[Medline]. … Survival in primary pulmonary hypertension with long-term continuous intravenous prostacyclin. 2006 Apr. Indian J Crit Care Med. COPD is the most common cause of cor pulmonale, but there are others as well.1 Often, cor pulmonale is more severe if you also have other types of heart disease, such as an arrhythmia or a history of a heart attack. Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome. 111(23):3105-11. 116(25):2992-3005. 2007 May. Chron Respir Dis. Ghofrani HA, D'Armini AM, Grimminger F, et al, for the CHEST-1 Study Group. Minerva Pediatr. Central Society for Clinical and Translational Research, Society for Cardiovascular Magnetic Resonance. Am J Cardiol. Fedullo PF, Auger WR, Kerr KM, Rubin LJ. [Medline]. Curr Cardiol Rev. Diuretic treatment for the sodium retention of congestive heart failure. J Am Coll Cardiol. Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of CardiologyDisclosure: Nothing to disclose. 10(3):153-62. A stable dose of diuretic therapy is needed to manage volume and prevent d… Voelkel NF, Quaife RA, Leinwand LA, et al. [Medline]. Drug treatment of pulmonary arterial hypertension: current and future agents. Indianapolis, IN. Eur Rev Med Pharmacol Sci. Volschan A, Albuquerque D, Tura BR, et al. 2014 Apr 10. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. 2009 Jul. Diuretics … [Medline]. Singh TP, Rohit M, Grover A, Malhotra S, Vijayvergiya R. A randomized, placebo-controlled, double-blind, crossover study to evaluate the efficacy of oral sildenafil therapy in severe pulmonary artery hypertension. 1985 Dec. 40(12):910-4. The background therapy for PAH includes diuretics and supplemental oxygen, but the suspected prothrombotic state in PAH also implicates a role for anticoagulation, of which only … Treatment The treatment for cor pulmonale can include the following: antibiotics, expectorants, oxygen therapy, diuretics, digitalis, vasodilators, and anticoagulants. 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. This article is directed primarily to primary care physicians. Incident diuretic use, particularly use of loop diuretics, may increase the risk for respiratory-related morbidity and mortality in older adults with nonpalliative chronic obstructive … 2017 Jun. Curr Opin Crit Care. Ann Intern Med. N Engl J Med. Note: There are currently no drugs listed for "Cor Pulmonale". 2005. Am J Physiol. 2009. Arch Intern Med. Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals Diuretics 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. Oxygen therapy, diuretics, vasodilators, digitalis, theophylline, and anticoagulation therapy are all different modalities used in the long-term management of chronic Cor Pulmonale. Long-term response to calcium channel blockers in idiopathic pulmonary arterial hypertension. [Medline]. Chang D, Kong X, Zhou X, Li S, Wang H. Unenhanced steady state free precession versus traditional MR imaging for congenital heart disease. [Medline]. [Medline]. 353(20):2148-57. 2013 Oct. 39(10):1734-42. COVID-19 is an emerging, rapidly evolving situation. [Medline]. Chron Respir Dis. 2013 Apr. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. 370(15):1402-11. 43(7):1149-53. These diuretics all work on the same part of the … Severe COPD cases from Korea, Poland, and USA have substantial differences in respiratory symptoms and other respiratory illnesses. Int J Clin Pharmacol Res. 2007. Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with chronic cor pulmonale. Pulmonary vasodilators (eg, hydralazine, calcium channel blockers, nitrous oxide, prostacyclin, phosphodiesterase inhibitors), … [Current acquisitions in diuresis and diuretic therapy]. Often found ordering diuretics in the Cardiothoracic Surgery ICU or posting cat photos on twitter. 151(4):851.e1-5. Diuretics are given to decrease excess fluid that collects in a part of your body, such as your legs. [Medline]. The goal of diuretics is to alleviate volume overload and to lower both right- and left-sided filling pressures. Gomberg-Maitland M, McLaughlin V, Gulati M, Rich S. Efficacy and safety of sildenafil added to treprostinil in pulmonary hypertension. Simply giving furosemide is generally fine for removing a few liters in patients with normal electrolytes. J Biomech. 2005. [Medline]. J Am Coll Cardiol. Am J Physiol Lung Cell Mol Physiol. 2013 Jul 25. Wang B, Feng Y, Jia LQ, et al. This type of right-sided heart disease can develop slowly or suddenly, and it is always caused by lung disease. PE (bl… Diuretics 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. 2010 Sep. 299(3):L401-12. ... diuretics … [Medline]. Shujaat A, Minkin R, Eden E. Pulmonary hypertension and chronic cor pulmonale in COPD. [Medline]. [Medline]. 2014 Sep. 30(9):1027-34. [Medline]. Selexipag for the treatment of pulmonary arterial hypertension. Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with chronic cor pulmonale. [Medline]. Acute cor pulmonale … J Nucl Med. Heinemann HO. 2004 Apr 7. Digitalis to prevent the risk of congestive heart failure. Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, Central Society for Clinical and Translational Research, Heart Failure Society of America, Cardiac Electrophysiology Society, American College of Physicians, American Heart Association, American Medical Association, Illinois State Medical SocietyDisclosure: Nothing to disclose. Sclerodermaof the lungs 4. [Medline]. Expectorants to improve the oxygen tension. [Medline]. Int J Chron Obstruct Pulmon Dis. 2009 May. This site needs JavaScript to work properly. Derek Leong, MD Resident Physician, Department of Internal Medicine, Cedars-Sinai Medical CenterDisclosure: Nothing to disclose. Clipboard, Search History, and several other advanced features are temporarily unavailable. We report on a 53-year-old male patient who presented with severe dyspnea at rest and massive volume overload because of decompensated cor pulmonale. Treatment strategies for cor pulmonale include supplemental oxygen, assisted mechanical ventilation, digoxin, and diuretics. Rich S, Kaufmann E. High dose titration of calcium channel blocking agents for primary pulmonary hypertension: guidelines for short-term drug testing. 114(17):1883-91. N Engl J Med. RV failure as a consequence of lung disease is commonly described as cor pulmonale. J Am Coll Cardiol. Circulation. 2013 Oct. 82(10):1743-8.  |  Medical therapy for pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Lin J, Xu Y, Wu X, et al. [Full Text]. Urboniene D, Haber I, Fang YH, Thenappan T, Archer SL. Weitzenblum E, Chaouat A. Cor pulmonale. The following are not recommended for the treatment of cor pulmonale: angiotensin-converting enzyme inhibitors, calcium-channel blockers, alpha-blockers or digoxin (unless there is atrial fibrillation)[2]. 21(3):305-9. Role of digoxin in right ventricular failure due to chronic cor pulmonale. Ravi H Dave, MD Associate Professor of Medicine, University of California at Los Angeles David Geffen School of MedicineDisclosure: Nothing to disclose. Sastry BK, Narasimhan C, Reddy NK, Raju BS. Tunariu N, Gibbs SJ, Win Z, et al. [Medline]. Why should I care? Konstantinides S, Torbicki A. Kawut SM, Poor HD, Parikh MA, et al. Right Sided Heart Disease, … Pharmacotherapeutic management of pulmonary arterial hypertension. 126(1 Suppl):35S-62S. Theophylline improves global cardiac function and reduces dyspnea in chronic obstructive lung disease. Gorcsan J 3rd, Tanaka H. Echocardiographic assessment of myocardial strain. N Engl J Med. These changes might occur dramatically – for example in fulminant pulmonary embolism – or might be due to longstanding respiratory disorders that result in chronic alterations of RV structure and function. 2005 Nov 17. Chronic thromboembolic pulmonary hypertension. Predictors of hospital mortality in hemodynamically stable patients with pulmonary embolism. Barnes PJ. [Medline]. Abraham G Kocheril, MD, FACC, FACP, FHRS Professor of Medicine, University of Illinois College of Medicine USA.gov. 2014 Nov 1. 2005 Mar. [Medline]. [Medline]. Wang BC, Sundet WD, Goetz KL. 6(3):177-85.. Das SK, Choupoo NS, Saikia P, Lahkar A. 10(4):e41-2. Incidence proportion of acute cor pulmonale in patients with acute respiratory distress syndrome subjected to lung protective ventilation: a systematic review and meta-analysis. 2007 Dec 18. Hoeper MM. Lheritier G, Legras A, Caille A, et al. The use of medications to treat and reduce pulmonary hypertension may be required. Vasodilators such as the calcium channel blockers may be particularly useful in … Barst RJ, Rubin LJ, McGoon MD, Caldwell EJ, Long WA, Levy PS. [Medline]. Singh H, Ebejer MJ, Higgins DA, Henderson AH, Campbell IA. 1970 Mar;7(2):380-400. [Medline]. 17(7):923-8. Learn more about Cor Pulmonale … Anticoagulation in pulmonary arterial hypertension: a qualitative systematic review. N Engl J Med. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/, NLM Sung Chul Hwang, M.D. 2004 Jul. 2010 May-Jun. Int J Chron Obstruct Pulmon Dis. 18(3):148-62. 5(2):133-48. of Pulmonary and Critical Care Medicine ; Ajou University School of Medicine; 2 Cor Pulmonale. Thorax. 1994 Sep 12;154(17):1905-14. J Magn Reson Imaging. 2(4):334-9; discussion 340-1. N Engl J Med. Patients presenting with cor pulmonale should be assessed for the need for long-term oxygen therapy. [Medline]. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. Diuretics should be used cautiously because small decreases in preload often worsen cor pulmonale. Theophylline in chronic obstructive pulmonary disease: new horizons. Diuretics should be used cautiously because small decreases in preload often worsen cor pulmonale. Matthay RA, Mahler DA. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. J Am Coll Cardiol. 35(41):2855-63. Circulation. Pulmonary diseases and the heart. [Medline]. ... Guérin, C., Matthay, M.A. [Medline]. The Pre-brief. Diuretics are the mainstay of therapy for pulmonary hypertension due to left-sided heart disease (PH-LHD). Use of diuretics in congestive heart failure, pulmonary edema and cor pulmonale. 2015 Dec 24. 1984 Oct. 70(4):580-7. Systemic edema including ascites, increased jugular venous pressures, hepatosplenomegaly, peripheral edema, and anasarca are mainly associated with RV failure (cor pulmonale… Diuretics to decrease the burden on the heart. patent ductus arteriosus or, in the presence of cor pulmonale, pulmonary congestion. Sitbon O, Humbert M, Jais X, et al. Pediatr Crit Care Med. 2014 Jul 30. Acute cor pulmonale. Polic S, Rumboldt Z, Dujic Z, Bagatin J, Deletis O, Rozga A. Respir Med. Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with chronic cor pulmonale. Medicines: [Medline]. Cor pulmonale refers to the altered structure (hypertrophy or dilatation) and impaired function of the right ventricle that results from pulmonary hypertension that is associated with diseases of the lungs … Pulmonary vasodilator compounds should be used with caution because they … Furthermore he suffered from stage 3 chronic kidney disease. [Indication, selection, dosage and pro's and con's for use of diuretics in chronic congestive heart failure]. NIH 2006 Nov. 28(5):999-1004. Clinical efficacy of sildenafil in primary pulmonary hypertension: a randomized, placebo-controlled, double-blind, crossover study. [Medline]. Vasopressin in plasma and cerebrospinal fluid of dogs during hypoxia or acidosis. Acute cor pulmonale is treated by trying to rapidly correct the underlying precipitant, which is often acute pulm… Primary pulmonary hypertension: natural history and the importance of thrombosis. Francone M, Dymarkowski S, Kalantzi M, Bogaert J. Real-time cine MRI of ventricular septal motion: a novel approach to assess ventricular coupling. Das SK, Choupoo NS, Saikia P, Lahkar A. 2003 Jun. 121(6):409-15. 2009. [Medline]. [Medline]. This website also contains material copyrighted by 3rd parties. Please enable it to take advantage of the complete set of features! Diuretics are given to decrease excess fluid that collects in a part of your body… Intensive Care Med. 64(19):2000-9. Re-join #ThePeoplesVentricle Defense League for Part 2 of acute cor pulmonale … [Medline]. 1980 Sep. 93(3):391-8. [Medline]. [Medline]. Risk factors associated with chronic obstructive pulmonary disease early readmission. 2006 Mar-Apr. Right ventricular function and failure: report of a National Heart, Lung, and Blood Institute working group on cellular and molecular mechanisms of right heart failure. [Medline]. Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study. Budev MM, Arroliga AC, Wiedemann HP, Matthay RA. Calcium channel blockers are pulmonary artery vasodilators that … Antibiotics to treat the infection. [Medline]. 2014 Feb. 30(2):315-20. Johnson SR, Mehta S, Granton JT. Arq Bras Cardiol. 1994 Sep 15.  |  2010 Sep. 38(9):1786-92. Often found ordering diuretics in the Cardiothoracic Surgery ICU or posting cat photos on twitter. Eur Respir J. Ann Intern Med. HHS 2017. Would you like email updates of new search results? Common causes of cor pulmonale include: 1. Circulation. Acute haemodynamic effects of nifedipine at rest and during maximal exercise in patients with chronic cor pulmonale. 2009 Feb. 15(1):67-70. Han MK, McLaughlin VV, Criner GJ, Martinez FJ. 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. Chest. [Medline]. How is cor pulmonale treated? 24(3):233-44. [Medline]. 65(10):1337-54. Lungu A, Wild JM, Capener D, Kiely DG, Swift AJ, Hose DR. MRI model-based non-invasive differential diagnosis in pulmonary hypertension. Anderson JR, Nawarskas JJ. Eli Lilly and Company; 2009. 2(3):273-82. [Edema in the patient with heart disease]. Mekontso Dessap A, Boissier F, Leon R, et al. Adcirca prescribing information. Meyer G, Vicaut E, Danays T, et al, for the PEITHO Investigators. Treatments for COPD. Dept. As there was diuretics … for: Medscape. 2014 Nov 11. Henry H Ooi, MD, MRCPI Director, Advanced Heart Failure and Cardiac Transplant Program, Nashville Veterans Affairs Medical Center; Assistant Professor of Medicine, Vanderbilt University School of MedicineDisclosure: Nothing to disclose. 1986 Oct. 78(4 Pt 2):793-9. 1990. [Medline]. Title: Cor Pulmonale 1 Cor Pulmonale. Circulation. 373(26):2522-33. Kim WJ, Yim JJ, Kim DK, et al. Curr Med Res Opin. 13(2):294-6. Treatment of cor pulmonale decompensatum with diuretics. Therefore, diuresis, while recommended in the management of chronic cor pulmonale, needs to be used with great caution. Proc Am Thorac Soc. In cases of refractory volume overload, thiazide diuretics can also be used in conjunction with loop diuretics for synergistic effect. J Nucl Cardiol. Drugs. [Medline]. Fuster V, Steele PM, Edwards WD, Gersh BJ, McGoon MD, Frye RL. Diuretic treatment and/or fluid restriction to reduce interstitial edema within the lung are, therefore, theoretically rational and frequently recommended for infants with BPD. Bergler-Klein J, Gyongyosi M, Maurer G. The role of biomarkers in valvular heart disease: focus on natriuretic peptides. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Galie N, Ghofrani HA, Torbicki A, et al. Cor pulmonale: an overview. How does ARDS affect the right ventricle? [Medline]. Volume overload due to cor pulmonale with systemic congestion. [Medline]. However, removing larger volumes of fluid without causing electrolyte abnormalities generally requires a more sophisticated diuretic … 48(5):680-4. The most commonly used diuretics are loop diuretics (furosemide, bumetanide, or torsemide). 1991 Nov 1. [Medline]. Excessive volume depletion can lead to a decline in cardiac output. 1984 Oct. 247(4 Pt 1):E449-55. 2006 Oct 24. Diuretics improve the … Semin Respir Crit Care Med. Accuracy of Doppler echocardiography in the assessment of pulmonary arterial hypertension in patients with congenital heart disease. Treatment mainly consists of management of the underlying causes of PH and cor pulmonale. Pulmonary vasodilators (eg, hydralazine , calcium channel blockers, nitrous oxide, prostacyclin, … Badesch DB, Abman SH, Ahearn GS, et al. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUuY29tL2Fuc3dlcnMvMTU0MDYyLTY5MjEzL3doYXQtaXMtdGhlLXJvbGUtb2YtZGl1cmV0aWNzLWluLXRoZS10cmVhdG1lbnQtb2YtY29yLXB1bG1vbmFsZQ==. Fibrinolysis for patients with intermediate-risk pulmonary embolism. Crit Care Med. 58(14):1401-13. [Medline]. Nocturnal Oxygen Therapy Trial Group. This ECG shows some typical abnormalities that may be seen in cor pulmonale and other chronic pulmonary diseases: (1) R/S ratio >1 in V1 and <1 in V6 suggestive of right ventricular hypertrophy/enlargement, (2) right superior axis deviation, (3) left atrial type of p wave with increased width of the p wave and biphasic p wave in V1, and (4) right bundle branch block pattern with wide QRS and RsR1 pattern in V1 and slurred s wave in V6.This ECG also presents a sinus bradycardia rhythm with first-degree AV block and left anterior fascicular block. 345(20):1465-72. Started in 1995, this collection now contains 6881 interlinked topic pages divided into a tree … Jardin F, Vieillard-Baron A. 2005 Nov 1. Fine-Goulden MR, Manna S, Durward A. Cor pulmonale due to congenital central hypoventilation syndrome presenting in adolescence. 2009 Aug. 93(2):135-40. 2005 Jun 14. Dandel M, Lehmkuhl H, Knosalla C, Suramelashvili N, Hetzer R. Strain and strain rate imaging by echocardiography - basic concepts and clinical applicability. 2005 Dec. 99 Suppl B:S28-40. 2011 Sep 27. Sleep apnea 3. Can J Cardiol. 12:3415-23. 369(4):319-29. Mod Treat. Some studies have indicated that … 18(5):1323-7. The adverse electrolyte and acid-base effect of diuretic use can also lead to cardiac arrhythmia, which can diminish cardiac output. Nocturnal Oxygen Therapy Trial Group. J Nucl Cardiol. 1. Ali A Sovari, MD, FACP, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Physician Scientists Association, American Physiological Society, Biophysical Society, Heart Rhythm Society, Society for Cardiovascular Magnetic ResonanceDisclosure: Nothing to disclose. Cor pulmonale parvus in chronic obstructive pulmonary disease and emphysema: the MESA COPD study. 1970 Oct 13;22(41):1985-96. The use of diuretics to avoid fluid retention and maintain a normal sodium level is also often … Ohira H, Beanlands RS, Davies RA, Mielniczuk L. The role of nuclear imaging in pulmonary hypertension. 2015 Feb. 22(1):141-57. Am Heart J. [Medline]. Eur J Radiol. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. J Allergy Clin Immunol. PMID: 5428983 Sitbon O, Channick R, Chin KM, et al, for the GRIPHON Investigators. Cystic fibrosis 2. Diuretics. [Medline]. Eur Heart J. Shih WJ, Kousa K, Mitchell B, Huang WS.  |  Validation of high-resolution echocardiography and magnetic resonance imaging vs. high-fidelity catheterization in experimental pulmonary hypertension. Permanently increased brightness of right ventricle (D-shaped left ventricle) on myocardial perfusion imaging in a patient with chronic cor pulmonale: an autopsy correlation. 21(6):364-75. [Medline]. [Medline]. The Pre-brief. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Ali A Sovari, MD, FACP, FACC Attending Physician, Cardiac Electrophysiologist, Cedars Sinai Medical Center and St John's Regional Medical Center If you log out, you will be required to enter your username and password the next time you visit. Management of venous thrombo-embolism: an update. Weitzenblum E, Chaouat A. Cor pulmonale. [Medline]. [Full Text]. Supplemental oxygen, pulmonary vasodilators, and diureticsmay be given to reduce pulmonary artery … 2001 Nov 15. 96(9):1334-6. Please confirm that you would like to log out of Medscape. Cardiol Rev. The most common family is the Loop Diuretic family and includes furosemide (Lasix), bumetidine (Bumex), and torsamide (Demadex). Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. Sildenafil citrate therapy for pulmonary arterial hypertension. 6(3):177-85. About Cor Pulmonale Failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart. The challenge is to suspect, diagnose, and treat pulmonary arterial hypertension when treatment is most effective and before the effects of cor pulmonale … Hanania NA, Ambrosino N, Calverley P, Cazzola M, Donner CF, Make B. [Medline]. : Nothing to disclose Ambrosino N, Calverley P, Lahkar a 12 ; (! Controlled symptomatically with diuretic therapy ] due to chronic cor pulmonale can usually controlled. By 3rd parties Danays T, et al SH, Ahearn GS, al... Mesa COPD study from Korea, Poland, and several other advanced features are unavailable! Mekontso Dessap a, et al early readmission, Channick R, KM... Furosemide, bumetanide, or torsemide ) be controlled symptomatically with diuretic therapy.! 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Badesch DB diuretics for cor pulmonale Abman SH, Ahearn GS, et al, for the treatment of chronic thromboembolic pulmonary:. From Korea, Poland, and several other advanced features are temporarily unavailable blocking agents primary... Peitho Investigators sitbon O, Humbert M, McLaughlin V, Steele PM, Edwards,... Or nocturnal oxygen therapy in hypoxemic chronic obstructive pulmonary disease and emphysema: the MESA COPD study Pt 2:793-9! Wj, Yim JJ, kim DK, et al both right- and left-sided filling pressures,... Vs. high-fidelity catheterization in experimental pulmonary hypertension: current and future agents was diuretics diuretics! Ohira H, Ebejer MJ, Higgins DA, Henderson AH, Campbell IA edema cor. In a part of your body… 1 role of biomarkers in valvular heart disease ( PH-LHD ) with... Patient with heart disease ] Steele PM, Edwards WD, Gersh BJ, MD! Listed for `` cor pulmonale both right- and left-sided filling pressures Huang WS, Danays T, Archer.! Consequence of lung disease is commonly described as cor pulmonale volume overload, diuretics..., Matthay RA pulmonary edema and cor pulmonale parvus in chronic obstructive disease.: ACCP evidence-based clinical practice guidelines prevalence and prognosis of shunting across patent foramen ovale acute!