Haemoptysis
Cardiac causes are few but important: mitral stenosis, pulmonary oedema, PE with infarction and pulmonary hypertension.
Echo approach, step by step
Most haemoptysis is pulmonary (bronchitis, bronchiectasis, tuberculosis, cancer). The cardiovascular causes are raised pulmonary venous pressure (mitral stenosis, acute pulmonary oedema), pulmonary infarction (PE), pulmonary hypertension and vascular malformations [6,8,124].
- Mitral valveRheumatic MS: planimetry, gradient, PASP [6].
- LV and filling pressureAcute pulmonary oedema (pink frothy sputum) [2,12].
- RV and PAPE signs, PH probability [8,124].
- SalineLate bubbles → pulmonary AVM [176].
- CongenitalEisenmenger physiology [25].
- Mitral valve (MS)
- LV function, filling pressure
- RV, PASP
- Saline study (AVM)
Causes & echo clues
| Cause | Echo clue | Next |
|---|---|---|
| Mitral stenosis | Commissural fusion, small MVA, high PASP | PMC or surgery [6] |
| Acute pulmonary oedema | Low EF or acute valve lesion; B-lines | Treat HF [12] |
| PE with infarction | RV strain (may be normal) | CTPA [124] |
| Pulmonary hypertension (PAH, CTEPH) | High TR velocity, RV dilatation | PH centre [8] |
| Pulmonary AVM | Late bubbles | CT [176] |
| Non-cardiac (TB, cancer, bronchiectasis) | Normal echo | CT, bronchoscopy |
Clinical pathway to the diagnosis
- Airway, breathing, bleeding sourceIs it haemoptysis or haematemesis? Check the volume and coagulation.
- Chest X-ray and CT (CT angiography if massive).
- EchoIf there is a murmur, AF, heart failure, PE risk or unexplained PH.
- BronchoscopyFor localisation when non-cardiac.
Clinical pearls & pitfalls
Practical tipHaemoptysis in pregnancy unmasks previously silent rheumatic MS as heart rate and volume rise. A diastolic murmur and echo make the diagnosis [6].
- Anticoagulated patient with haemoptysis: still look for the underlying lesion [124].
Red flags
- Massive haemoptysis (airway threat) — secure the airway first
- Young woman, pregnancy or AF with haemoptysis → mitral stenosis [6]
- Pleuritic pain, tachycardia, hypoxaemia → PE with infarction [124]
- Anticoagulation or antiplatelet therapy