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Pulmonology > 20 - Pulmonary Vascular Disease > Flashcards

20 - Pulmonary Vascular Disease Flashcards

1
Q

What factors influence pulmonary vascular resistance?

A
  • recruitment and distension
  • lung volume
  • intrathoracic pressure
  • increased viscosity
  • decreased vessel radius
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2
Q

How much pulmonary vascular destruction needs to occur before pulmonary hypertension occurs at rest/

A

50-70%

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3
Q

What is the definition of pulmonary arterial hypertension? What is the definition of pulmonary venous hypertension?

A

Arterial - mean arterial pressure ≥ 25 mmHg at rest, with a pulmonary capillary wedge pressure ≤ 15 mmHg (pre-capillary)

Venous - pulmonary capillary wedge pressure > 15 mmHg (post-capillary)

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4
Q

How does hypoxia cause pulmonary hypertension?

A
  • vasoconstriction

- remodeling (smooth muscle where it normally doesn’t belong)

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5
Q

What are the clinical findings of pulmonary hypertension?

A
  • dyspnea
  • syncope
  • lower extremity edema
  • JVD
  • tricuspid regurgitation murmur
  • right ventricular heave
  • loud P2 (from pulmonic closure)
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6
Q

Cor pulmonale is [right/left]-sided heart failure from lung disease. What causes it?

A

Right sided

Due to increased pulmonary vascular resistance and pulmonary hypertension

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7
Q

What are the acute and chronic causes of cor pulmonale? Which can lead to right ventricular failure and shock?

A

Acute - can lead to RV failure and shock if mean PA > 40
- massive pulmonary embolism

Chronic

  • idiopathic pulmonary arterial hypertension
  • pulmonary hypertension secondary to COPD or IPF
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8
Q

What are the 5 WHO groups for pulmonary hypertension? What are their causes? Which is the most common? What are their associated PVRs and PCWPs?

A 
1 - Pulmonary Artery Hypertension (PAH)
- idopathic
- connective tissue disease
- HIV
- cirrhosis
- congenital heart disease
- drug induced
Precapillary, greatly increased PVR, normal PCWP

2 - Pulmonary Venous Hypertension (most common)
- left heart disease (systolic or diastolic dysfunction)
Postcapillary, normal PVR, increased PCWP

3 - Hypoxia or Lung Issue
- sleep apnea
- obesity hypoventilation syndrome
- high altitude 
- COPD
- IPF
precapillary, increased PVR, normal PCWP

4 - Thromboembolic
Precapillary, increased PVR, normal PCWP

5 - Miscellaneous

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9
Q

What is the pathogenesis of pulmonary hypertension?

A
  • imbalance between vasodilators (decreased NO and prostacyclin) and vasoconstrictors (increased thromboxane and endothelin)
  • fibrinolytic defects
  • increased smooth muscle proliferation in pulmonary arteries/arterioles
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10
Q

NO is a [vasodilator/vasoconstrictor]. It is [increased/decreased] in pulmonary hypertension.

A

vasodilator; decreased

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11
Q

Prostacyclin is a [vasodilator/vasoconstrictor]. It is [increased/decreased] in pulmonary hypertension.

A

vasodilator; decreased

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12
Q

Thromboxane is a [vasodilator/vasoconstrictor]. It is [increased/decreased] in pulmonary hypertension.

A

vasoconstrictor; increased

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13
Q

Endothelin is a [vasodilator/vasoconstrictor]. It is [increased/decreased] in pulmonary hypertension.

A

vasoconstrictor; increased

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14
Q

What mutation is associated with pulmonary hypertension? What is the result of it?

A

BMPR2 –> increased TGF-beta induced smooth muscle cell proliferation in pulmonary arteries/arterioles

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15
Q

What is the best screening test for pulmonary hypertension?

A

cardiac echo

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16
Q

What is the workup required to make a diagnosis of pulmonary hypertension?

A
  • chest x ray
  • EKG
  • cardiac echo
  • PFTs
  • ABG
  • V/Q scan or CT-PA for pulmonary emboli
  • testing for HIV/cirrhosis/connective tissue disease
  • right heart catheterization
17
Q

What is the appropriate treatment for pulmonary hypertension?

A

Group 1:

  • oxygen
  • anticoagulation
  • vasodilators (calcium channel blockers)
  • endothelin antagonists
  • prostacyclins
  • PDE-5 inhibitor

Group 2-5: treat underlying disease

18
Q

What effect does prostacyclin treatment have in pulmonary hypertension?

A
  • anti-proliferative effect on smooth muscle and endothelium

- antiplatelet effect

19
Q

What effect does PDE-5 inhibitor treatment have in pulmonary hypertension?

A
  • increased cGMP

- guanylate cyclase stimulant (increases cGMP)

20
Q

What is Virchow’s triad?

A

Risk factors for pulmonary embolsim

  • stasis or immobilization
  • inflammation or injury
  • hypercoaguability (cancer, surgery, stroke, tobacco, OCPs, etc.)
21
Q

Why is a D-dimer test useful in regards to pulmonary embolism?

A

It has a high negative predictive value - if clinical suspicion is low and test is negative, you can rule out pulmonary embolism

22
Q

What is the most common x-ray finding with pulmonary embolism?

A

atelectasis

23
Q

What is the origin of most pulmonary emboli?

A

lower extremity DVT

24
Q

What are the clinical presentations of pulmonary embolism?

A
  • infarction syndrome or pleuritic chest pain + dyspnea + fever + hemoptysis (65%)
  • unexplained dyspnea or hypoxemia (22%)
  • massive pulmonary embolism (8%)
25
Q

What are the signs of an acute massive pulmonary embolism?

A
  • signs of right sided heart failure
  • right heart strain on EKG
  • hypotension
26
Q

What is the Wells Criteria used for?

A

determining pretest probability of PE

27
Q

What is the treatment for acute/chronic pulmonary embolism? What can be done prophylactically?

A

Acute PE

  • low molecular weight heparin (subcutaneous injection) or heparin (IV)
  • fondaparinux (Xa inhibitor)
  • oral direct factor Xa inhibitor

Chronic PE

  • warfarin (vitamin K antagonist)
  • rivaroxaban (Xa inhibitor)

Prophylaxis

  • heparin
  • venous compression boots
28
Q

Pulmonary embolism has a [normal/wide] A-a gradient.

Pulmonology (25 decks)

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