Q&A: Acute or chronic cor pulmonale

Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and edema?

A: You have obviously put a lot of thought into this question because it is difficult to differentiate between acute and acute-on-chronic cor pulmonale.

 

Cor pulmonale just means elevated right-sided circulatory pressures. Let’s take a typical patient with COPD. Because of loss of arterials and associated loss of alveoli, the patient’s pressures in the right system go up. It’s like squeezing the end of a hose. The pressure goes up on the end of the hose because you have less caliber, less diameter.

 

With emphysema, for instance, the pressures that the pulmonary artery has to push up against are elevated. When that happens, we call that cor pulmonale and increased right-sided heart pressures. When the right ventricle fails, we call that right-heart failure.

 

When the right ventricle fails, fluid backs up into the peripheral circulation, into the legs, into the head and into the liver.  You see swelling or a fluid accumulation in those areas.

 

In a patient who comes in with an acute exacerbation of COPD and has cor pulmonale, how do you differentiate between acute cor pulmonale as the principal diagnosis,  acute cor pulmonale as an additional diagnosis, or merely chronic cor pulmonale?

 

You’re not going to like this answer, but when my patients who have chronic cor pulmonale from COPD–in other words, they may oftentimes have a little pedal edema or a little facial swelling or extension of neck veins–come in acutely exacerbated, they indeed may have more swelling in their legs. I think of that as sort of an acute exacerbation of chronic cor pulmonale. I don’t look at it as acute primary cor pulmonale, which I associate with conditions such as pulmonary embolus, where you have suddenly elevated increased right-sided pressures and a sudden development of right-heart failure. That’s what’s classically considered acute cor pulmonale, and you would report an additional diagnosis.

 

Editor’s Note: William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Florida, answered this question. Contact him at behaik@aol.com. This answer was provided based on limited information submitted to JustCoding and published in the Sept. 9, 2014, edition of its newsletter.