PANCE Blueprint Pulmonary (10%)

Cor pulmonale

Patient will present as → a 65-year-old man comes to the office due to 3 days of progressive dyspnea and purulent sputum production. The patient takes albuterol and tiotropium bromide for moderate chronic obstructive pulmonary disease. His medical history is relevant for a 40-pack-year smoking history, type II diabetes mellitus, hyperlipidemia, and coronary artery stenting 2 years ago. Physical exam shows a barrel-shaped chest, inspiratory crackles, hepatojugular reflux, pulsus paradoxus, and ventricular gallop. His temperature is 38.1°C (100.5°F), the pulse is 130/min, respirations are 28/min, blood pressure is 130/84 mmHg, and pulse oximetry on room air shows an oxygen saturation of 86%.

Cor pulmonale is right ventricular enlargement and eventually failure secondary to a lung disorder that causes pulmonary artery hypertension

  • Lung disorders such as PE, vasculitis, ARDS, COPD (most common), asthma, and ILD cause pulmonary artery hypertension
  • Pulmonary artery hypertension then leads to right ventricular failure
  • Findings include peripheral edema, neck vein distention, hepatomegaly, and a parasternal lift

Pathophysiology of Cor Pulmonale

The diagnosis of cor pulmonale is usually made with an echocardiogramincreased pressure in the pulmonary arteries and right ventricle

  • Spirometry can be done to look for chronic lung disease
  • The gold standard diagnostic test to directly measure pulmonary pressures and assess for response to vasodilating medications is a right heart catheterization

Treatment of chronic cor pulmonale generally focuses on the underlying pulmonary disease

  • Early identification and treatment of the cause are important before cardiac structural changes become irreversible
  • Although patients may have significant peripheral edema, diuretics are not helpful and may be harmful; small decreases in preload often worsen cor pulmonale
  • Right ventricular ischemia or pulmonary artery stretching can cause anginal chest pain in cor pulmonale that does not respond to nitrates

osmosis Osmosis
Question 1
A 65-year-old man presents with a chronic productive cough, dyspnea, and wheezing. Examination reveals cyanosis, distended neck veins, and a prominent epigastric pulsation. What is the most likely diagnosis?
A
cor pulmonale
B
chronic bronchitis
C
emphysema
D
pneumonia
Question 1 Explanation: 
Cor pulmonale is right ventricular hypertrophy and failure resulting from pulmonary disease. It is most commonly caused by chronic obstructive pulmonary disease, which is this patient's underlying disorder precipitating the failure. While the other three diagnoses may have similar symptoms, none of them would present with distended neck veins and prominent epigastric pulsations.
Question 2
A 62-year-old woman with pulmonary hypertension called 911 complaining of sweating and difficulty in breathing. Upon arrival to her home the paramedics found her to have pallor, diaphoresis, tachypnea, hypotension, and tachycardia. Her pulse oximetry was 89%, so they gave her oxygen via nonrebreather mask and transported her to the emergency department (ED). She was not complaining of angina. The ED physician assistant noted her to be in acute distress with elevated jugular venous pressure, a medial heave, a tender palpable liver, a systolic murmur of tricuspid regurgitation, and an S4 gallop. ECG demonstrated right axis deviation and right ventricular hypertrophy with no ST-T changes. Her arterial blood gas (ABG) demonstrated a low PaO2 and a low PaCO2. What is her likely diagnosis?
A
acute coronary syndrome
Hint:
Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes.
B
cor pulmonale
C
heart failure
Hint:
Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales.
D
pulmonary embolus
Hint:
patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.
Question 2 Explanation: 
Patients with all of these conditions may be diaphoretic and complaining of dyspnea. Marked hypotension in acute coronary syndrome occurs when the right coronary artery is affected. Acute coronary syndromes do not usually present with systolic murmurs, but patients will complain of angina and the ECG changes will include ST-segment changes. Patients who have severe heart failure will have similar symptoms but also have pulsus alternans and pulmonary rales. Finally, patients with pulmonary embolus may have hemodynamic changes but usually have a low PaO2 and a normal PaCO2. ECG may show right-axis deviation in a pulmonary embolus as well.
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References: Merck Manual · UpToDate

Brian Wallace PA-C Podcast: Pulmonary Circulation (Prev Lesson)
(Next Lesson) Pulmonary embolism (ReelDx)
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