Cor pulmonale

Background

• Remodeling of right ventricle in response to pulmonary pathology
• Often caused by COPD, pulmonary hypertension, PE, ARDS

Clinical Features

Pathophysiology

• Pulmonary vasoconstriction (hypoxia, acidemia)
• Destruction of pulmonary vasculature by emphysema, interstitial lung disease
• Increased blood viscosity (sickle cell disease, polycythemia)

Chronic

• RVH

Acute

• RV dilation

Signs and Symptoms

• Cough
• Dyspnea
• Tachypnea
• Hemoptysis
• Syncope
• Peripheral edema
• Cyanosis

Differential Diagnosis

• Cardiovascular
  • ACS
  • Acute Valve Dysfunction
  • Aortic Dissection
  • Dysrhythmia
  • Endocarditis
  • Hypertensive Emergency
  • Pericardial Tamponade
• Pulmonary
  • COPD
  • PE
  • pneumonia
• Other
  • Pure volume overload
    • Renal Failure
    • Post-Transfusion
  • Sepsis

Evaluation

Blood tests

• CBC (polycythemia)
• ABG (oxygenation, acid-base status)
• α-1-antitrypsin
• ANA
• Coagulation studies (protein C/S, factor V Leiden etc)

CXR

• Enlarged pulmonary arteries
• Cardiomegaly
• Decreased retrosternal air space

ECG

• RVH
• Right axis deviation
• Right bundle branch block
• R:S ratio > 1 in V1
• TWI in V1-3 in acute right heart strain (as opposed to upright t-waves in posterior MI)
• S1 Q3 T3 in acute right heart strain
• Large P wave in II, III, aVF
• Arrhythmia (PAC, SVT, MFAT, A-fib, A-flutter)

Echocardiography

• Increased RV thickness
• RV dilation
• Tricuspid insufficiency
• High estimated PA pressures
• Septal bowing into LV

Management

• Treat underlying disease
• Fluids, vasoconstrictors to support BP in acute setting
• Oxygen therapy: decreases pulmonary vasoconstriction
• Diuretics: decrease RV filling volume
• Calcium channel blockers: vasodilate the pulmonary arteries
• Beta agonists (epoprostenol, iloprost): bronchodilate
• Phlebotomy for severe hypoxia leading to polycythemia
• Lung transplant or heart-lung transplant as last resort

See Also

• Pulmonary Embolism
• COPD