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lionte_cor_pulmonale2010

lionte_cor_pulmonale2010

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Cor Pulmonale
Cor Pulmonale
C
C\u0103t\u0103lina Lionte, MD, PhD
\u0103t\u0103lina Lionte, MD, PhD
Definition
Definition
\u2022
\u2022Alteration of the right ventricular structure or
Alteration of the right ventricular structure or
function that is due to pulmonary hypertension
function that is due to pulmonary hypertension
(PHTn) caused by diseases affecting the lung or
(PHTn) caused by diseases affecting the lung or
its
itsv asculature
vasculature,
, airways, thorax, or respiratory
airways, thorax, or respiratory
control mechanisms.
control mechanisms.
\u2022
\u2022Excludes
Excludes
\u2013
\u2013Left sided heart dis.
Left sided heart dis.
with 2
with 2nd
ndchanges
changes
\u2013
\u2013Congenital heart dis.
Congenital heart dis.
\u2022
\u2022Cor pulmonale
Cor pulmonalemay be
may be
acute or chronic.
acute or chronic.
The most common
The most common
cause of acute
cause of acuteco r
cor
pulmonale
pulmonale
Massive or multiple
Massive or multiple
pulmonary emboli
pulmonary emboli
Etiology of
Etiology of Cor Pulmonale
Cor Pulmonale( I )
( I )
Lung and Airways
Lung and Airways
\u2022
\u2022COPD
COPD
\u2022
\u2022Asthma
Asthma
\u2022
\u2022Bronchiectasis
Bronchiectasis
\u2022
\u2022DILD (Diffuse
DILD (Diffuse
Infiltrative Lung
Infiltrative Lung
Disease)
Disease)
\u2022
\u2022Pulmonary
Pulmonary
tuberculosis
tuberculosis
Vascular
Vascular
Occlusion
Occlusion
\u2022
\u2022Multiple Emboli
Multiple Emboli
\u2022
\u2022Schistosomiasis
Schistosomiasis
\u2022
\u2022Filariasis
Filariasis
\u2022
\u2022Sickle Cell
Sickle Cell
\u2022
\u2022P. Pulmonary
P. Pulmonary
Hypertension
Hypertension
The most common cause of chronic
The most common cause of chroniccor
cor
pulmonale
pulmonale-
-COPD
COPD
Thoracic Cage
Thoracic Cage
\u2022
\u2022Kyphosis
Kyphosis> 100
> 100o
o
\u2022
\u2022Scoliosis > 120
Scoliosis > 120o
o
\u2022
\u2022Thoracoplasty
Thoracoplasty
\u2022
\u2022Pleural fibrosis
Pleural fibrosis
N
N-
-M Disease
M Disease
\u2022
\u2022Polio
PolioMyelitis
Myelitis
\u2022
\u2022Myasthenia Gravis
Myasthenia Gravis
\u2022
\u2022ALS (
ALS (Amyotrophic
Amyotrophic
lateral sclerosis )
lateral sclerosis )
\u2022
\u2022Muscular
Muscular
Dystrophy
Dystrophy
Etiology of
Etiology of Cor Pulmonale
Cor Pulmonale ( II )
( II )
Abnormal Respiratory Control
Abnormal Respiratory Control
\u2022
\u2022Idiopathic hypoventilation Syndrome
Idiopathic hypoventilation Syndrome
\u2022
\u2022Obesity hypoventilation syndrome
Obesity hypoventilation syndrome
(Pick
(Pick-
-Wickian
Wickiansyndrome)
syndrome)
\u2022
\u2022Cerebrovascular
Cerebrovasculardisease
disease
Etiology of
Etiology of Cor Pulmonale
Cor Pulmonale ( III )
( III )
P
PATHOPHYSIOLOGY
ATHOPHYSIOLOGY
\u2013
\u2013Pulmonary Artery vasoconstriction
Pulmonary Artery vasoconstriction
\u2022
\u2022Alveolar hypoxia
Alveolar hypoxia
\u2022
\u2022Blood acidosis
Blood acidosis
\u2013
\u2013Anatomic red
Anatomic reduction
uctionof pulmonary vascular bed
of pulmonary vascular bed
secondary to lung disorders
\u2022
\u2022Emphysema
Emphysema
\u2022
\u2022Pulmonary emboli
Pulmonary emboli
\u2013
\u2013Increased blood viscosity
Increased blood viscosity
\u2022
\u2022Erythrocytosis (Includes polycythemia)
Erythrocytosis (Includes polycythemia)
\u2022
\u2022Sickle
Sickle-
-cell disease
cell disease
\u2013 Idiopathic primary pulmonary hypertension
Pathophysiological
Pathophysiologicalmechanisms causing pulmonary
mechanisms causing pulmonary
hypertension include:
hypertension include:
Pulmonary Vessel
Restriction
Hypoxia
Hypercapnea
Acidemia
Anatomic changes
Chronic Cor Pulmonale
Right Ventricular Failure
Increased
Viscosity
Acidosis
Increased C.O.
P
PATHOPHYSIOLOGY
ATHOPHYSIOLOGY
Failure of right ventricle:
Failure of right ventricle:
\u2022
\u2022Pulmonary hypertension
Pulmonary hypertension
\u2022
\u2022Myocardial anoxia
Myocardial anoxia
\u2022
\u2022Repeatedly pulmonary infection:
Repeatedly pulmonary infection:
effect of bacterial toxin to the heart
\u2022
\u2022Acid base disorder
Acid base disorder:
:
arrhythmia
Patients with COPD
Patients with COPD
\u2022
\u2022Most frequent cause of cor pulmonale
Most frequent cause of cor pulmonale
\u2022
\u2022Right ventricular hypertrophy (RVH) in
Right ventricular hypertrophy (RVH) in
\u2013
\u201340% of patients with FEV1 < 1.0 L
40% of patients with FEV1 < 1.0 L
\u2013
\u201370% of patients with FEV1 < 0.6 L
70% of patients with FEV1 < 0.6 L
\u2022
\u2022Independent predictors of RVH
Independent predictors of RVH
\u2013
\u2013Hypoxemia
Hypoxemia
\u2013
\u2013Hypercapnea
Hypercapnea
\u2013
\u2013Erythrocytosis (
Erythrocytosis (not Polycythemia
not Polycythemia)
)
Pathologic Features
Pathologic Features
\u2022
\u2022Lung : consistent with
Lung : consistent with
Specific diseases
Specific diseases
\u2022
\u2022Common Features
Common Features:
:
hypertrophy of
hypertrophy of
microvasculatures
microvasculatures
\u2022
\u2022Hallmark :
Hallmark : Rt. Ventricular
Rt. Ventricular
Hypertrophy
Hypertrophy
60g
60g\u2013
\u2013200g, > 0.5 CM,
200g, > 0.5 CM,
RV/LV <2.5
RV/LV <2.5
\u2022
\u2022Left Ventricular
Left Ventricular
Hypertrophy
Hypertrophy
\u2022
\u2022Hypertrophy of Carotid
Hypertrophy of Carotid
Body
Body
Natural History
Natural History
\u2022
\u2022Several months to years to develop
Several months to years to develop
\u2022
\u2022All ages from child to old people
All ages from child to old people
\u2022
\u2022Repeated infections aggravate RV strain
Repeated infections aggravate RV strain
into RV failure
into RV failure
\u2022
\u2022Initilly respondes
Initilly respondeswell to therapy but
well to therapy but
progressively becomes refractory
progressively becomes refractory
Symptoms of CP
Symptoms of CP
\u2022
\u2022Directly attributable to PHTn
Directly attributable to PHTn
\u2013
\u2013Dyspnea on exertion, fatigue, lethargy
Dyspnea on exertion, fatigue, lethargy
\u2013
\u2013Chest pain, syncope with exertion
Chest pain, syncope with exertion
\u2022
\u2022Typical exertional angina
Typical exertional angina
\u2013
\u2013Occurs in patients with primary or secondary PHTn even in the
Occurs in patients with primary or secondary PHTn even in the
absence of epicardial CAD
absence of epicardial CAD
\u2013
\u2013Subendocardial RV ischemia induced by hypoxemia and
Subendocardial RV ischemia induced by hypoxemia and
increased transmural wall tension
increased transmural wall tension
\u2013
\u2013Dynamic compression of left main coronary by enlarged PA
Dynamic compression of left main coronary by enlarged PA
\u2022
\u2022Less common
Less common
\u2013
\u2013Cough, hemoptysis, hoarseness
Cough, hemoptysis, hoarseness
\u2022
\u2022With severe right ventricular (RV) failure
With severe right ventricular (RV) failure
\u2013
\u2013Passive hepatic congestion
Passive hepatic congestion
\u2013
\u2013Anorexia, right upper quadrant discomfort
Anorexia, right upper quadrant discomfort
Physical Findings
Physical Findings
\u2022
\u2022Cardiac findings
Cardiac findings
\u2013
\u2013RVH
RVH
\u2022
\u2022Prominent A wave in the jugular venous pulse.
Prominent A wave in the jugular venous pulse.
with right sided 4
with right sided 4th
thheart sound
heart sound
\u2013
\u2013RV failure leads to systemic venous HTn
RV failure leads to systemic venous HTn
\u2022
\u2022Elevated jugular venous pressure with a prominent
Elevated jugular venous pressure with a prominent
V wave
V wave
\u2022
\u2022RV S3
RV S3
\u2022
\u2022High pitched tricuspid regurgitant (TR) murmur
High pitched tricuspid regurgitant (TR) murmur
\u2013
\u2013Extra cardiac changes
Extra cardiac changes
\u2022
\u2022Hepatomegaly, pulsatile liver
Hepatomegaly, pulsatile liver
\u2022
\u2022peripheral edema
peripheral edema-
-often related to hypercarbia and
often related to hypercarbia and
passive Na+ and water retention
passive Na+ and water retention
Other Areas of Fluid Retention
Other Areas of Fluid Retention
\u2022
\u2022Pleural effusion, often bilateral
Pleural effusion, often bilateral
\u2013
\u2013Right heart failure until proved otherwise
Right heart failure until proved otherwise
\u2013
\u2013Also kidney and liver
Also kidney and liver
\u2022
\u2022Engorged inferior vena cava
Engorged inferior vena cava
\u2022
\u2022Hepatic congestion
Hepatic congestion
\u2022
\u2022Ascites
Ascites
\u2022
\u2022Anasarca
Anasarca
Right Atrial Pressure Tracing
Right Atrial Pressure Tracing
Jugular Pulsations
Jugular Pulsations
A wave
\u2022RAP transmitted to jugular veins (JV)
during right atrial systole
V wave

\u2022Rise in RA and JVP due to continued
inflow of blood to the venous system
during late ventricular systole when the
tricuspid valve is still closed

\u2022May also be elevated in heart failure
and renal failure, but not cirrhosis.
Hepatojugular Reflux
Hepatojugular Reflux
\u2022
\u2022Assessed by applying firm sustained
Assessed by applying firm sustained
pressure over the upper abdomen with pt.
pressure over the upper abdomen with pt.
breathing quietly.
breathing quietly.
\u2022
\u2022Response
Response
\u2013
\u2013Transient elevation by approximately 1 cm in
Transient elevation by approximately 1 cm in
normal response
normal response
\u2013
\u2013In RHF sustained elevation
In RHF sustained elevation
\u2013
\u2013Low specificity and sensitivity
Low specificity and sensitivity

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