Cor pulmonale

Published on 02/04/2015 by admin

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Last modified 22/04/2025

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102 Cor pulmonale

Instruction

Examine this patient’s chest.

Salient features

History

• Symptoms of COPD (p. 369)

• Easy fatiguability, shortness of breath on exertion, weakness

• Leg oedema, and right upper quadrant pain.

Examination

• Patient is short of breath at rest and is centrally cyanosed

• Tar staining of the fingers

• JVP is raised: both ‘a’ and ‘v’ waves are seen, ‘v’ waves being prominent if there is associated tricuspid regurgitation

• On examination of the chest, there is bilateral wheeze and other signs of chronic bronchitis (p. 368).

Proceed as follows:

• Examine the cardiovascular system for signs of pulmonary hypertension:

• Left parasternal heave (often absent when the chest is barrel shaped)
• Right ventricular gallop rhythm
• Loud P and a loud ejection click
• Pansystolic murmur of tricuspid regurgitation
• Early diastolic Graham Steell murmur in the pulmonary area.

• Look for signs of:

• Hepatomegaly
• Pedal oedema.

Diagnosis

This patient has chronic cor pulmonale (lesion) caused by long-standing COAD (aetiology) and is in congestive cardiac failure (functional status).

Questions

What do you understand by the term cor pulmonale?

Cor pulmonale is right ventricular enlargement caused by the increase in afterload that occurs in diseases of the lung, chest wall or pulmonary circulation.

Mention a few causes of cor pulmonale

Respiratory disorders:

• Obstructive:

• COAD
• Chronic persistent asthma.

• Restrictive:

• Intrinsic: interstitial fibrosis, lung resection
• Extrinsic: obesity, muscle weakness, kyphoscoliosis, high altitude.

Pulmonary vascular disorders:

• Pulmonary emboli (Fig. 102.1)

• Vasculitis of the small pulmonary arteries

• Adult respiratory distress syndrome

• Primary pulmonary hypertension.

image

Fig. 102.1 Acute cor pulmonale secondary to pulmonary embolism simulating inferior and anterior infarction. An S1Q3T3, a QR in V1 with poor R wave progression in the right precordial leads (‘clockwise rotation’), and right precordial to midprecordial T wave inversion (V1 to V4). The S1Q3 pattern is usually associated with a QR or QS complex, but not an rS, in aVR. Furthermore, acute cor pulmonale per se does not cause prominent Q waves in II (only in III and aVF).

Advanced-level questions

How would you manage a patient with cor pulmonale?

• Treat the underlying cause

• Treat respiratory failure. If Pao is <8 kPa, administer 24% oxygen. There is no need for oxygen if Pao is >8 kPa. Monitor blood gases after 30 min. If Paco2 is rising (by 1 kPa), monitor blood gases hourly. If Paco2 continues to rise, administer doxapram. If, in spite of this, the deterioration continues, the patient may merit artificial ventilation

• Treat cardiac failure with furosemide

• Consider venesection if the haematocrit is >55% (Lancet 1989;ii:20–1)

• Consider heart–lung transplantation in young patients.

What is the prognosis in cor pulmonale?

Approximately 50% of patients succumb within 5 years.

What is the relationship between chronic obstructive pulmonary disease and left ventricular function?

Even early-stage COPD influences stroke volume and left ventricular size. Left ventricular volume and stroke volume are decreased in COPD without changes in the LV ejection fraction. This decrease is related to the percent emphysema and to the degree of airway obstruction (N Engl J Med 2010;362:217–27). This impairment in left ventricular filling is probably caused by endothelial dysfunction (and not just loss) of the pulmonary microvasculature as a result of smoking.

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