Bangalore.
Annexure- II
Proforma For Registration Of Subjects For Dissertation
1. / NAME OF THE CANDIDATE AND ADDRESS
(IN BLOCK LETTERS) / DR.ABHISHEK
PG IN GENERAL MEDICINE,
KARNATAKA INSTITUTE OF
MEDICAL SCIENCES,
HUBLI-580022.
2. / NAME OF THE INSTITUTION / KARNATAKA INSTITUTE OF
MEDICAL SCIENCES,HUBLI-22.
3. / COURSE OF STUDY AND SUBJECT / M.D. IN GENERALMEDICINE.
4. / DATE OF ADMISSION TO COURSE / 31-05-2011
5. / TITLE OF THE TOPIC / A STUDY ON CLINICAL PROFILE,RADIOLOGICAL FEATURES,ELECTROCARDIOGRAPHIC AND ECHOCARDIOGRAPHIC CHANGES IN CHRONIC COR PULMONALE
6. / brief resume of the intended work:
6.1 NEED FOR STUDY:
Cor pulmonale is dilatation and hypertrophy of right ventricle in response to disease of pulmonary vasculature or lung parenchyma. Chronic cor pulmonale is not a single disease entity but resulting secondary to many bronchopulmonary vascular disease and also from thoracic cage abnormalities.Cor pulmonale accounts for 5-10% of all heart diseases, 20-30% ofall admissions for heart failure and 9.2% in the cardiac autopsies.Chronic cor pulmonale is recognized as a serious protracted, ultimately fatal human experience consuming frequently a large segment of the sufferer’s life. Thus it constitutes a serious problem in public health and preventive medicine. The reported incidence of the disease in different areas show wide disparities and may reflect these inconsistencies in the diagnostic terminology and conventions. These reports also indicate real variations in disease experience and may give important clues to those differences in local environment or ways of life which may underlie the geographical distribution of the disease The following study is done to know the clinical presentation and its correlation with radiological, ECG and Echocardiographic changes in chronic cor pulmonale
6.2 REVIEW OF THE LITERATURE:
N. K. Gupta, Ritesh Kumar Agrawal, A. B. Srivastav, in their study on echocardiographic evaluation of COPD in 40 patients, observed that 50% cases had normal echocardiographic parameters. Measurable tricuspid regurgitation (TR) was observed in 27/40 cases (67.5%). Pulmonary hypertension (PH), which is defined as systolic pulmonary arterial pressure (sPAP)> 30 mmHg was observed in 17/27 (63%) cases in which prevalence of mild, moderate, and severe PH were 10/17 (58.82%), 4/17 (23.53%), and 3/17 (17.65%), respectively. The frequencies of PH in mild, moderate, severe, and very severe COPD were 16.67%, 54.55%, 60.00%, and 83.33%, respectively. Right atrial pressure was 10 mmHg in 82.5% cases and 15 mmHg in 17.5% cases. Cor pulmonale was observed in 7/17 (41.17%) cases; 7.50% cases had left ventricle (LV) systolic dysfunction and 47.5% cases had evidence of LV diastolic dysfunction defined as A ≥ E (peak mitral flow velocity of the early rapid filling wave (E), peak velocity of the late filling wave caused by atrial contraction (A) on mitral valve tracing) Left ventricle hypertrophy was found in 22.5% cases.
Rajashree in her study on 50 patients admitted with chronic cor pulmonale, 32 weremales and 18 were females. The peak incidence was found in the 4th , 5th and 6th decades of life. Smoking was found to be a major cause for COPD andhence cor pulmonale. Among 50 patients 30 were smokers. Among 50 cases,(60%) were diagnosed to have chronic bronchitis with or withoutemphysema. Chest x-ray showed details relevant to the clinical profile. ECG showed 22% cases with RVH, 66% with RAD, 28% RBBB and 94% with P pulmonale. 6% of patients had ventricular ectopics. Every patients showed echocardiographic features suggesting chronic cor pulmonaleexcept 2 patients who showed global hypokinesia.
Miriam Schena, Enrico Clini, Donatella Errera, and Armido Quadri, in their study on left ventricular impairment on 2D-Echo in 30 patients of chronic cor pulmonale showed a marked enlargement of RV, compressing the left through a leftward shift ofinterventricular septum. A linear regression analysis detected a significant correlation betweenmPAP and the following parameters: RV/LV diastolic and systolic area indexes (r=0.75, p<0.0001;r=0.84, p<0.000, respectively), mitral A/E index (r=0.61, p<0.0005), and LV diastolic and systoliceccentricity indexes (r=0.93, p<0.0001; and r=0.83, p<0.0001). No correlations were found betweenecho-Doppler data and functional respiratory parameters. From these results,they concluded thatchronic RV pressure overload induces LV filling impairment despite a normal systolic phase, dueto septal leftward shift. In fact, chronic RV pressure overload distorts early diastolic LV geometrydelaying LV filling phase, and the functional diastolic impairment of the LV is closely correlated topulmonary hypertension levels.
Putnik M, Povazan D, Vindis-Jesic Min their study on Sixty patients with a chronic obstructive pulmonary disease (COPD) and clinical symptoms of cardiac decompensation , The diagnosis of CPHD was established by electrocardiography in 43 patients (78.18%) while in 57 patients (95%) it was done by ultrasound cardiography. Morphologic changes of the right ventricle (RV) were quantified, i.e. the diagnosis of chronic pulmonary heart disease was confirmed by echocardiography parameters such as right ventricle free wall thickness--RVFWT (0.82 +/- 0.09 cm), enddiastolic right ventricle dimension--ERVD (3.78 +/- 0.73 cm) and tricuspid regurgitation--TR (2.9 +/- 0.59, i.e. 2.58 +/- 0.55 after therapy). Echocardiography has been concluded to be of better sensitivity than ECG in diagnosing CPHD and both methods, noninvasive and easily applicable, have an important role in examining cardiac changes in patients with COPD.
Necla ozer , Lale Tokgozoglu, FACC, Lutfu Çoplu and Sirri Kesin their study on 40 patients of COPD , Patients were divided into 2 subgroupsaccording to pulmonary artery pressures: 25patients with pulmonary hypertension (group 1)and 23 patients with normal pulmonary arterypressure (group 2). As a control group, 59 normalsubjects were studied (group 3). Patients in group 1had higher tricuspid peak A velocity, lower tricuspidE velocity, longer isovolumetric relaxation time,higher mitral A wave, lower mitral E wave, andslower color propagation velocity than groups 2 and3. There was no significant difference between leftventricular diastolic filling parameters betweengroups 2 and 3. Patients with COPD and pulmonaryhypertension have left and right ventricular diastolicdysfunction. However, patients with COPDand normal pulmonary artery pressure have normalleft and right ventricular diastolic function.
6.3 AIMS AND OBJECTIVES OF THE STUDY:
1. To know the clinical profile in chronic cor pulmonale.
2. To know the radiological features, electrocardiographic and
echocardiographic changes in clinically proven cases of chroniccor pulmonale.
7. / MATERIALS AND METHODS :
7.1 SOURCE OF DATA:
A total of 50 patientsadmitted in MEDICAL WARDS, Department of Medicine,Karnataka Institute of Medical Sciences,Hubli,during the period of December 1st 2011 to November 30th2012 will be taken for study considering the inclusion and exclusion criteria.
7.2 METHODS OF COLLECTION OF DATA:
- Information will be collected through a pre tested and structured proforma for each patient.
- The study will be carried out on patients presenting with clinical features suggestive of chronic cor pulmonale
- In all the selected patients detailed history and physical examination will be note and all patients will be subjected to chest x-ray PA view, 12 lead ECG, 2D-Echocardiogram
TYPE OF STUDY:CROSS SECTIONAL HOSPITAL BASED TIME BOUND STUDY.
SAMPLING:
As per hospital statistics 10000 patients were admitted in Department of Medicine, KIMS, Hubli in the year 2010. Of them 160 patients were diagnosed to have CHRONIC COR PULMONALE. However this being a time bound study (December 1st2011 to 30thNovember 2012), all the patients admitted to Medical Wards of Karnataka institute of medical sciences,Hubli during this period will be taken for the study.
Inclusion criteria :
All patients will be included in the study with chronic cor pulmonaleof both the genders as cases. The diagnosis of chronic cor pulmonale will beestablished by;
Clinical history with cough with sputum, paroxysmal cough,dyspnoea, fluid retention with edema and sometimes ascites,recurrent chest infections, cyanosis, fatigue, chest pain, near
syncope, palpitation.
General physical examination suggesting RVF.
Radiological examination, electrocardiographic and echocardiographic
changes associated with chronic cor pulmonale.
Exclusion criteria:
Patients with primary involvement of left side of the heart.
Patients with valvular or myocardial disease.
Patients with arterial occlusive disease from emboli.
Patients with primary pulmonary hypertension.
Patients with congenital heart disease.
Parameters used:clinical profile, 12-lead ECG changes,2-D echo findings.
Statistical Analysis:percentages,proportions,chi-square,correlation.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? (If so, please describe briefly)
YES,
1)ROUTINE BLOOD INVESTIGATIONS
2) CHEST X-RAY
3) ECG
4) 2-D ECHO
5) PULMONARY FUNCTION TESTS
7.4 Has ethical clearance been obtained from ethical committee of your institution in case of 7.3?
Yes, ethical clearance has been obtained from the ethical committee
KIMS, Hubli.
8. / List of References:
1 : Braunwald E. Heart failure and Cor pulmonale. In: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL Jameson JL, editors.
Harrison’s principles of internal medicine 18th Edition VOLUME 2 p.1913-1915
2 : Gandhi MJ. Cor pulmonale and pulmonary hypertension. In: Shah SN, editor. API Text Book of Medicine. 7t h ed. Mumbai: The Association of Physicians of India ; 2003.p.487-490
3 : Necla ozer , Lale Tokgozoglu, FACC, Lutfu Çoplu and Sirri Kes Echocardiographic Evaluation of Left and Right Ventricular Diastolic Function in Patients with Chronic Obstructive Pulmonary Disease
4 : N. K. Gupta, Ritesh Kumar Agrawal, A. B. Srivastav,
Echocardiographic evaluation of heart in chronic obstructive pulmonary disease patient and its co-relation with the severity of disease
5 : Bhargava RK. Corpulmonale (Pulmonary Heart Disease). New YorkUSA: Futura publishing company; 1973.
6 : White J, Bullock RE, Hudgson P, Gibson GJ. Neuromuscular disease,Respiratory failure and Cor pulmonale. Postgraduate Med J1992;68:820-823.
7 : John B, Pier G, Agaston. Cor pulmonale. In: Murray Nadel, editor. Text
Book of Respiratory Medicine. 2nd ed. Vol-2. Philadelphia : W.BSaunders company; 1988.p.1779-1798.
8 : Emmanuel Weitzenblum , General cardiology Chronic cor pulmonale. Heart 2003;89:225–230
9. / Signature of the candidate
10. / Remarks of the guide
11. / Name and Designation
11.1 Guide / DR.VASANTHA.KAMATh
PROFESSOR,
DEPARTMENT OF MEDICINE
KIMS, HUBLI.
11.2 Signature
11.3 Co-Guide
11.4 Signature
11.5 Head of the Department / Dr. H. MALLIKARJUN SWAMY.
PROFESSOR AND HEAD,
DEPARTMENT OF MEDICINE
KIMS, HUBLI.
11.6 Signature
12. / 12.1 Remarks of the Principal and Chairman
12.2 Signature