Cor Pulmonale

Basuki Rahmat
Cor Pulmonale
Right Sided Heart Disease, secondarily
caused by abnormalities of lung
parenchyme, airways, thorax, or
respiratory control mechanisms.
Noevidence of other heart conditions,
Acute vs. Chronic
Epidemiology
Prevalence
In the U.S.: 510% of adult heart diseas
es
Chronic obstructive pulmonary disease (
COPD) and chronic bronchitis are respo
nsible for approximately 50% percent of
the cases in North America.
Sex
More common in men than in women

Smoking
Predisposition for venous thrombosis
Residence at high altitude

Patophysiology
Develops in response to acute or chronic changes in the pul
monary vasculature and/or the lung parenchyma that are suf
ficient to cause pulmonary hypertension The common patho
physiologic mechanism in each case is pulmonary hypertens
ion that is sufficient to lead to RV dilation, with or without th
e development of concomitant RV hypertrophy.
The most common mechanisms that lead to pulmonary hype
rtension include vasoconstriction, activation of the clotting c
ascade, and obliteration of pulmonary arterial vessels.

Massive or multiple pulmonary emboli
- Diseases leading to hypoxic vasoconstriction Chronic bronchitis
COPD
Chronic hypoventilation
Obesity
Neuromuscular disease
Chest wall dysfunction
Living at high altitude
- Diseases that cause occlusion of the pulmonary vascular bed Re
current pulmonary thromboembolism
Primary pulmonary hypertension
Venocclusive disease
Collagen vascular disease
Drug-induced lung disease
- Diseases that lead to parenchymal disease Chronic bronchitis
COPD
Bronchiectasis
Cystic fibrosis
Pneumoconiosis
Sarcoidosis
Idiopathic pulmonary fibrosis
Acute cor pulmonale Sudden onset of severe dyspnea and cardiov
ascular collapse
Occurs in the setting of massive pulmonary embolism
Pallor
Sweating
Hypotension
Rapid pulse of small amplitude
Neck vein distention
Pulsatile distended, tender liver
Systolic murmur of tricuspid regurgitation along the left sternal bor
der
Presystolic (S
4
) gallop

Sign n symtomp chronic cor pulmonale
Tachypnea: characteristic feature
Nonproductive cough
Anterior chest pain
Hepatomegaly
Lower extremity edema
Cyanosis due to arterial hypoxemia and low cardiac output
RV heave: palpable along the left sternal border or in the epigastriu
m
High-pitched pulmonary ejection click may be audible to the left of
the upper sternum.
Fixed, narrow splitting of the second heart sound (S2)
Right ventricular protodiastolic gallop (S
3
) increasing during inspirat
ion
Systolic murmur of tricuspid regurgitation augmented by inspiration
Diastolic murmur of pulmonary regurgitation
DIFFERENSIAL DIAGNOSTIC
RV myocardial infarction
Left-sided heart failure
Congenital heart disease with left-to-right shuntin
g
Constrictive pericarditis
Pulmonary Vessel
Restriction
Hypoxia
H
Hypercapnea
A
Acidemia
Anatomic changes
C
Chronic Cor Pulmonale
Rt. Ventricular Failure
Increased
Viscosity
Acidosis
Increased C.O.
Pathologic Features
Lung : consistent with Specific diseases
Common Features: hypertrophy of
microvasculatures
Hallmark : Rt. Ventricular Hypertrophy
60g 200g, > 0.5 CM, RV/LV <2.5
Lt. Ventricular Hypertrophy
Hypertrophy of Carotid Body


Natural History
Several months to years to develop
All ages from child to old people
Repeated infections aggravate RV strain
into RV failure
Initilly respondes well to therapy but
progressively becomes refractory
Prevalence
Emphysema : less frequent
Cronic bronchitis : more common
US : 6-7 % of Heart failure
Delhi : 16%
Sheffield in UK : 30 40%
Autopsy in Chronic Bronchitis : 50%
More prevalent in pollution area or
smokers

Lab. Findings
X-Ray : Prominent pulmonary hilum
pulmonary artery dilatation
Rt MPA > 20 mm
EKG : P- pulmonale, RAD, RVH
Echocardiography : RVH, TR, Pulm.
Hypertension
ABG : Hypoxemia, Hypercapnea,
Respiratory acidosis
CBC : polycythemia
Cardiac catheterization

Treatment
Treat Underlying Disease : COPD Tx, Steroid,
Infection control, theophylline,
medroxyprogesterone,
Continuous O2 : < 2-3L/min
Diuretics
Phlebotomy
Digoxin : controversial
Pul. Vasodilators
Beta adrenergic agents
Reduce Ventilation/Perfusion imbalance :
Amitrine bimesylate
Prognosis
1960-1970 : 3 yr mortality 50-60%

Recent times : 5 - 10 years or more