Cor Pulmonale

what are 3 causes for acute Cor Pulmonale?

- PE - Withdrawal of pHTN meds - ARDS * patients with pHTN are usually on vasodialtors. disconnecting them will cause acute constriction leading to higher pressures and failure of the right ventricle.

what are the 3 categories of pulmonary embolism?

- acute PE - submassive PE - massive PE

CV blood flow is mediated by (4x)?

- chamber contraction - valves - pressure gradients - vessel compliance

what 3 things modify stroke volume?

- preload - inotropy - afterload

right ventricular dysfucntion/failure as a result of pulmonary disease is known as?

Cor Pulmonale * aka "heart lung disease"

true or false: pulmonary vasodilators may be stopped on a pHTN pt

FALSE! NEVER stop pulmonary vasodilators on a pHTN pt.

true or false: intubation should be one of the initial interventions for cor pulmonale patients

FALSE! it is the absolutely last resort for the management of cor pulmonale * breathing in negative pressures draws blood into the chest improving RV preload, decreases RV afterload and makes cardiac output better. intubating a pt and introducing positive pressure will make everything much worse. * high flow nasal cannula is a great alternative to intubation in these patients

what physical exam finding can help you get an idea of the patient's central venous pressure?

JVP

what can cause the RV afterload to go up very suddenly?

PE

what are causes for chronic Cor Pulmonale?

WHO GROUPS: 1) PAH 2) left sided heart failure 3) chronic lung disease: COPD, LID, OSA, CF 4) CTEPH 5) sarcoid, vasculitis, etc...

patient present ill appearing, with shortness of breath, AMS, and chest pain. these are subjective findings with what type of cor pulmonale?

acute

a clot with no RV strain, with a hemodynamically stable pt describes what category of PE?

acute PE

pt with any of WHO group pulmonary hypertension who develop a PE, ARDS, or severe hypoxemia can fall into what category of Cor Pulmonale?

acute on chornic * acute: no time to adapt to RV dilation

tachycardia, tachypnea, hypoxia, hypotension and cool skin, are objective findings with what type of cor pulmonale?

acute; patients look very ill * like chronic cor pulmonale, JVD can be seen here too.

the force the ventricle must pump against is known as?

afterload (peripheral resistance)

how do pt with chronically high PA pressures compensate?

by remodeling the RV; making the RV larger and constrict blood vessels

a clot with RV strain, with a hemodynamically stable describes what type of PE?

submassive PE

patient presents with shortness of breath, *cough*, *fatigue*, *peripheral edema*, *anorexia*, *GI distress* and *weight gain*. these are subjective findings with what type of cor pulmonale?

chronic cor pulmonale. * much more subtle, when compared to acute.

Ascites, sternal heave, hepato/splenomegaly are objective findings with what type of cor pulmonale?

chronic; subtle findings that mimic other disease. * can also find JVD, seen in acute cor pulmonale as well.

true or false: pretty much all of the WHO groups can fall within the acute Cor Pulmonale umbrella

false! within the chronic cor pulmonale * chronic: there is time for the RV to adapt. RV hyperthrophy with or without dilation

if pressure builds up in a given 'compartment' of the circulation, flow ______, blood backs up, and pressures will build up ______ to that compartment

flow decrease, proximal to. * remember that blood flows from an area of high pressure to an area of lower pressure. this means that if pressure becomes too high flow will decrease to that area.

the strength of ventricular squeeze is known as?

inotropy

mcconnell's sign on echo means?

it is a very specific sign for PE, if you see this it is PE until proven otherwise. with this sign the apex of the heart is normal while the base of the RV is failing. you will see RV dilatation with a normal apex.

in an RV strain in what direction does the septum of the heart move?

it moves right to left, normally should be left to right.

most common cause for chronic cor pulmonale?

left sided heart failure, WHO group 2

concentric fibers, thick wall, and low compliance describes what ventricle?

left ventricle

elevated right sided pressures reduces _____ cardiac output

left ventricle. as the RV dilates it smushes the LV. as the LV gets smaller, cardiac output drops

a clot with RV strain, with a hemodynamically unstable pt describes what type of PE?

massive PE. * remember that the size of the clot doesnt matter, a pt can have a massive PE with a tiny clot and an acute PE with a big clot. the grading scale for PE comes from the effects of the clot of the right ventricle

should you give a cor pulmonale pt fluids?

maybe, you can try a small fluid bolus if you have to. however, the right side of the heart is already overwhelmed with fluids, giving a large bolus will cause the RV even more stress. pts might present with low BP but the hypotension is because of a weak LV not because of hypovolemia.

- high pressure - high resistance - low compliance these describe what type of circulation?

systemic circulation * low compliance high elastnace

end diastolic blood vol. is known as?

preload

how is a pulmonary capillary wedge measured?

pressure is measured when the balloon at the tip of the catheter occludes the pulmonary artery. it measures the pressures distal to it while occluding all pressures proximal to it. It measures the pressures that effect the left atrium.

what pressure do we need to measure to diagnose pulmonary hypertension?

pulmonary artery pressure.

- low pressure - low resistance - high compliance these describe what type of circulation?

pulmonary circulation. * high compliance low elastnace

pulmonary arterial hypertension causes pressures to rise in the _____ atrium and ventricle

right

verticle fibers, thin wall, and high compliance describe what ventricle?

right ventricle * the right ventricle is like a spring collapsing on itself. if pressures go up it does not have the contraction force the left ventricle has so it fails. However, it is very compliant and if can extend to great sizes when it is filled with fluids- like a balloon.

how can dilation of the RV cause reduced perfusion/circulation to the heart muscle?

the RCA comes off the aorta. blood flows from high to low pressures, blood flows from the aorta to the RV. as the right ventricle increases in size and squishes the left side the pressures in the aorta become low. this decreases the coronary blood flow, decreasing perfusion of heart muscle

Starling's law of the heart states that

the volume of blood that enters the heart during diastole directly affects the force of contraction at systole. to put it more simply, the heart pumps more blood when more blood returns

what does 'diastolic step up' mean?

when you move the pulmonary artery catheter into the pulmonary artery you get this diastolic step up because the pulmonary valve closes, preventing pressures from equalizing into the right ventricle.

what does 'systolic step up' mean?

when you move the pulmonary artery catheter into the right ventricle you get a 'systolic step up' because the RV contracts during systole