Cor Pulmonale

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Contents 1 Introduction 2 Etiology 3 Clinical-manifestations 4 Laboratory 5 Diagnostic-procedures 6 Radiology 7 Complications 8 Management 9 More General Terms 10 Additional Terms 11 References

Introduction

• Enlargement of the right ventricle secondary to disease of the lung, thorax or pulmonary circulation. It may be accompanied by right ventricular failure with elevation of right ventricular end- diastolic pressure.

Etiology

• ( pulmonary hypertension)
• chronic bronchitis (50%), uncommon with emphysema
• pulmonary emboli
• acute respiratory distress syndrome ( ARDS)
• pulmonary vasculitis
• restrictive lung disease

• intrinsic disease

• interstitial fibrosis
• lung resection

• extrinsic disease

• obesity
• myxedema
• kyphoscoliosis
• high altitude
• diminished contraction of muscles of respiration

Clinical-manifestations

• dyspnea

• on exertion or at rest
• not relieved by sitting up

• non-productive cough
• jugular venous distention
• hepatomegaly
• hepatojugular reflux
• ankle edema
• S3 gallop increasing with inspiration may be present
• fixed splitting of 2nd heart sound may be present
• physical findings of right ventricular failure may resolve when pulmonary artery pressure is reduced by relief of hypoxemia

Laboratory

• lung biopsy to demonstrate vasculitis

Diagnostic-procedures

• electrocardiogram:

• evidence of right ventricular hypertrophy
• RBBB in 15%
• multifocal atrial tachycardia may be associated with decompensated COPD

Radiology

• chest X-ray

• enlarged pulmonary trunk & hilar vessels
• widening of right pulmonary artery shadow

• echocardiogram

• enlargement of right ventricular cavity
• elevation of right ventricular systolic pressure
• tricuspid or pulmonic regurgitation may be noted

• magnetic resonance imaging ( MRI)

• right ventricular mass
• wall thickness
• cavity volume
• ejection fraction

• radionuclide ventriculography
• myocardial perfusion scintigraphy (Th[201] or sestamibi)
• cardiac catheterization

• precise measurement of pulmonary vascular pressure
• measurement of pulmonary vascular resistance

• response to oxygen
• response to vasodilators

• pulmonary angiography to assess pulmonary vascular obstruction

Complications

• 
  
• disease interaction(s) of heart failure with urinary incontinence
• disease interaction(s) of obstructive sleep apnea (OSA) with heart failure

Management

• optimal managemnt of underlying lung disorder
• judicious administration of oxygen

• improves pulmonary vasoconstriction secondary to alveolar hypoxia & hypercarbia
• reduces pulmonary artery pressure & pulmonary vascular resistance
• diminished tachypnea & signs of right-sided heart failure

• bronchodilators may reduce airflow obstruction
• diuretic help relieve edema

• loop diuretics may induce metabolic alkalosis & blunt respiratory drive

• digoxin if right ventricular failure is present
• phlebotomy if hematocrit > 55-60%

More General Terms

• heart failure (HF)

Additional Terms

• acute respiratory distress syndrome; acute lung injury (ARDS, ALI)
• chronic obstructive pulmonary disease (COPD)
• pulmonary embolism (PE)
• pulmonary hypertension
• restrictive lung disease

References

1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1324-27
2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 738
3. Smith R., Jewish Home for the Aging, Reseda CA, 2001, unpublished

cor pulmonale (right heart failure, right ventricular failure)