Rapid Review·Cardiovascular
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Heart Failure
T1Must knowCor Pulmonale
Focus on
Right heart failure caused by lung disease or pulmonary vascular disease — not by the left heart. COPD is the classic cause, massive PE the acute one. Treat the lung (oxygen is the survival drug in hypoxemic COPD), diurese gently because the RV is preload-dependent, and separate it from left-sided failure with the wedge pressure.
Key takeaways
What it is and what causes it
What this shows
Cor pulmonale
isolated right heart failure caused by a primary lung disorder that has produced advanced pulmonary hypertension; the left heart is not the cause.- It can be acute (most often a massive pulmonary embolism) or chronic.
Parenchymal disease or chronic hypoxia
chronic obstructive pulmonary disease (COPD, the most common), cystic fibrosis, interstitial lung disease, obstructive sleep apnea.Pulmonary vascular disease
pulmonary embolism.Clinical features
Symptoms of right-sided failure
exertional dyspnea and fatigue.Exertional angina
because the strained right ventricle demands more oxygen.Exertional syncope
because cardiac output cannot rise with exertion.Examination
the right heart is failing against a high pressure.- Jugular venous distension, peripheral edema, a pulsatile enlarged liver, and a positive hepatojugular reflux.
- A palpable right ventricular heave and a tricuspid regurgitation murmur.
- A loud P2, which is a strong clue to pulmonary hypertension.
Diagnosis
Electrocardiogram (ECG)
incomplete or complete right bundle branch block, right ventricular hypertrophy with right axis deviation, and right atrial enlargement.Transthoracic echocardiography
pulmonary hypertension, right ventricular dilation or dysfunction, and often tricuspid regurgitation.Right heart catheterization is the gold standard for confirmation
raised filling pressures, a low cardiac output, and pulmonary hypertension.Management
Treat the underlying cause of the pulmonary hypertension
the lung disease drives the right heart failure.A patient with COPD develops worsening dyspnea, jugular venous distension, hepatomegaly and pitting edema, with clear lungs and a right ventricular heave. What is the diagnosis, and what is the underlying mechanism?
Cor pulmonale: isolated right heart failure from pulmonary hypertension caused by the lung disease (COPD is the most common cause). The left heart is not the cause, and treatment targets the cause of the pulmonary hypertension.
How it's tested
COPD patient with worsening dyspnea, JVD, hepatomegaly and pitting edema, clear lungs and an RV heave: cor pulmonale — the edema is right heart failure from hypoxic pulmonary hypertension.
Which treatment improves survival in COPD with a resting PaO2 of 52: continuous long-term oxygen.
Cor pulmonale treated with aggressive diuresis, now hypotensive with a rising creatinine: the RV is preload-dependent — back off the diuretic.
Sudden dyspnea, hypotension, JVD, clear lungs and a dilated RV on echo: massive PE with acute RV failure — thrombolysis.
Pulmonary hypertension with left atrial enlargement and a wedge pressure of 24: pulmonary hypertension from left heart disease — not cor pulmonale.
Go deeper
Guidelines: 2022 ESC/ERS Pulmonary Hypertension Guideline · 2022 AHA/ACC/HFSA Heart Failure Guideline
Related Step 2 pages: Heart Failure, Obstructive Shock, Jugular Venous Pressure, Tricuspid Regurgitation, Heart Sounds & Murmurs
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