Clinical Aspects of Pulmonary Hypertension (DISEASE MECHANISMS) Flashcards
What is included in thromboembolic disease?
DVT
PE
What is a PE?
Blockage of a pulmonary artery by a blood clot, fat tumour or air
If blood flow ad oxygen to a lung tissue is compromise the lung tissue may die. What is this process called?
Pulmonary infarction
Which DVTs are most likely to embolism and lead to chronic venous insufficiency and venous leg ulcers?
Proximal (ileo-femoral DVT)
Which DVTs are least likely to embolism?
Distal (Popliteal DVT)
What is the clinical presentation of DVT?
Swollen, hot, red, tender
Whole leg or calf
Which investigations can be used to diagnose DVT?
US-Doppler scan to exclude Baker’s cyst and pelvic mass
CT scan of oleo-femoral vein, IVC, and pelvis
What should be in the differential for DVT?
Popliteal synovial (Baker’s) cyst
Superficial thrombophlebitis
Calf cellulitis
What is the clinical presentation of a large PE?
Cardiovascular shock
Low BP
Central cyanosis
Sudden death
What is the clinical presentation of a medium PE?
Pleuritic pain
Haemoptysis
Breathless
What is the clinical presentation of small recurrent PEs?
Progressive dyspnoea
Pulmonary hypertension
Right heart failure
What can happen the to RV if under long term strain?
Can dilate causing ventricular dysfunction leading to hypertension
What are the risk factors for DVT and PE?
Thrombophilia Contraceptive pill Hormone replacement therapy (HRT) Pregnancy Pelvic obstruction Trauma Surgery (esp. hip, pelvis, knee) Immobility Malignancy Pulmonary hypertension/vasculitis Obesity
What would be expected in the history of presenting complaint for a patient with a PE?
Shortness of breath (often acute onset) Pleuritic chest pain Haemoptysis Leg pain / swelling Collapse / sudden death
What are the clinical features of PE?
Tachycardia Tachypnoea Cyanosis Low BP Crackles Pleural rub Pleural effusion
Why would ABGs show low PaO2, low SaO2 and normal or low PaCO2 for a PE?
Because PE is a perfusion not ventilation issue
What would be seen an a CXR for a patient with a PE`
Normal early on before infarction
Basal atelectasis, consolidation
Pleural effusion
What are the different methods to diagnose and investigate a PE?
ECG D-dimer V/Q scan CT pulmonary angiogram (CTPA) Leg and pelvic US Echocardiogram
What D-dimer reading would you expect for a PE?
Raised D-dimer
What would you expect on the ECG for a PE patient?
Acute right heart strain pattern
S1Q3T3; T inversion in V1-3)
Why is a V/Q scan useful in PE Ix?
Sensitive for small peripheral emboli
Perfusion defect before infarction
V/Q match defect after infarction
What is a CTPA used for?
Image pulmonary arter filling defect and pick up larger clots in larger vessels
What does a leg and pelvic US deter?
Silent DVT
What can an echocardiogram measure and detect for PEs?
Pulmonary arter pressure and RV size
Acute dilation of RV in keeping with acute PE
If there is no obvious cause of PE which factors should be investigated?
Cancer
SLE
Thrombophilia
How can cancer causing PEs be detected?
Clinical exam CXR PSA (Prostate specific antigen) CA125 (cancer antigen - protein) CEA (carcinoembryonic antigen) Pelvic USS CT abdo/pelvis
How SLE as the underlying cause of PEs be detected?
Antinuclear antibodies
Anti-Cardiolipin antibodies
What is tested for in a thrombophilia screen?
Anti-thrombin-III deficiency
Protein C or S deficiency
Factor V Leiden
Increased VIII
How can DVT be prevented?
Early post-op mobilisation
TED compression stockings
Calf muscle exercises
Subcutaneous low dose low mol wt heparin preoperatively (Dalteparin - Fragmin)
Novel Oral anticoagulant (NOAC) medication
- Dabigatran - direct thrombin inhibitor
- Rivaroxaban / apixaban - direct inhibitor of activation factor Xa
