Module 11 : Pulmonary Hypertension Flashcards
what is pulmonary hypertension characterized by
- elevated pulmonary arterial pressures secondary to RV failure
how are the categories of pulmonary hypertension characterized
- based on which area of the circulatory system they affect which increased the pulmonary pressure
what is pulmonary HTN
- increased pressure in the pulmonary vasculature
what is pulmonary HTN defined as
- PCWP > 15mmHg
- SPAP = RVSP if no RVOT obstruction 30-35
- MPAP >/= 35mmHg
- PVR >/= 3 wood units
what will be the respiratory symptoms of PHTN
- shortness of breath
- cough
- wheezing
- hemoptysis
- intercostal retraction
what are the 4 signs of right heart failure
- jugular venous congestion
- peripheral edema
- ascites
- hepatosplenomegaly
what are 5 associated cardiac symptoms with PHTN
- palpitations/arrhtymias
- chest pain
- shortness of breath on exertion
- othropnea
- syncope
what is normal RA and IVC pressure
0-4mmHg (average)
what is normal right ventricle systolic and diastolic pressure
< 25 / < 10
what is normal pulmonary artery systolic and diastolic pressure
< 25 / < 10
how do we calculate RVSP with RAP and TV pg
RVSP = RAP + TVpg
what is the RAP
RA pressure from IVC diameter
- 3,8,15
what is the TV pg
- tricuspid valve pressure gradient
- reflects the difference in pressure between RA and RV
what RVSP would indicate mild moderate or severe PHTN
< 30 mmHg
30-35 mmHg
> 35 mmHg
what is normal TR velocity
< 2.8-2.9 m/s
what are the 6 cardiac causes of right sided heart failure
- left sided heart failure is most common
- pulmonic valve stenosis
- right ventricular infarction
- massive TR
- congenital malformation
- shunts
what are the 2 categories of pulmonary causes of right heart failure
- parenchymal
- vascular disease
what are the 5 parenchymal causes of elevated right heart pressure
- COPD asthma
- interstitial lung disease
- adult respiratory distress syndrome
- chronic lung infection
what are the 2 vascular causes of right heart pressure increase
- pulmonary embolism
- primary pulmonary hypertension
how does left sided heart failure increase right heart pressure
- retrograde increased load/pressure
+ LV>LA>PLM VASC>RV>RA>IVC
why does cor pulmonale occur
- increased resistance in the pulmonary circulation
what is the pathophysiology of cor pulmonale
- progressively increasing chronic pressure overload of the right ventricle as it ejects into the high resistance vascular bed
+ if slow and gradual will first lead ti RV hypertrophy
+ if fast then RV dilation will happen first
+ then RV failure occurs
what is an acute pulmonary embolism most often caused by
- deep vein thrombosis
how is PE and DVT treated
- PE = treat DVT or lung resection
- DVT = IVC filter
what is eisenmengers syndrome
- shunt reversal in patients with significant shunt that have developed PHTN from the shunt
- shunt goes right to left
what 3 things does chronic elevation of RT heart pressures lead to
- dilated coronary sinus
- reopening of PFO
- dilated main PA
what are the 2 different categories of PHTN
- precapillary
- post capillary
what is the role of echo with PTHN
- identify cause of PHTN
+ precapillary post capillary
what are the 3 most common post capillary causes of PHTN
- LV systolic function
- LV diastolic function
- left heart valvular disease
what are the right side 2D signs of of pulmonary artery hypertension
- enlarged RV (hypoinetic)
- septal shifting (toward left)
- RA enlarged
- TV regurge
- PA dilated
- PV regurge
- IVC dialted
- SVC dilated
what are the 4 doppler right sided assessments of PAH
- TV regurge
- PV insufficiency
- IVC collapsible / reflux into hepatic veins
- arrhythmia on ECG
what are the left side 2D signs oF pAH
- LV enlargement
- LV hypo
- LV, IAS, IVS aneurysmal
- CMO
- LA enlarged
- MV abnormalities
- AV sclerosis
- prosthetic valves
what are the 5 left sided sided doppler features of PAH
- MV stenosis regurege
- AV stenosis or regurge
- systolic dysfunction
- diastolic dysfunction
- arrhythmia
what is the etiology of RVPO (RV pressure overload)
- any cause the increases pressure to the right heart
+ long standing regurge
+ primary pulmonary disease
what signs is seen with RVPO
- PSAX d sign seen in both systole and diastole
what does RVVO eventually become
- RVPO
what is the etiology of RVVO
- anything that causes increased volume to the right heart
+ a left to right shunt such as significant ASD
what sign is seen with RVVO
- PSAX D sign in only diastole
what are the 3 spectra doppler methods of summarizing PAH
- SPAP (RVSP
- MPAP
- PAEDP
what 2 things does RVSP/SPAP use
- TR max velocity
- RAP
what does MPAP use
- using PR early diastolic velocity (PW or CW)
what does PAEDP use
- PR end diastolic velocity
what should we use to calculate the RVSP if it is present
- the VSD jet
- more accurate
- reflects the pressure difference between LV and RV
what is the equation for RVSP using VSD
-RVSP = SBP - (4 V^2)
what 5 technical factors need to be adjusted with RVSP
- peak velocity with CW is angle dependant
- use color doppler to align
- sweep speed 100cm/s
- no feathering
- do not measure unless peal clearly seen
what 4 windows are used to interrogate peak velocity of TR jet
- PLAX RVIT
- PSAX
- A4C
- subcostal window
what is the equation for PAEDP
PAEDP = 4V ^2 + RAP
what velocity is used int he PAEDP equation
- PR CW trace at end diastole
what is normal PAEDP
< 10-12 mmHg
what is the real formula for MPAP
MPAP = 79 - (0.45 x PAT)
PAT = pulmonary acceleration time
what is the rough estimate formula for MPAP
MPAP = 80 - ( 0.5 x PAT)
can PR jet velocity be used to asses MPAP and PAEDP
- yes
- should be done whenever RVSP is suspected to be elevated
how is the MPAP and PAEDP calculated with PR jet
- PG from early diastolic velocity tells us the MPAP (with RAP)
- RVEDP is estimated from end diastolic velocity of the PR jet
what is normal SPAP (RVSP)
18-25 mmHg
what is mild elevated SPAP
30-40 mmHg
what is moderate elevated SPAP
40-70mmHg
what is severe elevated SPAP
> 70 mmHg
what is normal RVOT AT
> /= 120ms
what is mild decreased RVOT AT
80-110ms
what is moderate decreased RVOT AT
60-80 ms
what is severe decreased RVOT AT
< 60ms
what is normal MPAP
< 25 mmHg
9-18 average
what is mild elevated MPAP
30-40mmHg
what is moderate elevated MPAP
40-50mmHg
what is severe elevated MPAP
> 50 mmHg
what is normal PAEDP
4-12 mmHg
