Mod 9 Hypertension Flashcards
Pulmonary hypertension [PH] is defined as?
An increase in mean pulmonary artery pressure [mPAP] > 25mmHg
Normal mPAP?
10-20
assessed via right heart catheter
What happens when pulmonary pressures increase?
Right ventricular afterload increases
What does a increase in hypertrophic of the right ventricle mean?
More pressure = increase in size of tissue/space
Where do signs and symptoms usually present for pulmonary hypertension?
Right sided heart failure, so usually don’t present until the disease is advance
2 classifications of pulmonary hypertension?
Pre-capillary and post-capillary pulmonary hypertension
Pre-capillary pulmonary hypertension can be defined as?
PAWP < 15 mmHG
Elevation in pulmonary vascular resistance (PVR)
What does elevation in pulmonary vascular resistance (PVR) entail?
- Pulmonary arterial hypertension (PAH)
- Pulmonary hypertension due to lung diseases and/or hypoxemia
- Chronic thrombo-embolic pulmonary hypertension
- Pulmonary hypertension with unclear or multifactorial mechanisms
Post-capillary pulmonary hypertension is defined as?
PAWP > 15 mmHg
- NOt associated w/increased PVR
- due to left heart failure
How many groups are there for pulmonary hypertension?
5
Define traits of Group 1 hypertension :
pulmonary arterial hypertension (PAH)
- Precapillary pulmonary hypertension
- Due idiopathic, heritable, or drug induced PAH
- will see pulmonary arterial remodeling
Define traits of Group 2 hypertension : Post capillary hypertension [PAH]
Post Capillary, most common
- will see pulmonary arterial remodeling
- Due to left heart disease (secondary to MI or other heart tissue damage)
- may have preserved or reduced LVEF
Specifics:
- mPAP > 20 mmHg w/left sided valve disease (or systolic/diastolic function)
- valvular heart disease (bicuspid valve)
- congenital/acquired cardiovascular conditions leading to post cap. hypertension
Define traits of Group 3 hypertension: [PAH]
Precapiliary pulmonary hypertension
- Will see pulmonary arterial remodeling
- Most common (second to group 2), PH due to lung disease or hypoxia
- Developmental lung disease
- Seen in obstructive/restrictive lung diseases: ARDS, COPD, Pulmonary fibrosis etc.
**edit and add slide info for the five groups slide 5-9
Hypertrophy is associated with what?
- how does it differ from hyperplasia?
The growth of muscle vs. growth of new muscle
Mortality of pulmonary artery hypertension is associated w/what?
- increasing age
- impaired right ventricular function
- poor functional capacity (MET score)
Signs and symptoms of pulmonary hypertension
not usually seen until advanced disease
Dyspnea
Dizziness, confusion, light-headedness
Fatigue
Non productive cough
Hemoptysis
Syncope
Chest pain
Peripheral edema
Tachycardia
GOLD standard of pulmonary hypertension?
Echocardiogram
Treatment plans for Group 1
** Calcium channel blockers** (nifedipine)
- **prostanoids **
- endothelia receptor antagonists
- phophdiesterase inhibitors
- lung or heart plants
Treatment plans for Group 2?
Goal: Improve heart function
Treating underlying condition
- lifestyle change
- meds (inotrope, diuretics)
Treatment plans for Group 3
Long term oxygen therapy (LTOT)
Treatment plans for Group 4
Blood thinning medications
potential surgery
Goal is to reduce or slow progression of PH
Treatment plans for Group 5
Treatment directed at the cause of PH
- Goal is to reduce or slow progression of PH
Role of nitric oxide [NO] in treatment of hypertension?
Vasodilation
- 20 ppm
- short acting, topical
** (neonates) **
Role of Florian (epoprostenol) in treatment of hypertension?
Another Vasodilator
- Typically w/adult population
- Much less expensive than NO
Pulmonary edema is characterized by what 2 aspects?
An accumulation of extra calculate fluid in the lungs
- Increase in pulmonary capillary hydrostatic presssure secondary to left sided heart disease [cardiogenic pulmonary edema]
- Increased membrane permeability [noncardiogenic pulmonary edema]
Is CHF left or right sided heart failure
Left sided (can lead to right side as well)
Cardiogenic Pulmonary Edema
Describes the rate of filtration of fluid
(there is a formula)
- Ensure that intestinal fluid does not acclimate into a edema?
What is hydrostatic pressure in a vessel?
pressure against the vasculature walls
What are oncotic pressures in the capillary
Pressures that that pull proteins back within the vessels
What happens as hydrostatic pressures increase?
Excess filtrate seeks and fills the peri-bronchovascular interstitial spaces
- accommodates 300-400 mls of fluid
What happens when interstitial spaces are full/brimming?
Fluid begins to fluid the alveolar spaces
Common causes of Cardiogenic pulmonary edema
- Heart failure
- MI
- Cardiomyopathy (impaired ability to pump blood)
- Valve leak
- Arrhythmias (lead to blood build up)
Noncardiogenic pulmonary edema results from what?
Injury to the lungs sufficient to increase endothelial permeability and cause extravasating of protein rich fluid into the interstitial and alveolar spaces
(leaking fluid out of capillary)
interstitial vs alveolar edema?
edit slide 8
Common causes of noncardiogenic pulmonary edema
- Severe ARDS
- Toxins or injury/trauma
- Reperfusion injury
What would you expect to see for a Pulmonary edema CxR?
“bat wings”
- Bilateral fluffy opacities
- Dilated pulmonary arteries
- left ventricular hypertrophy (cardiomegaly)
- Kerley A and B lines
- pleural effusion
what does “bat-wing” shadow reflect about portions of the lungs?
Infiltrates in the central (peri-hilar) portions of the lungs
Add info on Kerley A + B lines (edema slide 14)
Pulmonary Edema CxR:
What does pleural effusion and cardiomeagly reflect on a CxR?
Severe heart failure
Treatments for Pulmonary edema?
- Reduce preload
- Reduce afterload
- Oxygen therapy (low and high flow)
- CPAP and NIV (NIV for vent. failure)
- Intubate and ventilate
What Tx could you apply to reduce preload?
add info on diuretics from slide 16 to another slide
- Diuretics
- loop diuretics
- Thiazides
- Spironolactone - Vasodilation via nitroglycerin
Group 4 PAH
Pre capillary
Due to:
- artery obstructions, after treating a pulmonary emboli
- Increase in resistance to flow in pulmonary tree
- Congenital stenosis (pulmonary artery blockages)
Group 5 PAH
Mix of pre and post capillary
- unknown factors, can be hematological disorders, systemic and metabolic disorders, chronic renal failure etc.
Pathogenesis of PAH (aka development of disease)
Fibrotic changes: pulmonary artery remodeling
- vascular proliferation (increase in blood vessels)
- hypertrophy (important role in PH development)
TLDR: things that can generally cause or include
Inflammation, vasoconstriction, thrombosis
What does hypertrophy of the vessels do?
- how does it have a role in pulmonary hypertension [PH]?
Preface:
- In PH, pulmonary arteries become stiff and narrow = increase resistance to blood flow in the RV of heart to lungs
What happens:
- Pulmonary arteries have to work harder to pump blood through narrowed vessels = increase in size
- when pulmonary arteries increase in size, it narrows the arteries causing more resistance to blood
General Treatments for PAH?
- aka non-specific to any group?
Nitric oxides (neonates)
- results in vasodilation
- short acting + topical
Flolan (Epoprostenol)
- For adults
- less expensive than NO, P. vasodilator
