COR-PULMONALE

S S DANBAUCHI

Objectives

• Define Cor-Pulmonale or Pulmonary heart disease.
• Define briefly Chronic Obstructive Pulmonary Disease.
• Identify common Symptoms and Signs of the COPD patients with the diagnosis of Cor-Pulmonale.
• Outline routine diagnostic tests used to confirm the Cor-Pulmonale diagnosis.
• Recognize standard treatments used for COPD Patients with Cor-Pulmonale.

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Pulmonary Heart Disease (Cor-Pulmonale)

Cor pulmonale is a condition in which there is right ventricle hypertrophy/enlarges (with or without right-sided heart failure) as a result of diseases that affect the structure or function of the lung or its vasculature.

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Any disease affecting the lungs and accompanied by hypoxemia may result in Cor-pulmonale

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Definition of Cor-pulmonale

Pathophysiology

Pulmonary disease can produce physiologic changes that in time affect the heart and cause the right ventricle to hypertrophy/enlarge and eventually fail.

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Any condition that deprives the lungs of oxygen can cause hypoxemia and hypercapnia resulting in ventilatory disorders

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Pathophysiology

Cor-pulmonale

Pathophysiology

There are several mechanisms leading to pulmonary hypertension and cor- pulmonale:

• Pulmonary vasoconstriction (hypoxia)
• Anatomic changes in vascularization (remodeling)
• Increased blood viscosity (polycythemia)
• Idiopathic or primary pulmonary hypertension end result of above changes

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COPD to Cor Pulmonale�

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• The pathway from COPD to Cor-Pulmonale.

Alexandria. healthlibrary. Ca 2008

COPD to Cor- Pulmonale

• The chronic inflammation and hypoventilation causes the pulmonary vasoconstriction and signals the kidney to release erythropoietin in response to the low oxygen levels.

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• This in turn stimulates the bone marrow to produce reticulocytes which are released into the bloodstream to become erythrocytes.

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• Because of the chronic low oxygen levels this process is continually occurring causing an excess of red blood cells (polycythemia).

Pathway of COPD to Cor-Pulmonale

• COPD is the most common cause of Cor- Pulmonale.

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• A chronic increase in pulmonary vascular resistance causes the right ventricle to distend and undergo hypertrophy. When the right ventricle can no longer compensate, it causes an increase in the right ventricular end-diastolic pressure and the right atrial pressure; causing right heart failure know as Cor-Pulmonale.

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• Cor-Pulmonale is a maladaptive response to pulmonary hypertension.

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COPD to Cor Pulmonale

• The progression of COPD results in chronic hypoxic pulmonary vasoconstriction, polycythemia, impaired gas exchange secondary to mucus overproduction and air trapping which destroys the pulmonary vascular bed because of decreased oxygen supply.

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• The progression leads to pulmonary hypertension; which puts a stress on the right ventricle causing it to distend and hypertrophy.

• Hypertrophy to the right ventricle is known as Cor-Pulmonale.

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Lung changes in emphysema

Lung changes in emphysema

Pulmonary hypertension

Causes of Cor-pulmonale

• Acute:
• Pulmonary embolism

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• Exacerbation of chronic cor pulmonale

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• Acute respiratory distress syndrome (ARDS)

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Causes of Cor-pulmonale

• Chronic:
• COPD
• Primary pulmonary hypertension
• Uncontrolled Persistent Asthma
• Destroyed lung syndrome
• Loss of lung tissue following trauma or surgery
• Pierre Robin sequence
• End stage Pneumoconiosis

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Causes of Cor pulmonale

• Sarcoidosis
• T1-4 Vertebral subluxation
• Obstructive sleep apnea (untreated)
• Interstitial lung disease
• Sickle cell anemia
• Bronchopulmonary dysplasia (in infants)
• Severe thoracic kyphoscoliosis

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Etiology of Cor-pulmonale

Clinical Presentation of the Cor-Pulmonale

• Most of the symptoms of Cor-Pulmonale are not often recognized because the symptoms of COPD are similar and can be overlooked. The symptoms of Cor- Pulmonale are: increased weakness, dyspnea, and fatigue, cough etc

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• The clinical exam is very important in detecting these subtle findings.

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• Active or silent precordium, displaced apex (Cardiomegaly), left parasternal heave,

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Symptoms of Cor-pulmonale

Clinical presentation

ECG or EKG changes of PE

• The most common ECG abnormalities in the setting of pulmonary embolism are tachycardia and nonspecific ST-T wave abnormalities. The finding of S₁ Q₃ T₃ is nonspecific and insensitive in the absence of clinical suspicion for pulmonary embolism. The classic findings of right heart strain and acute cor-pulmonale are tall, peaked P waves in lead II (P pulmonale); right axis deviation; right bundle-branch block; an S₁ Q₃ T₃ pattern; or atrial fibrillation

CXR in PE(pulmonary embolism)

• Hampton’s Hump – consists of a pleura based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface.

Right Ventricular changes

Effect on the Heart

Clinical Examination of Patient

• The patient uses home oxygen at 2L/nasal cannula at bedtime.
• The patients resting pulse oximeter reading is ≤90% on room air.
• Bilateral lower extremity pitting edema.
• The patient has jugular venous distension ( raised jugular venous pressure).

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Clinical Examination of Patient

• Right upper quadrant discomfort upon palpation –enlarged liver

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• A holosystolic murmur at the left lower sternal border characteristic of tricuspid insufficient (regurgitation)

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• The patient complains of exertional dyspnea and fatigue despite use of bronchodilators ( Albuterol inhaler and Pulmicort inhaler).

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Compensatory emphysema on the left lung

Congenital emphysema

Destroyed lung syndrome

Destroyed lung syndrome: CT scan

Smokers lungs

Emphysema patient

Ambulatory treatment of COAD, home oxygen administration

Histology of emphysema

����Patient have continued dyspnea, fatigue, and a low pulse oximeter despite wearing oxygen because of�

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• The progression of the COPD causing changes in respiratory function. The increased mucus production and increased resistance to outflow cause the increased SOB and fatigue.

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• The low pulse oximeter reading is as a result of the worsening ventilation-perfusion imbalance in the lungs and increased pulmonary hypertension

Review

• Lets Review. Why does the Cor-Pulmonale . Patient have increased dyspnoea, fatigue, and weakness?

Increased mucus production, increased right sided heart failure, and progression of COPD.

Yes!

Increased cardiac output and Decreased pulmonary vascular resistance.

No.

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We know cor- pulmonale has decreased cardiac output and increased PVR.

??Leukemia.

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No we know that polycythemia is present in cor-pulmonale patients.

Chest Radiograph

The radiograph would show an enlarged pulmonary artery due to pulmonary hypertension. The lateral view would show a loss of retrosternal air space due to the enlargement of the right ventricle.

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Chest x ray of emphysema

Why do we hear a holosystolic murmur?

• The increased intensity of the S2 heart sound (the split second heart sound) is a secondary effect of pulmonary hypertension.
• The tricuspid valve regurgitation of blood because of pulmonary hypertension.

CT Angiogram in PE

• Chest computed tomography scanning demonstrating extensive embolization of the pulmonary arteries.

Chest Radiograph

Learningradiology.com 2012

CT Scan of the chest- lungs with emphysema

Electrocardiogram

The EKG or ECG would possibly show

►a right bundle branch block and right axis deviation because of the right ventricle hypertrophy and atrial enlargement.

► There will be dominant R waves in V1 and V2 and prominent S waves in V5 and V6 because of right ventricular hypertrophy.

►Increased P wave amplitude in Lead II due to right atrial enlargement.

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ECG OR EKG OF CORPULMONALE

ECG OR EKG OF CORPULMONALE

RIGHT VENTRICULAR OVERLOAD

Echocardiogram

The echocardiogram will show

►right ventricular hypertrophy,

►right ventricular dilation

►tricuspid regurgitation due to right ventricular enlargement.

►right atrial enlargement

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Pulmonary Function Test

The pulmonary function test will indicate an

► impaired diffusion capacity due to the acidotic pH.

►It may also show a restrictive ventilatory defect.

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Right Heart Catheterization

• This is considered the gold standard for Cor Pulmonale Diagnosis (many years ago)

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• The patient who presents with chest pain and has non-diagnostic or normal results of the chest radiograph, echocardiogram, EKG, and pulmonary function tests will have a right heart catheterization done to confirm the diagnosis.

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3 Major Physiological Goals of �Cor-Pulmonale Treatment

• Reduce the right ventricular after load causing a reduction of the pulmonary artery pressure.

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• Decrease right ventricular pressure.

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• Improve the contractility of the right ventricle.

Treatment of Cor-pulmonale

Treatment of Patients with Cor- Pulmonale

Oxygen therapy for patients with hypoxemia.

‣The oxygen will improve hypoxic vasoconstriction.

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‣Oxygen also may improve pulmonary artery pressure and pulmonary vascular resistance

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‣ Reduce polycythemia associated with hypoxia.

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Treatment (cont.)

• Diuretic therapy to improve right ventricular function due to increased right ventricular pressures.
• Diuretics must be used carefully because cor- pulmonale patients are preload dependent and an under filling of the right ventricle may decrease the stroke volume and increase their symptoms.
• The diuretics may also increase the patients risk of developing arrhythmias and metabolic acidosis because of the loss of potassium from the diuretics.

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Treatment (cont.)

• Inotropic agents are used to increase the right ventricle contractility and decrease the right ventricle after load by inducing pulmonary vasodilatation.

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Conclusion

• What are the 3 major physiological goals we carry out when treating a patient with Cor- Pulmonale?

Reduce right ventricular afterload.

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Yes! That is one!

Decrease right ventricular pressure.

Yes! That is two!

Improve the contractility of the right ventricle.

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Yes! That is three!

Summary

• Cor pulmonale is a condition in which there is right ventricle hypertrophy/enlarges (with or without right-sided heart failure
• Pulmonary disease can produce physiologic changes that in time affect the heart and cause the right ventricle to hypertrophy/enlarge and eventually fail
• Cor-pulmonale can either be acute or chronic
• The clinical exam is very important in detecting these subtle findings.
• Investigation is aimed at confirming the diagnosis
• Treatment is both non pharmacological and pharmacological

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END