Download Cor Pulmonale

Cor Pulmonale
Right heart failure caused by Chronic Pulmonary Hypertension induced by chronic
hypoxia secondary to diseases of the lung, its vessels or the thoracic cage.
Causes
Lung disease
Asthma (severe, chronic)
Bronchiectasis
Pulmonary fibrosis
Multiple pulmonary emboli
Sickle-cell disease
Parasite infestation
Kyphosis
Scoliosis
Thoracoplasty
Myasthenia gravis
Poliomyelitis
Motor neurone disease
Sleep apnoea
Enlarged adenoids in children
Cerebrovascular disease
Pulmonary vascular disease
Thoracic cage abnormality
Neuromuscular disease
Hypoventilation
Typical presentation
CCF +/- infective bronchitis (dyspnoea, cyanosis).
More common in Blue-bloaters than pink puffers.
Typical symptoms  Exertional dyspnoea and fatigue

Pulmonary hypertension Chest pain,
Syncope,
Loud P2,
4th heart sound,
Pulmonary flow murmur,
Diastolic murmur from pulmonary regurgitation

Right heart hypertrophy Right ventricular heave,
Dominant R wave in lead V1 on ECG

Right heart failure
Peripheral oedema,
Anorexia,
Nausea,
Raised JVP from liver and GI engorgement,
Ascites,
Tender smooth hepatomegaly,
Tricuspid regurgitation

Functional tricuspid regurge - because right heart enlarges. Pansystolic murmur, v
wave in the JVP, pulsatile liver, more rarely ascites and right-sided pleural effusion
Tests
 ABGs
 Blood/Sputum cultures if infection suspected clinically
 CXR: Enlarged right atrium and ventricle and prominent pulmonary artery
 ECG: P pulmonale (peaked P wave), right axis deviation, right ventricular
hypertrophy/'strain': tall R in V1, deep S in V6, if severe - inverted T wave in V1-V4
Causes of Pulmonary Hypertension
Increased pulmonary vascular resistance - any cause of chronic hypoxia, primary
pulmonary hypertension, collagen vascular disease, drugs, toxins: crotolaria, denatured
rape-seed oil
High pulmonary blood flow - left to right shunts (VSD, ASD, patent ductus arteriosis).
Increased pulmonary flow leads to increased resistance causing increased right-sided
pressure. Eventually right heart pressure > left heart pressure, shunt reverses causing
cyanosis. Called Eisenmenger's syndrome, irreversible.
Chronic pulmonary venous hypertension - Chronic LVF or mitral stenosis
Management
 If irreversible, or resistant to treatment - steady decline to cor pulmonale and death
 Reduce work load of right heart - reduce pulmonary resistance and arterial pressure
 Treat any underlying condition
 Treat infective exacerbations vigorously
 Continuous oxygen therapy (at least 15h/day) reduces hypoxia, lowers pulmonary
resistance, increases survival
 Treat fluid overload with frusemide and appropriate potassium supplements.
 Venesection may reduce severe polycythaemia
 Consider heart-lung transplantation