7 cor pulmonale
TRANSCRIPT
Cor Pulmonale(Pulmonary Heart Disease)
Guo Yubiao, M.D & Ph.D
Pulmonary & Critical Care Medicine The first Affiliated Hospital of Sun-Yat Set University
Presentation Outline
Definition Epidemiology/Classification Clinical manifestations
Symptoms Signs
Diagnostic workup & Differential Diagnosis Diagnosis Differential Diagnosis
Treatment & Prevention Summary
Classification
Acute Cor Pulmonale Massive pulmonary embolism
Chronic Cor Pulmonale
Epidemiology
High prevalence(1992, 4.42‰) District difference Smoking Acute exacerbation
Definition of Chronic Cor Pulmonale
Hypertrophy and dilatation of the right ventricle Secondary to the pulmonary hypertension Caused by disease of the pulmonary parenchym
a, and/or chest wall, and/or pulmonary vascular system
With or without right heart failure Exclusion the causes of congenital heart
disease and left heart disease
Etiology
Pulmonary parenchyma disease COPD80%~90%,asthma,bronchiectasis,severe tuberculosis, idiopathic interstitial pneumonia,
sarcoidosis, eosinophilic granuloma,silicosis, etc.
Disorders of the neuromuscular apparatus and chest wall Poliomyelitis ,Guillain-Barré syndrome,
Kyphoscoliosis
Etiology
Pulmonary vascular disorders chronic pulmonary thromboembolism,
pulmonary arteriolitis, allergic granulomatosis, primary pulmonary hypertension
Others primary alveolar hypoventilation,
sleep apnea syndromes
Pathophysiology
The formation of pulmonary hypertension Functional factors of increase of vascular
resistance Anatomical factors of increase of vascular
resistance Increased blood volume and hyperviscosity
Cardiac disorders and heart failure Damage to other vital organs
Functional factors of increase of vascular resistance
Hypoxia is the most important factor for pulmonary hypertention.
Hypoxic pulmonary vasoconstriction Determined mostly by the ratio of vasoconstrictive
substances to vasodilative substances Leukotriene, 5-HT, Ang II, PAF,EDCF/ NO, PGI2 ,EDRF
Direct effect of hypoxia on the increase of the smooth muscular cell membrane permeability to Ca2+
Acidosis increases the sensitivity of vasoconstriction to hypoxia
Anatomical factors of increase of vascular resistance
Vasculitis Emphysema, increased intra-alveolar
pressure, compressed pulmonary capillaries
Reduction in pulmonary capillary bed Pulmonary vascular remodeling Multiple pulmonary micro-arteriole
thrombosis
Increased blood volume and hyperviscosity
Secondary polycythemia and hyperviscosity Water and sodium retention
Aldosterone Renal arteriole constriction
Cardiac disorders and heart failure
Right ventricular hypertrophy secondary to pulmonary hypertension.
Sustained pulmonary hypertension exceeds the compensation of right ventricle, and causes the increase of right ventricular end diastolic pressure, and dilation and failure of right ventricle.
A few may develop left heart failure.
Damages to other vital organs
Hypoxia and acidosis can also do damages to other vital organs, e.g. brain,liver,kidney,gastrointestine,
endocrine system.
Pulmonary diseases
Hypoxia, hypercapnia/acidosis
Pulmonary Destruction of capillary bed Blood volume ↑
vasoconstrition Blood viscosity ↑
Pulmonary hypertension
Right heart workload↑ Right ventricular hypertrophy
Right heart failure
Impaired Toxic effect from bacteria
Cardiac
myocardial function on myocardium arrythmia
Myocardial hypoxia Recurrent Electrolytic and
Accumulation of lactate pneumonia acid-base disturbance
Clinical manifestations Compensatory stage of the respiratory
and cardiac function De-compensatory stage of the
respiratory and cardiac function
Compensatory stage of the respiratory and cardiac function
Symptoms: cough, sputum, short of breath, dyspnea and palpitation on exertion, fatigue and decrease of exercise tolerance
more severe in acute exacerbation. A few with chest pain or hemoptysis.
Compensatory stage of the respiratory and cardiac function
Signs: cyanosis, signs of emphysema, moist rales and/or rhonchi,
distal heart sound, systolic murmur of tricuspid area, P2>A2 , subxiphoid visible/palpable cardiac impulse, distended jugular venous pulsation
De-compensatory stage of the respiratory and cardiac function
Respiratory failure Symtoms: severe dyspnea,especially at
night, headache, insomnia,inappetence,
somnolence, dizziness,confusion, even delirium.
Signs: congunctiva congestion and edema, retinal vasodilatation, optic papillary edema. weakness or disappear of deep reflexes, pathological reflexes, redness, sweaty
Right heart failure
Symptoms: predominant short of breath,palpitation, inappetence,nausea
Signs: cyanosis,tachycardia,arrhythmia,subxiphoid systolic murmur or even diastolic murmur. Tender hepatomegaly,Hepatojugular reflux, lower extremity edema, ascites
signs
Chest radiography Signs of pulmonary hypertension: Enlarged right descending pulmonary artery with
diameter ≥15mm The ratio of the diameter of right descending
pulmonary artery to trachea≥1.07 Bulge of pulmonary artery/with the height≥3mm dilation of the main pulmonary artery and its
branches with concurrent underperfusion of the peripheral branches
Signs of right ventricular enlargement Signs of underlying diseases and infection
Electrocardiography Right-axis deviation with a frontal plane axis
greater than +90° Marked clockwise rotation of the electrical axis Rv1+Sv5≥1.05mv P-pulmonale pattern Incomplete or rarely complete right bundle
branch block Low voltage QRS Occasional large Q wave or QS in V1,V2, even
V3,suggesting healed myocardial infarction
Electrocardiography of Chronic Cor Pulmonale
Echocardiography The right ventricular outflow ≥ 30 m m The right ventricular internal dimension ≥20mm Anterior RV wall thickness Ratio of left to right ventricular internal dimension <2 Increased right pulmonary artery or pulmonary artery
dimension (Peak systolic pulmonary artery pressure) Increased right atrium dimension
Arterial blood gas analysis
Hypoxemia and/or hypercapnia Respiratory failure: PaO2<60mmHg PaCO2>50mmHg
Serum assessment
Increased RBC count and Hemoglobin Increased blood and plasma viscosity Increased WBC count and neutrophilic
ratio when infection occurs Change of renal or hepatic function Electrolyte imbalance
Others
Pulmonary function test For early stage or non-exacerbation
stage patients Sputum culture
For guidance of antibiotics selection in patients with acute exacerbation stage
Diagnosis
History of COPD and pulmonary parenchymal or chest wall or pulmonary vascular disease,
Symptoms and signs of pulmonary hypertension and right heart dilation or failure,
combined with the signs of right heart hypertrophy and dilation by ECG, X-ray,UCG.
Differential Diagnosis Coronary atherosclerotic heart diseases
History of left heart failure, hypertension, hyperlipoidemia ; Symtoms of angina pectoris, myocardial infarction Left ventricular hypertrophy in P.E. and X-ray, myocardial isc
hemia in ECG Rheumatic heart diseases
History of rheumatic arthritis and myocarditis Usu. involving other cardiac valves Special signs in X-ray, ECG and UCG
Primary cardiomyopathy No history of chronic pulmonary diseases Enlargement of entire heart No signs of pulmonary hypertension in X-ray
Therapy
Stage of Acute exacerbation Control of infection Oxygen therapy Control of heart failure Control of cardiac arrythmia Anticoagulatory therapy Patient care
Control of infection
Antibiotics based on sputum culture Before the culture, based on infection
acquired location and sputum smear gram stain
CAP: G positive; HAP:G negative Penicillins,
aminoglycerides,quinolones and cephalosporins
Secondary fungal infection
Oxygen therapy
Clearance of respiratory tract Correction of hypoxia and
hypercapnia
Control of heart failure Different to heart failure caused by
other cardiac disease May be improved after control of
infection and normality of blood gas Diuretics Vasodilators Positive inotropic agents-digitalis
Diuretics Reduction of blood volume and right
heart load,elimination of edema Small dosage and short period Moderate
degree:HCT .antisterone;Severe cases: furosemide
Adverse effect: alkalosis with low K+&CL-
thickened sputum blood condensation
Vasodilators
Reduction of cardiac pre- and after- load and oxygen consumption, improve the myocardial contractibility.
Adverse effect: low blood pressure, tachycardia and hypoxemia and hypercapnia
Positive inotropic agents-digitalis
Low tolerance to digitalis due to chronic hypoxia and infection: arrhythmia
Correction of hypoxia and hypokalemia before use Low dosage, fast action and fast metabolite agents:
lanatoside C(cedilanid),strophanthin K Indications:
refractory edema after improvement of infection and respiratory function and no effect on diuretics
right heart failure without obvious infection acute left heart failure
Control of arrhythmia:usually self-limited
Anticoagulatory therapy:heparin or low molecular weight heparin
Intensive patient care:monitoring, airway secretion aspiration
Stage of non-exacerbation
Combined with Chinese medicine Long-term home oxygen therapy Pulmonary Rehabilitation Regulation of immune system Nutrition
Complications
Pulmonary encephalopathy Acid-base and electrolyte
disturbance Cardiac arrhythmia:af,aF,at Shock Gastrointestional haemorrhage Disseminated intravascular
coagulation
Prognosis
Recurrent acute exacerbation, progressing with gradually impairment of pulmonary function
Motality of 10%-15% Prolong lifespan and improve
quality of life
Prevention
Smoking cessation Treatment of the predisposing
factors respiratory tract infection, inhalation
of noxious gases, occupational protection, etc
Education
Thank You!