis requires a comprehensive approach. A healthcare provider will typically begin with a detailed medical history and a physical examination, paying particular attention to signs of heart failure, lung disease, or infection. Blood tests, including a complete blood count (CBC), coagulation studies, and cultures, may be performed to assess for infection or clotting abnormalities.

Imaging studies, such as chest X-ray or CT scan, are often used to identify lung pathology, while echocardiography or cardiac MRI can help evaluate cardiac causes. If needed, bronchoscopy may be performed to directly visualize the airway and obtain samples for microbiologic testing or biopsy.

Conclusion

Hemoptysis can be caused by a wide variety of conditions, and cardiac diseases play an important role in its pathogenesis. Timely recognition of these conditions is essential for appropriate management and to prevent life-threatening complications. Healthcare providers rely on a combination of clinical evaluation, imaging, and laboratory tests to determine the underlying cause of hemoptysis and guide treatment decisions.