COR PULMONALE

PREPARED BY:
Baylon, Henessy Nikka
Bermejo Sr. Leony
Brusola Jezalyn
Dimaiwat Janlyn
Fuentes Jon Deider
Magistrado Chenille Shaira Mariah
Obis Christine Joy
Olaso Jane Bernadette
Revereza Shierra May
Sumpay Jessamine
Tataro Cyrus
Velitario Juvy Anne

GROUP 3

DEFINITION
is a condition that causes the right side of the heart to fail. Long-term high blood
pressure in the arteries of the lung and right ventricle of the heart can lead to cor
pulmonale.

Description
This term describes impairment in right ventricular function as a result of respiratory
disease leading to increased resistance to blood flow in the pulmonary circulation.
The structure and function of the right ventricle is adversely affected by pulmonary
arterial hypertension, induced by a disease process affecting the lungs, their ventilation
or blood supply. For cor pulmonale to come about, mean pulmonary arterial pressure is
usually >20 mm Hg. Complete right ventricular failure usually ensues if mean pulmonary
arterial pressure is 40 mm Hg. It is thought that chronic hypoxia leads to pulmonary
arteriolar constriction through excessive action of the physiological mechanism that acts
to maintain the balance of ventilation and perfusion in the lungs.
Other mechanisms that may raise mean pulmonary arterial pressure in cases of cor
pulmonale include:

Chronic hypercapnoea and respiratory acidosis causing pulmonary

vasoconstriction.
Anatomic disruption of the pulmonary vascular bed due to primary lung disease
(for example, in emphysema, pulmonary thromboembolic disease and pulmonary
fibrosis).
Increased blood viscosity due to lung disease and its effects (for example, in
secondary polycythaemia).

A wide range of pulmonary and cardiopulmonary disease processes may cause the
condition. It is usually a chronic and progressive process, but does occur acutely due to
sudden causes of pulmonary hypertension, usually following pulmonary embolism.
If right-heart failure occurs due to primary disease of the left side of the heart, or
because of a congenital cardiac lesion then it is not normally considered to be cor
pulmonale.

ANATOMY AND PHYSIOLOGY

Human Cardiovascular System

The cardiovascular system consists of the heart, which is an anatomical pump, with its
intricate conduits (arteries, veins, and capillaries) that traverse the whole human body
carrying blood. The blood contains oxygen, nutrients, wastes, and immune and other
functional cells that help provide for homeostasis and basic functions of human cells
and organs.[1, 2]
The pumping action of the heart usually maintains a balance between cardiac output
and venous return. Cardiac output (CO) is the amount of blood pumped out by each
ventricle in one minute. The normal adult blood volume is 5 liters (a little over 1 gallon)
and it usually passes through the heart once a minute. Note that cardiac output varies
with the demands of the body.[3]
The cardiac cycle refers to events that occur during one heart beat and is split into
ventricular systole (contraction/ejection phase) and diastole (relaxation/filling phase). A
normal heart rate is approximately 72 beats/minute, and the cardiac cycle spreads over
0.8 seconds. The heart sounds transmitted are due to closing of heart valves, and
abnormal heart sounds, called murmurs, usually represent valve incompetency or
abnormalities.[4]
Blood is transported through the whole body by a continuum of blood vessels. Arteries
are blood vessels that transport blood away from the heart, and veins transport the
blood back to the heart. Capillaries carry blood to tissue cells and are the exchange
sites of nutrients, gases, wastes, etc.[5]

Heart
The heart is a muscular organ weighing between 250-350 grams located obliquely in
the mediastinum. It functions as a pump supplying blood to the body and accepting it in
return for transmission to the pulmonary circuit for gas exchange.
The heart contains 4 chambers that essentially make up 2 sides of 2 chamber (atrium
and ventricle) circuits; the left side chambers supply the systemic circulation, and the
right side chambers supply the pulmonary circulation. The chambers of each side are
separated by an atrioventricular valve (A-V valve). The left-sided chambers are
separated by the mitral (bicuspid) valve, and right-sided chambers are divided by the
tricuspid valve. Blood flows through the heart in only one direction enforced by a
valvular system that regulates opening and closure of valves based on pressure
gradients (see image below).

Unique properties of cardiac muscle

Cardiac muscle cells are branching striated, uninucleate (single nucleus) cells that
contain myofibrils.
Adjacent cardiac cells are connected by intercalated discs containing desmosomes and
gap junctions. The myocardium behaves as a functional syncytium because of electrical
coupling action provided by gap junctions.
Cardiac muscle has abundant mitochondria that depend on aerobic respiration primarily
to generate adenosine tri-phosphate (ATP), the molecule that provides energy for
cellular function (see the images below).

Cardiac muscle cells.

Myocardial gap junctions.

Systemic Circulation
The systemic circuit originates in the left side of the heart and functions by receiving
oxygen-laden blood into the left atrium from the lungs and flows one way down into the
left ventricle via the mitral valve. From the left ventricle, oxygen rich blood is pumped to
all organs of the human body through the aortic semilunar valve (see the image below).

Systemic and pulmonary circulation.

Pulmonary Circulation
The pulmonary circuit is on the right side of the heart and serves the function of gas
exchange. Oxygen-poor systemic blood reaches the right atrium via 3 major venous
structures: the superior vena cava, inferior vena cava, and coronary sinus. This blood is
pumped down to the right ventricle via the tricuspid valve and eventually through the
pulmonic valve, leading to the pulmonary trunk that takes the oxygen deprived blood to
the lungs for gas exchange. Once gas exchange occurs in the lung tissue, the oxygenladen blood is carried to the left atrium via the pulmonary veins, hence completing the
pulmonary circuit (see the image above).

Coronary Circulation
Coronary circulation is the circulation to the heart organ itself. The right and left
coronary arteries branch from the ascending aorta and, through their branches (anterior
and posterior interventricular, marginal and circumflex arteries), supply the heart muscle
(myocardial) tissue. Venous blood collected by the cardiac veins (great, middle, small,
and anterior) flows into the coronary sinus. Delivery of oxygen-rich blood to the
myocardial tissue occurs during the heart relaxation phase (see the image below).

Coronary circulation.
Vessel Anatomy
An artery is a blood vessel that carries blood away from the heart to peripheral organs
(see the image below). They are subdivided into larger conducting arteries, smaller
distributing arteries, and the smallest arteries, known as arterioles, that supply the
capillary bed (the site of active tissue cells gas exchange).

Arterial cross-section.

Capillaries are vessels that are microscopic in size and provide a site of gas, ion,
nutrient, and cellular exchange between blood and interstitial fluid. They have
fenestrations that allow for and enhance permeability for exchange of gas, ion, nutrient,
and cellular elements (see the image below).

Capillary structure.
A vein is a blood vessel that has a larger lumen, and sometimes veins serve as blood
reservoirs or capacitance vessels, containing valves that prevent backflow. This system
of vessels in general returns blood to the heart from the periphery (see the image
below).

Veins: blood flow and valve structure.

PATHOPHYSIOLOGY
Cor pulmonale usually presents chronically, but 2 main conditions can cause acute cor
pulmonale: pulmonary embolism (more common) and acute respiratory distress
syndrome (ARDS). The underlying pathophysiology in massive pulmonary embolism
causing cor pulmonale is the sudden increase in pulmonary resistance. In ARDS, 2
factors cause right ventricular (RV) overload: the pathologic features of the syndrome
itself and mechanical ventilation. Mechanical ventilation, especially higher tidal volume,
requires a higher transpulmonary pressure.
In chronic cor pulmonale, RV hypertrophy (RVH) generally predominates. In acute cor
pulmonale, right ventricular dilatation mainly occurs. In the case of ARDS, cor
pulmonale is associated with increased possibility of right-to-left shunt through the
patent foramen ovale and carries a poorer prognosis.[2]
Several different pathophysiologic mechanisms can lead to pulmonary hypertension
and, subsequently, to cor pulmonale. These pathogenetic mechanisms include the
following:

Pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia This can

result in pulmonary hypertension and if the hypertension is severe enough, it
causes cor pulmonale.
Anatomic compromise of the pulmonary vascular bed secondary to parenchymal
or alveolar lung disorders (eg, emphysema, pulmonary thromboembolism,
interstitial lung disease, adult respiratory distress syndrome, and rheumatoid
disorders) These conditions can cause elevated pulmonary blood pressure.
Chronic obstructive pulmonary disorder is the most common cause of cor
pulmonale, and some connective tissue disorders with pulmonary involvement
may result in pulmonary hypertension and cor pulmonale.
Increased blood viscosity secondary to blood disorders (eg, polycythemia vera,
sickle cell disease, macroglobulinemia)
Increased blood flow in pulmonary vasculature
Idiopathic primary pulmonary hypertension

The result of the above mechanisms is increased pulmonary arterial pressure.

RV and LV output
The RV is a thin-walled chamber that is more a volume pump than a pressure pump. It
adapts better to changing preloads than afterloads. With an increase in afterload, the
RV increases systolic pressure to keep the gradient. At a point, a further increase in the
degree of pulmonary arterial pressure produces significant RV dilatation, an increase in
RV end-diastolic pressure, and RV circulatory collapse.

A decrease in RV output with a decrease in diastolic left ventricle (LV) volume results in
decreased LV output. Because the right coronary artery, which supplies the RV free
wall, originates from the aorta, decreased LV output diminishes blood pressure in the
aorta and decreases right coronary blood flow. What ensues is a vicious cycle between
decreases in LV and RV output.

RV and LV morphogenesis
Genetic investigations have confirmed that morphogenesis of the right and left ventricle
originated from different sets of progenitor cells and sites. This polymorphism could
explain the differing rates of hypertrophy of the right and left ventricles. [3]

RV overload
Right ventricular overload is associated with septal displacement toward the left
ventricle. Septal displacement, which is seen on echocardiography, can be another
factor that decreases LV volume and output in the setting of cor pulmonale and RV
enlargement.

Causes
High blood pressure in the arteries of the lungs is called pulmonary hypertension. It is
the most common cause of cor pulmonale.
In people who have pulmonary hypertension, changes in the small blood vessels inside
the lungs can lead to increased blood pressure in the right side of the heart. This makes
it harder for the heart to pump blood to the lungs. If this high pressure continues, it puts
a strain on the right side of the heart. That strain can cause cor pulmonale.
Chronic lung conditions that cause low blood oxygen levels in the blood over a long time
can also lead to cor pulmonale. A few of these are:

Chronic obstructive pulmonary disease (COPD)

Chronic blood clots in the lungs
Cystic fibrosis (CF)
Scarring of the lung tissue (interstitial lung disease)
Severe curving of the upper part of the spine (kyphoscoliosis)
Obstructive sleep apnea, which causes stops in breathing because of airway
inflammation

Symptoms

Shortness of breath or light-headedness during activity is often the first symptom of cor
pulmonale. You may also have a fast heartbeat and feel like your heart is pounding.
Over time, symptoms occur with lighter activity or even while you are at rest. Some
symptoms you may have are:

Fainting spells during activity

Chest discomfort, usually in the front of the chest

Chest pain

Swelling of the feet or ankles

Symptoms of lung disorders, such as wheezing or coughing

Lips and fingers that turn blue (cyanosis)

Exams and Tests

Your health care provider will perform a physical exam. This may show:

Fluid buildup in your belly

Abnormal heart sounds

Bluish skin

Liver swelling

Swelling of the neck veins, which is a sign of high pressure in the right side of the heart

Ankle swelling
These tests may help diagnose cor pulmonale:

Blood antibody tests

Blood test to check for a substance called brain natriuretic peptide (BNP)

Chest x-ray
CT scan of the chest, with or without an injection of a contrast fluid (dye)
Echocardiogram (ECG or EKG)
Lung biopsy (rarely done)

Measurement of blood oxygen by checking arterial blood gas (ABG)

Pulmonary (lung) function tests
Right heart catheterization
Ventilation and perfusion scan of the lungs (V/Q scan)

Treatment
The goal of treatment is to control symptoms. It is important to treat medical problems
that cause pulmonary hypertension, because they can lead to cor pulmonale.
Many treatment options are available. Your doctor will decide which medicine is best for
you. In general, the cause of your cor pulmonale will determine which treatment you
receive.
If your doctor prescribes medicines, you may take them by mouth (oral), receive them
through a tube that goes into a vein (intravenous or IV), or breathe them in (inhaled).
You will be closely monitored during treatment to watch for side effects and to see how
well the medicine works for you. Never stop taking your medicines without first talking to
your doctor.
Other treatments may include:

Blood thinners to reduce the risk of blood clots

Oxygen therapy at home

A lung or heart-lung transplant, if medicine does not work

Important tips to follow:

Avoid strenuous activities and heavy lifting.

Avoid traveling to high altitudes.

Get a yearly flu vaccine, as well as other vaccines, such as the pneumonia vaccine.

If you smoke, stop.

Use oxygen if your doctor prescribes it.

Do not get pregnant (women).

Outlook (Prognosis)
How well you do depends on the cause of your cor pulmonale.
As your illness gets worse, you will need to make changes to your home so that you can
manage as well as possible. You will also need help around your house.

Possible Complications
Cor pulmonale may lead to:

Life-threatening shortness of breath

Severe fluid buildup in your body

Shock
Death

When to Contact a Medical Professional

Call your doctor or nurse if you have shortness of breath or chest pain.

Prevention
Avoid cigarette smoking to help prevent lung disease, because lung disease can lead to
cor pulmonale.

Alternative Names
Right-sided heart failure