What is cor pulmonale (right-sided heart failure due to pulmonary disease)?

From the Guidelines

Cor pulmonale should be managed by addressing the underlying lung condition, with oxygen therapy being essential for patients with hypoxemia, and medications such as diuretics, pulmonary vasodilators, and bronchodilators used as needed, as recommended by the European Society of Cardiology guidelines 1. The primary goal in managing cor pulmonale is to reduce the strain on the right ventricle by alleviating the underlying cause of pulmonary hypertension. This can be achieved through a combination of oxygen therapy, medications, and lifestyle modifications.

• Oxygen therapy is crucial for patients with hypoxemia, typically prescribed for at least 15 hours daily, as it helps to reduce pulmonary vasoconstriction and alleviate the strain on the right ventricle.
• Medications such as diuretics like furosemide (20-80mg daily) can be used to reduce fluid overload, while pulmonary vasodilators such as sildenafil (20mg three times daily) or bosentan (62.5-125mg twice daily) may be considered in selected cases.
• Bronchodilators like albuterol or tiotropium are essential for patients with obstructive lung diseases, as they help to improve lung function and reduce symptoms.
• Anticoagulation with warfarin (target INR 2-3) may be considered for patients with pulmonary hypertension, as it can help to reduce the risk of thromboembolic events.
• Lifestyle modifications, including smoking cessation, maintaining a low-salt diet (less than 2g sodium daily), and moderate physical activity as tolerated, are also crucial in managing cor pulmonale. According to the European Society of Cardiology guidelines 1, agents with documented effects on morbidity and mortality, such as ACEIs, β-blockers, and ARBs, are recommended in patients with co-existing pulmonary disease. However, the use of β-blockers should be initiated at a low dose and gradually up-titrated, as mild deterioration in pulmonary function and symptoms may occur.
• A history of asthma should be considered a contraindication to the use of any β-blocker, and inhaled β-agonists should be administered as required in patients with COPD.
• Supervised rehabilitation programmes may be appropriate to improve skeletal muscle function and fatigue in patients with cor pulmonale and COPD. The management of cor pulmonale requires a comprehensive approach, taking into account the underlying lung condition, as well as the patient's overall health status, as noted in the European Respiratory Journal 1.

From the Research

Definition and Causes of Cor Pulmonale

• Cor pulmonale is defined as right ventricular hypertrophy and/or dilation caused by pulmonary hypertension (PH) due to diseases affecting the lung function and structure 2.
• The leading cause of cor pulmonale is chronic obstructive pulmonary disease (COPD) 2.
• Cor pulmonale in COPD is generally known to occur due to loss of vascular bed and chronic hypoxic pulmonary vasoconstriction (HPV) due to alveolar wall destruction 2.

Diagnosis and Treatment of Cor Pulmonale

• Diagnosis of cor pulmonale is often difficult, since pulmonary vascular disease, pulmonary hypertension, and cor pulmonale have few specific manifestations, especially early in their evolution 3.
• Treatment is primarily directed at the underlying pulmonary or ventilatory disorder, rather than at the right ventricular failure per se 3.
• Supplemental oxygen is essential to avoid hypoxia; corticosteroids, anticoagulants, vasodilators, and other specific therapies are used as indicated to treat the underlying pulmonary disorders 3.

Relationship between COPD and Cor Pulmonale

• COPD is a major risk factor for the development of cor pulmonale 2.
• The use of inhaled corticosteroids, such as fluticasone propionate, in combination with long-acting beta2-agonists, such as salmeterol, may be beneficial in reducing the frequency of exacerbations and improving lung function in patients with COPD 4, 5, 6.
• However, the use of inhaled corticosteroids at high doses may increase the risk of pneumonia in patients with COPD 4.

Management of COPD Patients

• The management of COPD patients involves the use of long-acting beta2-agonists, such as salmeterol, alone or in combination with inhaled corticosteroids, such as fluticasone propionate 6.
• The combination of salmeterol and fluticasone propionate has been shown to improve lung function, reduce the frequency of exacerbations, and improve health status in patients with COPD 5, 6.