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Central hemodynamic findings in normal subjects
Variable Units Mean±SD
Cardiac index L/min/m2 4.0±0.9
Pulmonary mean transit time Cardiac cycles 6.2±0.7
Pulmonary blood volume mL/m2 312±44
Pulmonary artery pressure (mean) mmHg 11±3
Pulmonary wedge pressure mmHg 6±3
Pulmonary vascular resistance mmHg/L/min/m2 1.5±0.5
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Ipertensione arteriosa polmonare
• Condizione clinica associata ad aumento della pressione arteriosa polmonare (PAP) a riposo e durante sforzo.
• Per convenzione si pone diagnosi di ipertensione arteriosa quando PAP media è > 25 mmHg a riposo o > 30 mmHg durante sforzo.
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Ipertensione arteriosa polmonare
Entità PAP media (mmHg)
Lieve 26-35
Moderata 36-45
Grave >45
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Ipertesione polmonare: classificazione
Cuore polmonare
MPAP > 25 mmHgMPWP < 15 mmHg
Precapillare
Polmone cardiaco
MPAP > 25 mmHgMPWP > 15 mmHg
Postcapillare
Ipertensione arteriosa polmonare
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Ipertensione polmonare precapillare
• Idiopatica• Collagenopatie• Ipossica• Uso di anoressizzanti• Uso di cocaina• Uso di contraccettivi• HIV-correlata• Shunt cardiovascolare• Ipertensione portale• Gravidanza recente• Post-embolica cronica
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Ipertensione polmonare postcapillare
• Vizi valvolari mitralici
• Vizi valvolari aortici
• Cardiopatia ischemica
• Cardiopatia ipertensiva
• Cardiomiopatie
• Malattia veno-occlusiva polmonare
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Definizione di cuore polmonare
Ingrandimento del cuore destro (atrio,
ventricolo e tronco comune dell’arteria
polmonare) secondario a patologie
polmonari o extra-polmonari, in assenza di
cardiopatie sinistre o congenite.
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Cuore polmonare
Vasi polmonari
Parenchima
Patologie polmonari
Gabbia toracica
Sistema neuromuscolare
Centri respiratori
Patologie extra-polmonari
Ingrandimento sezioni destre del cuore dovuto a:
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Cuore polmonare secondario ad patologie vascolari polmonari
Patologia vascolare Tipo di CP
Embolia polmonare massiva Acuto
Sindrome da distress respiratorio acuto Acuto
Vasculiti Cronico
Ipertensione polmonare idiopatica Cronico
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Cuore polmonare secondario ad patogie parenchimali polmonari
Patologia parenchimale Tipo di CP
BPCO cronico
Asma grave e persistente cronico
Stato di male asmatico acuto
Pneumotorace ipertensivo acuto
Interstiziopatie cronico
Tubercolosi polmonare cronico
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Fattori determinanti IP in BPCO
• Restringimento anatomico del letto vascolare
• Compressione estrinseca di vasi collassabili
• Compressione di grossi vasi (enfisema bolloso)
• Neomuscolarizzazione di arteriole polmonari
conseguente ad ipossia
• Ostruzione trombotica di grossi rami arteriosi
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Hypoxic pulmonary arteriopathy
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Cuore polmonare “acuto in cronico”
Si verifica durante esacerbazione di BPCO
Aggravamento di ipossiemia ed ipercapnia, con
aumento della concentrazione idrogenionica, agiscono
sinergisticamente nell’aumentare il tono vascolare delle
fibrocellule muscolari lisce determinando aumento delle
resistenze vascolari polmonari.
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Manifestazioni cliniche di CP
Sintomo Tipo di CP
Dispnea improvvisa Acuto
Dispnea graduale Cronico
Dolore toracico Acuto e cronico
Sincope Acuto e cronico
Emoftoe Acuto e cronico
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Rilievi obiettivi di CP
• Riduzione del rumore respiratorio
• Sollevamento del cuore (bordo sternale inferiore sinistro)
• Rinforzo della componente polmonare del II tono
• Soffio sistolico da insufficienza tricuspidale
• Turgore giugulare
• Epatomegalia
• Edemi improntabili agli arti inferiori
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Indagini diagnostiche per IP
• Radiografia standard del torace
• Elettrocardiogramma
• Ecocardiogramma
• Risonanza magnetica
• Cateterismo cardiaco destro
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MPAP = 41 mmHg; MPWP = 10 mmHg
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Criteri ECG di CP
• Onde P di tipo polmonare (> 2.5 mm)
• Deviazione assiale destra
• Blocco di branca destro (rSR’ in V1)
• Rapporto R/S >1 in V1
• Rapporto R/S <1 in V5 oV6
• Depressione ed inversione del tratto ST-T
nelle derivazioni precordiali destre.
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Acute cor pulmonaleECG findings
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Criteri ecocardiografici di IP
Ecocardiogramma 2-D Valore misurato
Diametro atrio destro > 40 mm
Diametro ventricolo destro (VD) > 26 mm
Spessore parete libera VD > 6 mm
Diametro arteria polmonare >24 mm
Velocità rigurgito tricuspidale >250 cm/sec
Ipocinesia parete libera VD -
Spostamento a sinistra setto IV -
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Echocardiographic assessment of pulmonary
hypertension in patients with advanced lung disease (From Arcasoy, Am J Respir Crit Care Med 2003)
• Sample: 374 patients.
• Doppler echocardiography (DE) within 72 hr of right
heart catheterization (RHC).
• Pulmonary hypertension (PH): systolic PAP≥45 mmHg.
• Echocardiographic abnormalities suggestive of PH:
right ventricular dilatation, hypertrophy, or hypokinesis.
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Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease
(From Arcasoy, Am J Respir Crit Care Med 2003)
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Sensitivity, specificity, and predictive value of echocardiography for the diagnosis of
pulmonary hypertension
FindingSensitivity
(%)Specificity
(%)PPV (%)
NPV (%)
Systolic PAP 85 55 52 87
RV abnormalities 85 66 33 96
(From Arcasoy, Am J Respir Crit Care Med 2003)
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Echocardiographic assessment of pulmonary hypertension in patients with
advanced lung disease (From Arcasoy, Am J Respir Crit Care Med 2003)
“Estimation of systolic pulmonary artery
pressure by echocardiography is frequently
inaccurate in patients with advanced lung
disease and leads to considerable
overdiagnosis of pulmonary hypertension.”
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Cateterismo cardiaco destro
• Misura pressioni in arteria polmonare• Misura portata cardiaca• Calcolo delle resistenze vascolari polmonari• Test di vasoreattività con NO (10-20 ppm)
“Responder”: riduzione di MPAP al di sotto di 40 mmHg senza riduzione consensuale della portata cardiaca.
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Severe pulmonary hypertension and chronic obstructive pulmonary disease(From Chaouat, Am J Respir Crit Care Med 2005)
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Lung function, blood gases, and hemodynamic data in 11 patients with severe PH and no other disease
Variable Median IQR
FEV1, % pred 50 (44-56)
PaO2 46 (41-53)
PaCO2 32 (28-37)
DLCO ml/min/mmHg 4.6 (4.2-6.7)
RAP, mmHg 7 (5-9)
MPAP, mmHg 48 (46-50)
CI, L/min/m2 2.3 (1.9-3.8)
PVR, IU/ m2 21.3 (17.6-26.6)
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Severe pulmonary hypertension and chronic
obstructive pulmonary disease(From Chaouat, Am J Respir Crit Care Med 2005)
• Severe PH is uncommon in patients with COPD.
• When it occurs, another cause must be sought.
• COPD with severe PH and no other cause
shares features with pulmonary vascular
diseases, such as idiopathic PH.