Rupture Of The Right Ventricular Free Wall After Myocardial Infarction: Fill & Download for Free

cor pulmonale:-defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary htn. is the common link between lung dysfunction and the heart in cor pulmonale.etiopathogenesis:-Cor pulmonale usually presents chronically, but 2 main conditions can cause acute cor pulmonale: pulmonary embolism and ARDS(acute resp.distress syndrome.The underlying pathophysiology in massive pulmonary embolism causing cor pulmonale is the sudden increase in pulmonary resistance. In ARDS, 2 factors cause right ventricular (RV) overload: the pathologic features of the syndrome itself and mechanical ventilation. Mechanical ventilation, especially higher tidal volume, requires a higher transpulmonary pressure.In chronic cor pulmonale, RV hypertrophy (RVH) generally predominates. In acute cor pulmonale, right ventricular dilatation mainly occurs. In the case of ARDS, cor pulmonale is associated with increased possibility of right-to-left shunt through the patent foramen ovale and carries a poorer prognosis.Several different pathophysiologic mechanisms can lead to pulmonary hypertension and, subsequently, to cor pulmonale. These pathogenetic mechanisms include the following:Pulmonary vasoconstriction due to alveolar hypoxia or blood acidemia – This can result in pulmonary hypertension and if the hypertension is severe enough, it causes cor pulmonale.Anatomic compromise of the pulmonary vascular bed secondary to parenchymal or alveolar lung disorders (eg, emphysema, pulmonary embolism, ILD eg.pneumonia, adult respiratory distress syndrome, and rheumatoid disorders) – These conditions can cause elevated pulmonary blood pressure. Chronic obstructive pulmonary disorder is the most common cause of cor pulmonale, and some connective tissue disorders with pulmonary involvement may result in pulmonary hypertension and cor pulmonale.SymptomsThe patient may complain of fatigue, tachypnea, exertional dyspnea, and cough. Anginal chest pain can also occur and may be due to right ventricular ischemia (it usually does not respond to nitrates) or pulmonary artery stretching. A variety of neurologic symptoms may be seen due to decreased cardiac output and hypoxemia.Hemoptysis may occur because of rupture of a dilated or atherosclerotic pulmonary artery. Other conditions, such as tumors, bronchiectasis, and pulmonary infarction, should be excluded before attributing hemoptysis to pulmonary hypertension. Rarely, the patient may complain of hoarseness due to compression of the left recurrent laryngeal nerve by a dilated pulmonary artery.In advanced stages, passive hepatic congestion secondary to severe right ventricular failure may lead to anorexia, right upper quadrant abdominal discomfort, and jaundice. In addition, syncope with exertion, which may also be seen in severe disease, reflects a relative inability to increase cardiac output during exercise with a subsequent drop in the systemic arterial pressure.Elevated pulmonary artery pressure can lead to elevated right atrial, peripheral venous, and capillary pressure. By increasing the hydrostatic gradient, it leads to transudation of fluid and accumulation of peripheral edema. Although this is the simplest explanation for peripheral edema in cor pulmonale, other hypotheses explain this symptom, especially in a fraction of patients with chronic obstructive pulmonary disease (COPD) who do not show increase in right atrial pressure. A decrease in glomerular filtration rate (GFR) and filtration of sodium and stimulation of arginine vasopressin (which decreases free water excretion) due to hypoxemia play important pathophysiologic roles in this setting and may even have a role for peripheral edema in patients with cor pulmonale who have elevated right atrial pressure.SignsPhysical findings may reflect the underlying lung disease or pulmonary hypertension, right ventricular hypertrophy (RVH), and RV failure. An increase in chest diameter, labored respiratory efforts with retractions of the chest wall, distended neck veins with prominent a or v waves, and cyanosis may be seen.On auscultation of the lungs, wheezes and crackles may be heard as signs of underlying lung disease. Turbulent flow through recanalized vessels in chronic thromboembolic pulmonary hypertension may be heard as systolic bruits in the lungs.Splitting of the second heart sound with accentuation of the pulmonic component can be heard in early stages. A systolic ejection murmur with sharp ejection click over the region of the pulmonary artery may be heard in advanced disease, along with a diastolic pulmonary regurgitation murmur. Other findings upon auscultation of the cardiovascular system may be third and fourth sounds of the heart and systolic murmur of tricuspid regurgitation.RVH is characterized by a left parasternal or subxiphoid heave. Hepatojugular reflux and pulsatile liver are signs of RV failure with systemic venous congestion.On percussion, hyperresonance of the lungs may be a sign of underlying COPD; ascites can be seen in severe disease.Examination of the lower extremities reveals evidence of pitting edema. Edema in cor pulmonale is strongly associated with hypercapnia.investigations-routine blood investigationschest xray-oligaemic lung fields and enlarged pulmoary arteriesecg and echo-RVHarterial blood gas analysis-acidosistreatment:-Oxygen therapycardiopulmonary support:-Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with chronic cor pulmonale. Calcium channel blockers are pulmonary artery vasodilators that have proven efficacy in the long-term management of chronic cor pulmonale secondary to primary pulmonary arterial hypertension (PAH).US Food and Drug Administration (FDA)–approved prostacyclin analogues and endothelin-receptor antagonists are available for treatment of primary pulmonary hypertension (PPH). The beneficial role of cardiac glycosides, namely digitalis, on the failing right ventricle are somewhat controversial; these agents can improve RV function but must be used with caution and should be avoided during acute episodes of hypoxia.The main indication for oral anticoagulants in the management of cor pulmonale is in the setting of an underlying thromboembolic event or primary PAH.Methylxanthines, like theophylline, can be used as an adjunctive treatment for chronic cor pulmonale secondary to chronic obstructive pulmonary disease (COPD). Besides the moderate bronchodilatory effect of methylxanthine, this agent improves myocardial contractility, causes a mild pulmonary vasodilatory effect, and enhances diaphragmatic contractility. Diuretic agentsDiuretics are used in the management of chronic cor pulmonale, particularly when the RV filling volume is markedly elevated and in the management of associated peripheral edema. These agents may result in improvement of the function of both the right and left ventricles; however, diuretics may produce hemodynamic adverse effects if they are not used cautiously. Excessive volume depletion can lead to a decline in cardiac output.Another potential complication of diuresis is the production of a hypokalemic metabolic alkalosis, which diminishes the effectiveness of carbon dioxide stimulation on the respiratory centers and lessens ventilatory drive. The adverse electrolyte and acid-base effect of diuretic use can also lead to cardiac arrhythmia, which can diminish cardiac output. Therefore, diuresis, while recommended in the management of chronic cor pulmonale, needs to be used with great caution. Vasodilator drugsVasodilators have been advocated in the long-term management of chronic cor pulmonale with modest results. Calcium channel blockers, particularly oral sustained-release nifedipine and diltiazem, can lower pulmonary pressures, although these agents appear more effective in primary rather than secondary pulmonary hypertension.Other classes of vasodilators, such as beta agonists, nitrates, and angiotensin-converting enzyme (ACE) inhibitors have been tried but, in general, vasodilators have failed to show sustained benefit in patients with COPD, and they are not routinely used. A trial of vasodilator therapy may be considered only in patients with COPD with disproportionately high pulmonary blood pressure. Beta-selective agonist drugsBeta-selective agonists have an additional advantage of bronchodilator and mucociliary clearance effect. Right heart catheterization has been recommended during initial administration of vasodilators to objectively assess the efficacy and detect the possible adverse hemodynamic consequences of vasodilators.The FDA approved epoprostenol and bosentan for the treatment of PPH. Epoprostenol, treprostinil, and iloprost are prostacyclin (PGI2) analogues and have potent vasodilatory properties. Epoprostenol and treprostinil are administered intravenously (IV) and iloprost is an inhaler. Bosentan is a mixed endothelin-A and endothelin-B receptor antagonist indicated for PAH, including PPH. In clinical trials, bosentan improved exercise capacity, decreased rate of clinical deterioration, and improved hemodynamics.The PDE5 inhibitor sildenafil has been intensively studied and was approved by the FDA for treatment of pulmonary hypertension. Sildenafil promotes selective smooth muscle relaxation in lung vasculature.Tadalafil, another PDE5 inhibitor, was also approved by the FDA for the treatment of PAH to improve exercise ability.There are not enough data available yet regarding the efficacy of these drugs in patients with secondary pulmonary hypertension, such as in patients with COPD. Cardiac glycoside agentsThe use of cardiac glycosides, such as digitalis, in patients with cor pulmonale has been controversial, and the beneficial effect of these drugs is not as obvious as in the setting of left heart failure. Nevertheless, studies have confirmed a modest effect of digitalis on the failing right ventricle in patients with chronic cor pulmonale.This drug must be used cautiously, however, and should not be used during the acute phases of respiratory insufficiency when large fluctuations in levels of hypoxia and acidosis may occur. Patients with hypoxemia or acidosis are at increased risk of developing arrhythmias due to digitalis through different mechanisms, including sympathoadrenal stimulation. TheophyllineIn addition to bronchodilatory effects, theophylline has been reported to reduce pulmonary vascular resistance and pulmonary arterial pressures acutely in patients with chronic cor pulmonale secondary to COPD. Theophylline has a weak inotropic effect and thus may improve right and left ventricular ejection. Low doses of theophylline have also been suggested to have anti-inflammatory effects that help to control underlying lung diseases such as COPD.As a result, considering the use of theophylline as adjunctive therapy in the management of chronic or decompensated cor pulmonale is reasonable in patients with underlying COPD. WarfarinAnticoagulation with warfarin is recommended in patients at high risk for thromboembolism. The beneficial role of anticoagulation in improving the symptoms and mortality in patients with primary PAH has been demonstrated in several studies.The evidence of benefit, however, has not been established in patients with secondary PAH. Therefore, anticoagulation therapy may be used in patients with cor pulmonale secondary to thromboembolic phenomena and with underlying primary PAH.

This answer may contain sensitive images. Click on an image to unblur it.Ask a Coroner Q&A (Part 2) – Ask a Coroner“””” He described the blue color of the head and neck as the cardiac collar, indicating the man died from a heart attack. ... It is a distinct sign of sudden cardiac death. (Nov 2, 2016)””””, www.askacoroner.com › ask-a-coroner-qa-part-2 .- - -- - Trauma/Emergency RadiologyFree Access - -** Imaging Patients with Cardiac Trauma **Carlos S. Restrepo , Fernando R. Gutierrez, Juan A. Marmol-Velez, Daniel Ocazionez, Santiago Martinez-Jimenez - Author AffiliationsPublished Online: May 5 http://2012https://doi.org/10.1148/rg.323115123Quora required Attribution: Imaging Patients with Cardiac Trauma .“””” Abstract ~ In the United States, trauma is the leading cause of death among those who are 1–44 years old, with cardiovascular injuries representing the second most common cause of traumatic death after central nervous system injuries.Evaluation of trauma patients with suspected cardiac injury may be complex and include electrocardiography, measurement of cardiac biomarkers, and imaging examinations.Contrast material–enhanced computed tomography (CT) has become one of the most valuable imaging tools available for evaluating hemodynamically stable patients with suspected cardiac injury.The presence of hemopericardium, with or without cardiac tamponade, is one of the most significant findings of cardiac injury. Other complications that result from blunt cardiac injury, such as pericardial rupture and cardiac herniation, may be readily depicted at multidetector CT.Assessment of patients with cardiac injuries, particularly those with penetrating injuries, is a challenging and time-critical matter, with clinical and imaging findings having complementary roles in the formation of an accurate diagnosis.Patients who are hemodynamically stable, particularly those with penetrating cardiac injuries, also may benefit from a timely imaging examination. In addition to chest radiography, other available modalities such as transthoracic and transesophageal echocardiography, nuclear medicine, and magnetic resonance imaging may play a role in selected cases.In the United States, trauma is the leading cause of death among those who are between 1 and 44 years old. Among trauma victims, cardiovascular injuries are the second most common cause of death after central nervous system injuries, with more than 900,000 cases of cardiac trauma in the United States each year.The exact incidence of cardiac trauma is not known, and estimates vary greatly, from 8% in an autopsy study to 76% in a clinical series. These extreme variations reflect the lack of standardized diagnostic criteria for the diagnosis of cardiac trauma.In this article, we discuss the pathophysiology and classification of cardiac trauma and the triage of patients with cardiac trauma, with emphasis on timely diagnostic imaging in patients who are hemodynamically stable.Pathophysiology ~ Motor vehicle collisions are the major cause of blunt thoracic trauma, accounting for more than 80% of cases, followed by crush injuries, which account for 5% of cases.Direct impact to the chest wall transmits a substantial amount of kinetic energy and compresses the heart between the anterior sternum and the posterior spine.Abdominal and lower extremity trauma also may result in or contribute to cardiac trauma, either from upward displacement of the abdominal viscera or from the hydraulic effect (eg, increased venous return and pressure waves), in which forces are transmitted to the cardiac chambers.In patients who were involved in an explosion, cardiac injury may result from multiple mechanisms, such as the primary blast injury from the blast wave; secondary injury from ballistic trauma caused by shrapnel; and tertiary injury, a blunt or penetrating trauma that results from displacement of the victim or nearby buildings or structures from shock-waves.Because of its anterior location within the thoracic cavity, the right ventricular free wall is the primary site of myocardial injury; however, because mural pressure is higher on the left side of the heart, the mitral and aortic valves are at greater risk for injury than the tricuspid or pulmonic valves.Right ventricular injury causes impaired contractility, with decreased cardiac output by as much as 40%. Left ventricular output is also affected by decreased preload amounts in patients who are hypovolemic.ClassificationAs with all major traumas, cardiac trauma may be classified on the basis of the mechanism of injury into two broad categories: penetrating and nonpenetrating.Nonpenetrating injury is also referred to as blunt cardiac injury (BCI) and is more common than penetrating injury. In the past, the terminology used to describe nonpenetrating cardiac injuries was confusing.Currently, the preferred generic term to refer to a nonpenetrating injury is BCI. The term myocardial concussion refers to a subset of BCIs that includes wall motion abnormalities with no proved anatomic or cellular injury, whereas the term myocardial contusion denotes an anatomic injury that manifests as increased cardiac enzymes or tissue damage seen at surgery or autopsy.Blunt Cardiac Injury ~ BCI is the most common type of cardiac injury after blunt thoracic trauma, but it is difficult to diagnose. In cardiac concussion, the mildest form of cardiac injury, there is no myocardial cell damage, chemical or morphologic abnormalities, or elevated enzyme levels. Its main manifestation may be segmental wall motion abnormalities at echocardiography, a finding that represents a mild form of myocardial stunning. Cardiac arrhythmia also may be present.The histopathologic characteristics of cardiac contusion that leads to myocardial cell injury are similar to those of cardiac contusion that leads to myocardial infarction. Both types of cardiac contusion may cause myocardial necrosis and hemorrhage; in surviving patients, repair is achieved with varying degrees of irregular fibrosis.Cardiac contusion is difficult to diagnose because its symptoms, such as chest pain, are common in patients with thoracic trauma and often arise from a noncardiac source.Signs of congestive heart failure, pulmonary edema, cardiogenic shock, new cardiac murmur, or pericardial friction rub are less common but, when present, should prompt evaluation for cardiac involvement (Fig 1). Other traumatic injuries such as rib fractures (seen in 83% of patients), pneumothorax (39% of patients), hemothorax (31% of patients), lung contusion (13% of patients), clavicular fracture (13% of patients), and sternal fracture (10% of patients) are common in patients with cardiac trauma.External thoracic injury may not always be present, and extensive myocardial contusion and hemopericardium may be seen in the absence of external signs of thoracic trauma.In a postmortem study of 35 cases of BCI, all cardiac contusions and lacerations were located on the anterior surface of the heart, and less than 6% of cases had no sternal or rib fractures.Figure 1Figure 1 Large pneumopericardium secondary to nonpenetrating trauma in a patient with severe myocardial contusion and bilateral cardiogenic pulmonary edema.Chest radiograph shows extensive parenchymal opacities (white arrows) and a large amount of air (black arrow) within the pericardial sac.Measurement of cardiac biomarkers has also been extensively used to diagnose cardiac contusion, with variable results. Several studies have reported that creatine kinase (CK) and isoform levels are not reliable for detecting or excluding cardiac injury. Although elevation of CK levels has high sensitivity (>90%) for cardiac injury, it has poor specificity (<6.1%), both with and without the myocardial fraction (MB) component, and CK levels are commonly elevated in patients with severe blunt trauma resulting from noncardiac damage.Other biomarkers such as troponin T and, particularly, troponin I are both sensitive and specific (>90%) for detecting cardiac injury, and their level of elevation is proportional to the extent of myocardial damage. Cardiac troponin levels may help differentiate concussion from contusion in patients with BCI and abnormal electrocardiographic (ECG) or echocardiographic findings.ECG is a rapid and inexpensive test that should be routinely performed in all patients with suspected BCI.However, there is controversy about which ECG findings are diagnostic for BCI. In a systematic review of the literature, including 18 cardiac trauma series, Christensen et al (20) reported that there were 18 different definition of what constitutes an abnormal ECG finding.With these limitations in mind, Emet et al analyzed 88 patients with thoracic trauma and reported that ECG has sensitivity of 54%, specificity of 74%, negative predictive value of 83%, and positive predictive value of 41% for depicting BCI (12).In a meta-analysis that included multiple studies of trauma patients, the use of ECG for diagnosing substantial myocardial contusion was supported, and it was reported that patients with abnormal ECG findings had more significant complications that required treatment””””, Imaging Patients with Cardiac Trauma .Attribution: Imaging Patients with Cardiac Trauma .