VANIA

Acute Cor Pulmonale

• Cor pulmonale : alteration in the structure &
function of the right ventricle (RV) from
pulmonary hypertension caused by diseases
of the upper or lower airways, lungs, or
pulmonary vasculature.
• It is a state of cardiopulmonary dysfunction
that may result from multiple etiologies rather
than a specific disease state.
• Acute cor pulmonale is a disorder in which the
right ventricle (RV) is dilated and the muscular
wall is stretched thin, usually as a result of
acute pulmonary embolism.
• May present with often life-threatening car-
diogenic shock, or death, but if the patient
survives the initial event, then the RV often
recovers and cor pulmonale no longer exists
after several weeks
The symptoms are most often a result of right ventricular failure:
• Dyspnea, fatigue, chest pain, or syncope with exertion
• Right upper quadrant abdominal pain and anorexia (from passive
hepatic congestion)
• Hoarseness
• Signs of right ventricular failure: jugular venous distention,
peripheral edema, hepatic congestion, ascites, and a right
ventricular third heart sound
• Signs of associated tricuspid regurgitation: holosystolic murmur
heard best along the left parasternal border (augments during
inspira- tion), prominent V-wave on jugular venous pulse, and
pulsatile hepatomegaly (in severe tricuspid regurgitation)
• Rarely, cough and hemoptysis
 Pulmonary embolism
 Potentially life threatening condition
associated with a partial or complete
obstruction of the pulmonary artery caused by
thrombus breaks off from a peripheral veins,
migrate via RV, lodge in the pulmonary artery
circulation
• PHYSICAL FINDINGS & CLINICAL PRESENTATION
– Most common symptom: dyspnea (82%- 85%).
– Tachypnea (30%-60%).
– Cough (30%-40%)
– Wheezing (20%)
– Chest pain: may be nonpleuritic or pleuritic infarction
(40%-49%).
– Syncope (massive PE) (10%-14%).
– Fever, diaphoresis, apprehension.
– Hemoptysis (2%).
 Diagnosis
LABORATORY TESTS
• ABGs may reveal hypoxemia and respiratory alkalosis (decreased Pao2 and
Paco2 and increased pH).
• Alveolar-arteriolar (A-a) oxygen gradient, a measure of the difference in
oxygen con- centration between alveoli and arterial blood, may be
elevated
• High-sensitivity plasma D-dimer measurement: D-dimer assays by ELISA
detect the presence of plasmin-mediated degradation products of fibrin
that contain cross-linked D fragments in the whole blood or plasma.
• Elevated cardiac troponin levels
• Elevated serum BNP levels
• ECG is abnormal
– Frequent abnormalities are sinus tachycardia
– nonspecific ST-segment or T-wave changes
– S-1, Q-3, T-3 pattern (10% of patients)
– T-wave inversion in V to V
1 6

– new-onset atrial fibrillation

– ST segment depression in lead II
• Imaging
• Chest x-ray may be normal; suggestive findings
include elevated diaphragm, pleural effusion,
dilation of pulmonary artery, infil- trate or
consolidation, abrupt vessel cut-off, oligemia
distal to the PE (Westermark sign), or atelectasis
• CT angiography  accurate
• V/Q Lung scan (in patient with normal chest x-ray
examination)
Without hypotension and shock
With hypotension and shock
• Catheter- based thrombectomy or surgical
embolectomy are potential salvage therapies
in patients who cannot receive
anticoagulation or thrombolysis, or whose
condition contin- ues to deteriorate despite
thrombolytics and anticoagulation.
• Acute cor pulmonale may also be seen in cases of
acute respiratory distress syndrome (ARDS)
– hypercapnia/acidosis
– hypoxic pulmonary vasoconstriction, and the effects
of mechanical ventilation
– Treatment  supportive care for ARDS with low tidal
volume ventilation
• Intravenous inotropes may be employed to
support right heart contractility in decompen-
sated right heart failure.
 Hypertensive Emergency
• Acute elevation in BP (≥ 180/110 mmHg)
associated with active end organ damage,
specifically ongoing injury to the brain, heart,
aorta, kidneys and eye.
Rosen’s emergency medicine, 8th ed. p. 1116-23