Cor pulmonale

Introduction

• • Enlargement of the right ventricle of the heart

  • Response to increased resistance or high blood pressure in the lungs (pulmonary hypertension)

  • Chronic cor pulmonale usually results in right ventricular hypertrophy (RVH)

  • Acute cor pulmonale usually results in dilatation

Causes

• • Acute:

    • Massive pulmonary embolization

      • Exacerbation of chronic cor pulmonale

  • Chronic:

    • COPD

      • Primary Pulmonary Hypertension

      • Recurrent Pulmonary Embolism

      • Loss of lung tissue following trauma or surgery

    • Pierre Robin sequence

      • End stage Pneumoconiosis

    • Sarcoidosis

      • T1-4 Vertebral subluxation

    • Obstructive sleep apnea

    • Altitude sickness

      • Sickle cell anemia

      • Bronchopulmonary dysplasia (in infants)

Mechanisms

• • Pulmonary vasoconstriction

  • Anatomic changes in vascularization

  • Increased blood viscosity

  • Idiopathic or primary pulmonary hypertension

Signs and Symptoms

• • Loud P2

  • Hepatomegaly

  • Shortness of breath which occurs on exertion but when severe can occur at rest

• Wheezing

  • Chronic wet cough

• Ascites

  • Swelling of the ankles and feet (pedal edema)

  • Enlargement or prominent neck and facial veins

• Enlargement of the liver

  • Bluish discoloration of face

  • Presence of abnormal heart sounds

  • possible bi-phasic atrial response shown on an EKG due to hypertrophy

Investigations

• • Chest X-Ray

    • Right ventricular hypertrophy

    • Right atrial dilatation

    • Prominent pulmonary artery

    • Peripheral lung fields show reduced vascular markings

  • ECG

    • Right axis deviation

    • Prominent R wave in lead V1 & inverted T waves in right precordial leads

    • Large S in Lead I, II and III

    • Large Q in lead III

    • Tall Peaked P waves (P pulmonale) in lead II, III and aVF

• Echocardiogram

  • • Right ventricular dilatation and tricuspid regurgitation is likely

Treatment

• • Elimination of the cause is the most important intervention

  • Continuous oxygen therapy is the mainstay of therapy

  • Judicious use of diuretics is warranted

  • Drugs:

  • Ambrisentan (Letairis)

  • Bosentan (Tracleer)

  • Calcium channel blockers

  • Diuretics

  • Prostacyclin or similar medications

• Sildenafil