Cor Pulmonale
Physical exam findings
Prominent jugular venous a wave JVD Pitting peripheral edema Hepatojugular reflux Pulsatile liver
What is cor pulmonale?
Alteration in the structure and/or function of the right ventricle caused by a primary disorder of the respiratory system
Most common cause of Cor pulmonale
COPD
What causes chronic CP?
COPD
What is the most common cause of CP?
COPD
Cor Pulmonale
Defined as an alteration in the structure (hypertrophy or dilatation) and/ or function of the right ventricle caused by a primary disorder of the respiratory system
Echocardiography
Detects structural changes and estimates function Recognizes RVH Paradoxical bulging of the interventricular septum into the LV during systole Right ventricular dilatation Tricuspid regurgitation and right atrial enlargement Estimates pulmonary artery pressure
chest x-ray
Enlargement of central pulmonary arteries (PH) Oligemic peripheral lung fields Loss of retrosternal air space (RV hypertrophy) Increase in transverse diameter of heart shadow to the right (right ventricular enlargement)
Laboratory studies
Hemoglobin for polycythemia Serum alpha 1-antitrypsin levels- congenital problem for COPD Coagulation studies Arterial blood gases BNP
How does the right ventricle respond to chronic changes in afterload?
Hypertrophy
Clinical exam
Lung disease - wheezes, rales, rhonchi hyper resonance to percussion pulmonary hypertension increased P2 persistent splitting of second sound holosystolic murmur diastolic murmur
What causes acute CP?
Massive PE
Prognosis
Not good
Acute Cor Pumonale two main reasons
PE ARDS
How does the right ventricle respond to acute changes in afterload?
PE and Ards will cause rv dilatation
How do we diagnose CP?
Right heart cath
Why do patients with acute CP develop hemodynamic compromise?
Right ventricle dilates, and pushes inter-ventricular septum, it then decreases LV preload .
Pathophysiology
The right ventricle (RV) is normally thin-walled The RV is more a volume pump than a pressure pump Adapts better to changing preloads than afterloads Chronic increased afterload results in right ventricular hypertrophy (RVH) When hypertrophy can no longer compensate, RV dilates RV overload displaces interventricular septum resulting in decreased LV preload and subsequent decreased cardiac output Can also present as acute disease
Physical exam
Underlying lung disease pulmonary hypertension right ventricular hypertrophy right heart failure
As someone progresses
angina hemoptysis exertion syncope anorexia RUQ abdominal pain jaundice peripheral edema
PE studies
someone with chronic clots may develop chronic cor pulomonale
History
symptoms nonspecific and slowly progressive dyspnea on exertion cough fatigue lethargy
Therapy goals
decrease pulmonary artery pressure decrease pressure in the right ventricle improve how well right ventricle contracts
Reduction of RV pressure
diuretic but it is often not tolerated well
Reduction of RV after load
if they are hypoxic, and if the have pulmonary hypertension CCB
Improvement of RV contractility
no effective oral agents IV agents dobutamine, milirone rescue therapy for hemodynamically unstable patients
Right sided heart disease EKG
right axis deviation right bundle branch block RV hypertrophy Right atrial enlargement
What is the gold standard in diagnosis
right heart catheterization
what do you do for acute Cor pumonale
thrombolytic therapy, especially if it is due to a PE