L22 - Pulmonary HTN Flashcards
Pulmonary Hypertension is defined as:
- Increase in resting mean pulmonary arterial pressure ≥ ___ mmHg by right heart catheterization
- Normal pulmonary capillary wedge or left atrial pressure (less than or equal to ___ mm Hg)
- 25mmHg
2. less than or equal to 15mmHg
Pulmonary HTN is a (pathophysiological/hemodynamic) condition found in many clinical conditions
Both pathophysiological and hemodynamic
List the 5 groups in the WHO classification of PH
- Pulmonary arterial Hypertension
- PH due to LH disease
- Chronic lung disease
- Chronic thromboembolic PH (CTEPH)
- Unclear mechanisms
Group 2 is the most common cause of PH
Which group in the WHO classification of PH?
idiopathic, heritable, drug/toxin-induced, CT dz, HIV, portal HTN, CHD, schistosomiasis, hemolytic anemia, persistent PH of the new born
Group 1 PAH
Which group in the WHO classification of PH? (“pulmonary venous HTN”)
most common cause of PH
Group 2 (PH due to LH disease) is the most common cause of PH
Which group in the WHO classification of PH?
COPD, ILD, OSA, high altitude
Group 3 - Chronic Lung disease
Which group in the WHO classification of PH?
small vessel arteriopathy distal to thrombosis, persistent PH 6 mo after PE
Group 4 - Chronic thromboembolic PH
prevents clot formation in vessels by inhibiting platelet activation and vasodilates
prostacyclin - involved with vasoconstriction in the pathogenesis of PAH
This protein constricts or narrow blood vessels and increase pressure in the vessels.
endothelin - involved with vasoconstriction in the pathogenesis of PAH
3 processes that cause narrowing in PAH
- Vasoconstriction
- Smooth mm proliferation
- thrombosis
Which is NOT a symptom of PAH? A. Unexplained dyspnea B. Tachycardia C. Syncope D. Atypical chest pain E. Fatigue / exercise intolerance
B
Which 2 physical exam findings are characteristic of early stage PH?
- Diastolic murmur of PR
- Holosystolic murmur of TR
- Right ventricular gallop (right ventricular heave???)
- Accentuated P2 - second heart sound
- JVD, hepatojugular reflux and pulsatile liver
- Peripheral edema/ascites
- RV heave = left parasternal lift
4 and 7
The rest are advanced stage PH signs
A. What may be found on the 3 tests initially done in diagnosis of PAH are:
- ECG
- CXR
- Echocardiogram
B. Which is the best test?
A.
1. ECG – RV hypertrophy, right axis deviation , R atrial enlargement
2. CXR – Prominent vasculature in the hilum
3. Echocardiogram - Estimate PA systolic pressure; ID conditions that contribute to PH. D shaped septum, septum shifted L
• Best test
What is the Gold Standard for diagnosis of PAH?
Right Heart Cardiac Catheterization • Establish diagnosis differentiating pulmonary (arterial vs. venous) hypertension • Determine etiology • Exclude L heart disease • Assess L to R shunt • Establish severity & prognosis • Evaluate vasoreactivity • Adenosine, Flolan, NO • Guide treatment
- RH Catheterization pathway starting w/internal jugular.
- What do you expect to be the values of the following when doing a RHC on a patient with PH?
A. Wedge
B. RAP
C. RVP
D. mPAP
- through internal jugular –> RA –> RV –> PA –> inflate balloon and wedge it to get a sense of the LEFT sided heart pressures
2.
A. Normal (
Aside from ECG, CXR, echo, RHC, what are other diagnostic tests that can be done to diagnose PAH? (5)
- Serology (Gp 1) – ANA, HIV, liver function tests
• For CT disease - Sleep study (polysomnogram) (Gp 3)
- Pulmonary function tests, Chest CT scan, Arterial Blood Gas (Gp 3)
• Look for elevated PCO2 - VQ scan, pulmonary angiogram (Gp 4)
- Abdominal ultrasound
Which is not a predictor of poor survival in the ACCP IPAH Guidelines?
A. Poor reaction to PH therapies (PDE-5 inhibiotrs, endothelin receptor antagonists, prostanoids)
B. Advanced functional class
C. Poor exercise endurance (6 minute walk distance)
D. Syncope (sign of advanced disease)
E. Presence of pericardial effusion
F. Signs of RH failure (3)
A is not a predictor
Signs of RH failure
○ High Right Atrial Pressure
○ Low cardiac index - RVP so big that you are starting to have HF
○ High BNP (brain natriuretic peptide) level in blood
Determinants of Risk in patients with (lower risk/higher risk) of PH
- Clinical evidence of RV failure - No
- Progression - Gradual
- WHO class - II, III
- 6 min walk distance - longer (400+m)
- BNP - minimally elevated
- Echo findings - minimal RV dysfunction
- Hemodynamics - normal/near normal RAP and Cl
lower risk of PH
Determinants of Risk in patients with (lower risk/higher risk) of PH
- Clinical evidence of RV failure - yes
- Progression - rapid
- WHO class - IV
- 6 min walk distance - shorter (less than 300m)
- BNP - very elevated
- Echo findings - pericardial effusion, significatn RV dysfunction
- Hemodynamics high RAP, low Cl
higher risk of PH