From the Guidelines
Acute cor pulmonale is a life-threatening condition characterized by right ventricular failure due to abruptly increased RV afterload or decreased RV contractility, often caused by pulmonary embolism, hypoxia, acidemia, RV ischemia, or myocarditis. This condition occurs when the right ventricle of the heart becomes strained and enlarged as it struggles to pump blood against increased resistance in the pulmonary circulation, as described in the American Heart Association scientific statement 1. The RV is coupled to the high-compliance, low-resistance pulmonary circulation and is suited to adapt to changes in volume rather than pressure.
Key Characteristics
- Acute increase in RV afterload, such as a large pulmonary embolism, may abruptly decrease RV stroke volume, with minimal increase in RV systolic pressure 1.
- Acute reductions in RV contractility may also be caused by direct myocardial injury from mechanisms such as myocardial inflammation and ischemia.
- Reduced RV stroke volume results in RV dilation, which promotes tricuspid regurgitation, exacerbates RV dilation, and drives a ventricular-interdependent effect on LV filling.
Clinical Presentation and Diagnosis
- Symptoms include sudden shortness of breath, chest pain, rapid heart rate, low blood pressure, and signs of right heart failure such as jugular vein distention and peripheral edema.
- Diagnosis typically involves echocardiography, CT pulmonary angiography, and electrocardiogram, as these tools can help identify the underlying cause of acute cor pulmonale, such as pulmonary embolism or myocarditis 1.
Treatment and Management
- Treatment focuses on addressing the underlying cause, such as anticoagulation for pulmonary embolism, while providing supportive care including oxygen therapy, careful fluid management, and sometimes vasopressors to maintain adequate blood pressure.
- In severe cases, thrombolytic therapy for pulmonary embolism or mechanical circulatory support may be necessary to prevent cardiogenic shock and death, highlighting the importance of prompt and aggressive management of acute cor pulmonale 1.
From the Research
Definition and Causes of Acute Cor Pulmonale
- Acute cor pulmonale is a form of acute right heart failure produced by a sudden increase in resistance to blood flow in the pulmonary circulation 2.
- It is mainly observed as a complication of massive pulmonary embolism or acute respiratory distress syndrome 2.
- Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) 3.
Clinical Settings and Management
- Acute cor pulmonale is a life-threatening condition that may arise in different clinical settings, including emergency departments and intensive care units 3.
- A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed 3.
- Treatment consists in rapidly reducing resistance to blood flow in the pulmonary circulation, obtained by a specific strategy according to etiology 2.
- Therapeutic advances in mechanical circulatory support, pharmacotherapies to reduce afterload, mechanical and chemical lytic therapies for acute PE have improved outcomes of patients by offloading the right ventricle 4.
Diagnosis and Monitoring
- Right-ventricular function in patients with acute cor pulmonale should be closely monitored, and this is helped by the widespread use of echocardiography in intensive care units 5.
- Bedside echocardiography can rapidly recognize acute cor pulmonale 2.
- Pulmonary vascular dysfunction is associated with ARDS and leads to increased right-ventricular afterload and eventually right-ventricular failure, also called acute cor pulmonale 5.
Treatment Strategies
- Treatment strategies for cor pulmonale include supplemental oxygen, assisted mechanical ventilation, digoxin, and diuretics 6.
- Pulmonary vasodilator compounds should be used with caution because they can compromise gas exchange in cor pulmonale from secondary pulmonary hypertension 6.
- A right ventricle-protective ventilation approach is described, including the reduction of lung stress, the reduction of PaCO2, and the improvement of oxygenation 5.