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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
302
C. J. Rees et al.
C.Complications Specic to the Type of CSF Shunt: Atrial Shunt. In: Di Rocco C,
Turgut M, Jallo G, Martínez-Lage JF, editors. Complications of CSF Shunting in
Hydrocephalus [Internet]. Cham: Springer International Publishing; 2015 [cited
2015 Sep 3]. p. 177–85. Available from:
http://link.springer.com/10.1007/978-3-
319-09961-3_12] Caption from original
Electrocardiographic nding with advanced cor pulmonale. Note the complete
right bundle branch pattern with an RR′ in lead V1. This tracing demonstrates
pressure and volume overload of the right ventricle, consistent with cor pulmonale.
[Loh E.Chapter 01. In: Goldhaber S, editor. Cardiopulmonary Diseases and Cardiac
Tumors. Philadelphia: Current Medicine; 1995 (Braunwald E, editor. Atlas of heart
diseases; vol. 3.)] Caption adapted from original
Imaging
• The chest x-ray may be helpful in the evaluation for cor pulmonale. Chronic
pulmonary hypertension often leads to enlargement of the main pulmonary
artery, hilar vessels, and the descending right pulmonary artery. On the lateral
view, there may be loss of the retrosternal air space due to right ventricular
enlargement.
19 Cor Pulmonale
303
Chest radiograph demonstrating features of advanced cor pulmonale secondary
to pulmonary hypertension. Typical radiograph of a patient with primary pulmonary
hypertension and cor pulmonale. Note the peripheral oligemia of the pulmonary
vessels with mild bilateral enlargement of the main pulmonary arteries.[Loh
E. Chapter 01. In: Goldhaber S, editor. Cardiopulmonary Diseases and Cardiac
Tumors. Philadelphia: Current Medicine; 1995 (Braunwald E, editor. Atlas of heart
diseases; vol. 3.)] Caption adapted from original
• Transthoracic echocardiography (TTE) can be very helpful in the evaluation for
and diagnosis of cor pulmonale and pulmonary hypertension. Pulmonary
hypertension alone is associated only with signs of elevated right ventricular
pressure. In chronic cor pulmonale there is a thickened (hypertrophied) right
ventricular wall and right ventricular dilatation (early in the course of the disease,
only hypertrophy may be appreciated). The right ventricular dilatation usually
leads to tricuspid regurgitation. Acute cor pulmonale may lead to right ventricular
dilatation in the absence of right ventricular hypertrophy. Reduced function of
the right ventricle can also often be appreciated on TTE.
304
C. J. Rees et al.
Echocardiographic features of the heart in a patient with cor pulmonale. A,
Parasternal long-axis view from a patient with advanced primary pulmonary
hypertension complicated by cor pulmonale. Note the abnormal attening of the
interventricular septum and its abnormal bulging into the left ventricle (LV),
consistent with volume and pressure overload of the right ventricle (RV). [Loh
E. Chapter 01. In: Goldhaber S, editor. Cardiopulmonary Diseases and Cardiac
Tumors. Philadelphia: Current Medicine; 1995 (Braunwald E, editor. Atlas of heart
diseases; vol. 3.)] Caption from original
Short-axis view demonstrating a markedly enlarged RV with RV hypertrophy.
Abnormal bowing of the interventricular septum into the LV gives a characteristic
D conguration of the LV, consistent with volume and pressure overload of the RV.
[Loh E.Chapter 01. In: Goldhaber S, editor. Cardiopulmonary Diseases and Cardiac
Tumors. Philadelphia: Current Medicine; 1995 (Braunwald E, editor. Atlas of heart
diseases; vol. 3.)] Caption from original
19 Cor Pulmonale
305
Apical four-chamber view also demonstrating RV hypertrophy and abnormal
septal bowing as described in panels A and B.AO—aorta; LA—left atrium; RA—
right atrium. [Loh E.Chapter 01. In: Goldhaber S, editor. Cardiopulmonary Diseases
and Cardiac Tumors. Philadelphia: Current Medicine; 1995 (Braunwald E, editor.
Atlas of heart diseases; vol. 3.)] Caption from original
• Cardiac magnetic resonance imaging (MRI), if available, is superior to transthoracic echocardiography in the evaluation of right ventricular structure and
function.
• Right heart catheterization is considered the best diagnostic test for cor pulmonale and pulmonary hypertension. Patients with cor pulmonale will have right
ventricular dysfunction as evidenced by an elevated central venous pressure and
elevated right ventricular end-diastolic pressure, pulmonary hypertension (PA
pressure greater than 25 mmHg), and no evidence of left heart disease, as
evidenced by either a normal (less than 15 mmHg) left ventricular end-diastolic
pressure. All chamber dimensions and pressures can be directly measured.
Special Populations
Age
• Cor pulmonale is a disease of adults starting in middle-age.
• Most patients with chronic cor pulmonale will have had severe, underlying pulmonary disease for many years prior to the onset of cor pulmonale.
• In the pediatric patient, the vast majority of cases are secondary to cystic
brosis.
• Neonates with severe bronchopulmonary dysplasia are also susceptible to the
development of cor pulmonale.
306
C. J. Rees et al.
Co-morbidities
• Many co-morbid conditions can worsen the prognosis, and make the diagnosis of
cor pulmonale difcult. These include, but are not limited to, cardiac diseases,
other pulmonary diseases, liver disease, and kidney disease.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• It is imperative that all patients be evaluated for left ventricular dysfunction. The
most common cause of right heart failure is left heart failure, and left heart failure
precludes a diagnosis of cor pulmonale.
• It is also important to consider all alternative diagnoses that may cause worsening or acute dyspnea in patients with chronic pulmonary and heart disease. This
list includes, but is not limited to, pneumonia, CHF, pulmonary embolism, pneumothorax, signicant pleural effusion, and acute metabolic issues that can cause
dyspnea.
Mimics
• Left heart failure can mimic right heart failure.
• Other diseases that can present in a similar fashion include acute liver failure,
acute kidney failure, and others.
Time-Dependent Interventions
• The most important intervention is to decrease the work of breathing by correcting hypoxemia and respiratory acidosis. Correcting these will decrease pulmonary vascular resistance and thereby reduce demands on the right ventricle.
Overall Principles ofTreatment
• Optimizing treatment of the underlying lung disease can help improve hemodynamics and lessen the symptoms and progression of cor pulmonale.
19 Cor Pulmonale
• Specic treatment for cor pulmonale consists of managing three physiologic
parameters—pulmonary artery pressure; right ventricular pressure; and right
ventricular contractility—as follows:
• Reduce pulmonary artery pressure (reduce right ventricular afterload). This
pressure can be reduced by the use of supplemental oxygen to decrease the
effect of hypoxia-induced vasoconstriction. This is particularly necessary in
hypoxic patients.
• Reduce right ventricular pressure. Diuretic use has shown some utility in
improving hemodynamics in patients with markedly elevated right ventricular
pressure. Diuresis must be performed carefully, as over-diuresis can lead to
reduced right ventricular lling and a decrease in cardiac output.
• Improve right ventricular contractility. This therapy is generally reserved for
patients with severe cor pulmonale who have resistant hypotension and are in
shock. The most common inotropic agents used are dobutamine and milrinone.
• Patients should be evaluated for any underlying or acute issues that, if treated,
can help improve the symptoms of cor pulmonale. These include such issues as
pulmonary embolism, pneumonia, pneumothorax, and pleural effusions.
307
Disease Course
• Cor pulmonale is a chronic, progressive disease that occurs only when other
underlying pulmonary diseases have progressed and are severe.
• As noted above, acute cor pulmonale is less common but can occur.
• The overall long-term prognosis once cor pulmonale has been diagnosed is poor.
Mortality in the rst year after the diagnosis of cor pulmonale is around 35%.
• Survival is signicantly lessened once cor pulmonale complicates pre-existing
lung disease.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
308
C. J. Rees et al.
Practice Guideline
King C, May CW, Williams J, Shlobin OA.Management of right heart failure in the
critically ill. Crit Care Clin. 2014 Jul;30(3):475-98. https://doi.org/10.1016/j.
ccc.2014.03.003. Review. PubMed PMID: 24996606. http://www.ncbi.nlm.nih.
gov/pubmed/24996606 **
Rudski LG, Lai WW, Alalo J, Hua L, Handschumacher MD, Chandrasekaran
K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic
assessment of the right heart in adults: a report from the American Society of
Echocardiography endorsed by the European Association of Echocardiography, a
registered branch of the European Society of Cardiology, and the Canadian Society
of Echocardiography. J Am Soc Echocardiogr. 2010 Jul;23(7):685-713; quiz 786-8.
https://doi.org/10.1016/j.echo.2010.05.010. PubMed PMID: 20620859. http://
www.ncbi.nlm.nih.gov/pubmed/20620859 **
Review
Repessé X, Charron C, Vieillard-Baron A.Acute cor pulmonale in ARDS: rationale
for protecting the right ventricle. Chest. 2015 Jan;147(1):259-65. https://doi.
org/10.1378/chest.14-0877. Review. PubMed PMID: 25560864. http://www.ncbi.
nlm.nih.gov/pubmed/25560864 **
Gomez-Arroyo J, Sandoval J, Simon MA, Dominguez-Cano E, Voelkel NF,
Bogaard HJ. Treatment for pulmonary arterial hypertension-associated right
ventricular dysfunction. Ann Am Thorac Soc. 2014 Sep;11(7):1101-15. https://doi.
org/10.1513/AnnalsATS.201312-425FR. Review. PubMed PMID: 25079379.
http://www.ncbi.nlm.nih.gov/pubmed/25079379 **
King C, May CW, Williams J, Shlobin OA.Management of right heart failure in
the critically ill. Crit Care Clin. 2014 Jul;30(3):475-98. https://doi.org/10.1016/j.
ccc.2014.03.003. Review. PubMed PMID: 24996606. http://www.ncbi.nlm.nih.
gov/pubmed/24996606 **
Vonk-Noordegraaf A, Haddad F, Chin KM, Fora PR, Kawut SM, Lumens J,
Naeije R, Newman J, Oudiz RJ, Provencher S, Torbicki A, Voelkel NF, Hassoun
PM. Right heart adaptation to pulmonary arterial hypertension: physiology and
pathobiology. J Am Coll Cardiol. 2013 Dec 24;62(25 Suppl):D22-33.
org/10.1016/j.jacc.2013.10.027. Review. PubMed PMID: 24355638. http://www.
ncbi.nlm.nih.gov/pubmed/24355638 **
Fora PR, Vaidya A, Wiegers SE.Pulmonary heart disease: The heart-lung inter-
action and its impact on patient phenotypes. Pulm Circ. 2013 Jan;3(1):5-19. https://
doi.org/10.4103/2045-8932.109910. PubMed PMID: 23662171; PubMed Central
PMCID: PMC3641739.
Madsen PH, Hess S, Høilund-Carlsen PF, Alavi A.Positron emission tomogra-
phy in chronic obstructive pulmonary disease. Hell J Nucl Med. 2013
http://www.ncbi.nlm.nih.gov/pubmed/23662171
https://doi.
19 Cor Pulmonale
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May- Aug;16(2):121-4. Review. PubMed PMID: 23865084. http://www.ncbi.nlm.
nih.gov/pubmed/23865084
Greyson CR.Right heart failure in the intensive care unit. Curr Opin Crit Care.
2012 Oct;18(5):424-31.
https://doi.org/10.1097/MCC.0b013e3283577070. Review.
PubMed PMID: 22889868. http://www.ncbi.nlm.nih.gov/pubmed/?term=22889868
**
Hoeper MM, Granton J.Intensive care unit management of patients with severe
pulmonary hypertension and right heart failure. Am J Respir Crit Care Med. 2011
Nov 15;184(10):1114-24. https://doi.org/10.1164/rccm.201104-0662CI. Review.
PubMed PMID: 21700906. http://www.ncbi.nlm.nih.gov/pubmed/21700906 **
Barr RG.The epidemiology of vascular dysfunction relating to chronic obstructive pulmonary disease and emphysema. Proc Am Thorac Soc. 2011 Nov;8(6):522-
7.
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22052931; PubMed Central PMCID: PMC3359073. http://www.ncbi.nlm.nih.gov/
pubmed/22052931
Healy F, Hanna BD, Zinman R.Clinical practice. The impact of lung disease on
the heart and cardiac disease on the lungs. Eur J Pediatr. 2010 Jan;169(1):1-6.
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PMID: 19639339. http://www.ncbi.nlm.nih.gov/pubmed/19639339
Jardin F, Vieillard-Baron A. Acute cor pulmonale. Curr Opin Crit Care. 2009
Feb;15(1):67-70. Review. PubMed PMID: 19186411. http://www.ncbi.nlm.nih.
gov/pubmed/19186411 **
Weitzenblum E, Chaouat A.Cor pulmonale. Chron Respir Dis. 2009;6(3):177-
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heart. Circulation. 2007 Dec 18;116(25):2992-3005. Review. PubMed PMID:
18086941. http://www.ncbi.nlm.nih.gov/pubmed/18086941 **
Shujaat A, Minkin R, Eden E.Pulmonary hypertension and chronic cor pulmonale in COPD. Int J Chron Obstruct Pulmon Dis. 2007;2(3):273-82. Review.
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ncbi.nlm.nih.gov/pubmed/18229565
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Nov-Dec;9(6):331-42. Review. PubMed PMID: 16479737. http://www.ncbi.nlm.
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Clinical Trial
Liu WH, Luo Q, Liu ZH, Zhao Q, Xi QY, Zhao ZH.Differences in exercise capacity
in patients with chronic left heart failure and chronic right heart failure. Heart Lung
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2014 May 27. PubMed PMID: 24931066. http://www.ncbi.nlm.nih.gov/
pubmed/24931066
Comparative Study
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parvus in chronic obstructive pulmonary disease and emphysema: the MESA COPD
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pulmonale. Eur J Radiol. 2012 Feb;81(2):345-53. https://doi.org/10.1016/j.
ejrad.2010.11.004. Epub 2010 Nov 27. PubMed PMID: 21112711. http://www.
ncbi.nlm.nih.gov/pubmed/21112711 **
Park JH, Park YS, Kim YJ, Lee IS, Kim JH, Lee JH, Choi SW, Jeong JO, Seong
IW.Differentiation between acute and chronic cor pulmonales with midventricular
systolic strain of the right ventricle in the emergency department. Heart Vessels.
2011 Jul;26(4):435-9.
26. PubMed PMID: 21110197. http://www.ncbi.nlm.nih.gov/pubmed/21110197
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
(“Pulmonary Heart Disease”[Majr] OR “pulmonary heart disease”[tiab] OR “cor
pulmonale”[tiab] OR “right heart failure”[tiab])
https://doi.org/10.1007/s00380-010-0072-6. Epub 2010 Nov
Chapter 20
Costochondritis
ChristopherJ.Rees, RichardM.Cantor, CharlesV.Pollack,Jr.,
andVictoriaG.Riese
Name andSynonyms
Costochondritis; Costosternal Syndrome; Tietze’s Syndrome; Chest Wall Pain Syndrome
Incidence/Epidemiology
• Chest pain is a common presenting complaint to both Emergency Departments
and primary care ofces.
• There are an estimated six million emergency department visits a year for
chest pain.
• The evaluation of chest pain utilizes a substantial amount of health care
resources, primarily with the goal of excluding life-threatening diagnoses.
• Musculoskeletal causes of chest pain account for up to one-third of all causes
in the outpatient evaluation of chest pain.
• The true incidence of costochondritis and other musculoskeletal chest pain
syndromes is unknown, as many cases don’t present for evaluation.
C. J. Rees
Emergency Department, Pennsylvania Hospital, Philadelphia, PA, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, USA
C. V. Pollack,
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_20
Jr. ()
311© Springer Nature Switzerland AG 2019