Cor Pulmonale Revisited. From Ferrer and Harvey to the Present

Effects of Ivabradine on Right Ventricular Systolic Function in Patients With Chronic Obstructive Pulmonary Disease and Cor Pulmonale

Cor pulmonale is a clinical syndrome associated with pulmonary hypertension, frequently complicated by congestive heart failure, commonly caused by chronic obstructive pulmonary disease (COPD). Most patients with cor pulmonale have tachycardia. However, heart rate (HR) reduction represents a primary treatment goal to improve the survival and quality of life in these patients. Ivabradine can selectively slow HR at rest and during exercise. In this prospective study, we tested the hemodynamic effects, invasively determined using right-sided cardiac catheterization, of reducing HR with ivabradine. We selected 18 patients (13 men [72.2%], mean age 67 ± 10 years) with COPD and cor pulmonale, presenting with sinus tachycardia. All patients performed clinical evaluation, electrocardiogram, spirometry, echocardiogram, 6-minute walking distance, and right-sided cardiac catheterization within 1 month of enrollment. All tests were repeated after 6 months of ivabradine treatment (median assumed dose 11.9 mg/die). We noticed a significant decrease of HR (from 98 ± 7 to 77 ± 8 beats/min, p = 0.0001), with a concomitant reduction of the congestion index (from 25.9 ± 5.1 to 19.4 ± 5.7 mm Hg, p = 0.001), and the consequent improvement of the right ventricular systolic performance (right ventricular stroke volume augmented from 56.7 ± 7.9 to 75.2 ± 8.6 ml/beat, p = 0.0001). This allows an improvement in clinical status and exercise tolerance (Borg scale score decreased from 5.2 ± 1.4 to 4.1 ± 1.3, p = 0.01 and the 6-minute walking distance increased to 252 ± 65 to 377 ± 59 m, p = 0.001). In conclusion, HR reduction significantly improves hemodynamic and clinical status of patients with tachycardia affected by COPD and cor pulmonale.

Outcomes in Emergency Department Patients with Dyspnea versus Chest Pain: A Retrospective Consecutive Cohort Study

Dyspnea and chest pain are major and important causes of contact at the emergency department (ED). Dyspnea is associated with high morbidity and mortality, but data on characteristics and outcomes compared with chest pain in the ED are limited. This was a retrospective cohort study of consecutive patients with contact causes of dyspnea or chest pain at two Swedish EDs from 2010 to 2014. Hospital admittance, ED revisits, and mortality were analyzed using multivariable regression models, adjusted for ED and markers of disease severity (age, sex, centre, Charlson comorbidity index, c-reactive protein, troponin T, and arrival by ambulance). 29,291 patients (mean age 58.3 years; 48.9% women) with dyspnea (n = 8,812) or chest pain (n = 20,479) were included. Dyspnea patients were older than patients with chest pain (64 vs. 56 years, p < 0.001) and had more comorbidity and higher average blood troponin T and c-reactive protein levels. Dyspnea patients also had higher hospitalization rates (48% vs. 30%; adjOR (95% CI) 2.1–2.3), including the intensive care unit (1.4% vs. 0.1%; adjOR 6.9–15.9), and more ED revisits (11% vs. 7%; adjOR 1.2–1.7) in 30 days. Dyspnea patients had five-fold increased mortality compared to those with chest pain; hazard ratio (HR) 5.1 (4.8–5.4), adjusted for markers of disease severity, the mortality was two-fold higher, HR 2.2 (2.0–2.4). Compared with chest pain patients, ED dyspnea patients are older, have more comorbidity, and have worse outcomes in terms of hospitalization, morbidity, and mortality.

CLINICAL SIGNIFICANCE OF PULMONARY HYPERTENSION IN INTERSTITIAL LUNG DISEASE A Consensus Statement from The Pulmonary Vascular Research Institute's Innovative Drug Development Initiative ‐ Group 3 Pulmonary Hypertension

Pulmonary hypertension (PH) has been linked to worse outcomes in chronic lung diseases. The presence of PH in the setting of underlying Interstitial Lung Disease (ILD) is strongly associated with decreased exercise and functional capacity, an increased risk of hospitalizations and death. Examining the scope of this issue and its impact on patients is the first step in trying to define a roadmap to facilitate and encourage future research in this area. The aim of our working group is to strengthen the communities understanding of PH due to lung diseases and to improve the care and quality of life of affected patients. This introductory statement provides a broad overview and lays the foundation for further in‐depth papers on specific topics pertaining to PH‐ILD.

Lung Disease-Related Pulmonary Hypertension

Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.

Characteristics of length of stay and cardiovascular pharmacotherapy advice among chronic obstructive pulmonary disease patients

Chronic obstructive pulmonary disease (COPD) increases the global disease burden due to its diverse adverse health effects on the respiratory and cardiovascular systems. This study aimed to elucidate the potential indicators of length of stay (LOS) and pharmacotherapy advice among COPD patients. Thereafter, hospitalized COPD patients with clinical records and respiratory and cardiovascular pharmacotherapy advice were retrospectively collected from a tertiary hospital between April 2017 and September 2020, and the determinants of LOS and cardiovascular pharmacotherapy advice were explored using regression analyses. Overall, 475 patients with COPD were recruited and stratified according to exacerbation and presence of Cor pulmonale (CP). The extended LOS, increased B-type natriuretic peptides (BNP), and a higher percentage of cardiovascular pharmacotherapy advice were observed in COPD with CP regardless of exacerbation, although the percentage of respiratory prescriptions was comparable. The presence of CP indicated a longer LOS (B = 1.850, p < 0.001) for COPD regardless of exacerbation. Meanwhile, elevated BNP levels indicated cardiovascular pharmacotherapy advise for both COPD in exacerbation (OR = 1.003, p = 0.012) and absence of exacerbation (OR = 1.006, p = 0.015). Moreover, advice for trimetazidine use for COPD in exacerbation (OR = 1.005, p = 0.002) has been suggested. Therefore, CP appears to be an important comorbidity resulting in extended LOS for COPD, which is likely to be advised with cardiovascular pharmacotherapy, which might be guided through BNP monitoring.

The right ventricle

The healthy right ventricle (RV) has a thin-walled structure compared to the thick-walled left ventricle (LV). It has a complex shape that appears crescentic when viewed in cross section and triangular when viewed from the side.