Pulm Circulation II Flashcards
Define pulm hypertension
pathologic incr in pulm arterial pressure
what is normal pulm arterial pressure
25/10
mean = 15 mmHg
what is # criterion for pulm HTN
> 25 mmHg
what is pulm arterial pressure equation
PPA = CO x PVR + PLA PPA = mean pulmonary artery pressure PLA = left atrial pressure
based on equation for pulm arterial pressure, what can pulm HTN be caused by (3)
incr CO (less common b/c compensatory vessel dilation and recruitment)
incr pulm vascular resistance
incr LA pressure
what does pulm arterial HTN involve?
pre-capillary circulation
does pulm arterial HTN lead to edema? why?
NO because PAH does not incr pressure in microcirculation
3 types of pre-capillary HTN
1) primary vascular disorders
effect on pulm vascular resistance, DLCO, lung function
1) Primary vascular disorders –> incr pulm vascular resistance (no pulm edema, not affect lung parenchyma)
low DLCO
normal lung function
subtype of primary vascular disorder
idiopathic pulm arterial HTN
who does it mainly affect?
genetic or not?
affects young women
genetic = BMPR2 gene
3 types of pre-capillary HTN
2) pleural-pulm disease
what is it caused by?
effect on DLCO, FEV1 and FVC
impaired ventilation
destruction of lung
decr DLCO, decr FEV1, decr FVC
3 types of pre-capillary HTN
3) chronic alveolar hypoventilation
caused by?
chronic elev of PCO2 without parenchymal lung disease
–> causes vascular remodeling –> HTN
Define pulm venous hypertension
post-capillary hypertension due to obstruction between pulm venous system and LA
symptoms of pulm venous hypertension
1) edema
2) Kerley B lines
3) vascular redistribution
Dana point classification of pulm HTN
1) Pulm arterial hypertension
2) Pulmonary HTN due to left heart disease
3) Pulmonary HTN assoc with lung disease and/or hypoxemia
4) thromboembolic pulmonary hypertension
5) pulmonary hypertension with unclear multifactorial mechanisms
subtypes of pulmonary arterial hypertension
- 1) Idiopathic (Primary)
- 2) Heritable
- 3) Diet or drugs (weight loss medications = fen-phen = pulmonary arterial HTN, cocaine, meth)
- 5) HIV
- 6) Connective tissue disease = scleroderma = vessels thickened and narrowed
subtypes of pulmonary arterial hypertension
- 1) Idiopathic (Primary)
- 2) Heritable
- 3) Diet or drugs (weight loss medications = fen-phen = pulmonary arterial HTN, cocaine, meth)
- 5) HIV
- 6) Connective tissue disease = scleroderma = vessels thickened and narrowed
Causes of acute pulm HTN
1) pneumonia (hypoxic vasoconstriction)
affecting entire lung
2) thromboembolic disease (incr PVR)
3) hypoxia (high altitude)
Risk factors for DVT
1) Trauma
2) stasis
3) hypercoagulability
Effects of pulmonary emolism
1) RV strain (submassive, use collaterals) or RV failure (massive low blood pressure, can’t get blood thru lungs)
2) incr myocardial O2 demand (oxygenated blood can’t enter coronaries to feed RV to sustain RV pushing against obstruction)
3) decr myocardial O2 delivery
4) death
Idiopathic pulmonary arterial HTN
paradigm of WHO group 1 disease
affects young women in 30’s and 40’s
median survival without treatment = 2.8 yrs
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4 classes of approved medications for PAH
1) endothelin receptor antagonists
2) PDE-5 inhibitors
3) prostacyclins
4) calcium channel blockers
names and mechanism of endothelin receptor antagonists
names = bosentan
ambrisentan
block receptors to cause vasodilation
names and mechanism of PDE-5 inhibitors
sildenafil
tadalafil
promote accum of cGMP to enhance NO-mediated vasodilation
names and mechanism of prostacyclins
epoprostenol
iloprost
trepostinil
- upregulate cAMP to cause vadoilation and decr RV afterload
- antithrombotic
- continuous IV
mechanism of calcium channel blockers
block Ca2+ channel –> vasodilation
work in subtype of IPAH (have acute response to admin of an iNO or IV prostacyclin during right heart cath
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how to work up patient with PE
1) H&P with Wells score
2) D-dimer breakdown product of thrombin
3) ECG
4) CXR
5) V/Q san
6) CT angiogram
7) angiogram
8) echo
Clinical presentation of pulmonary embolism
1) dypsnea
2) chest pain
3) hypoxemia
4) hemoptysis
CXR of pulm embolism
1) normal or areas of atelectasis, effusions, or wedge shaped infarcts
Hampton’s Hump = lung not getting sufficient blood flow = and filling with fluid = infarcted lung
Westermark’s Sign = hypoperfusion = region of lung underperfused due to blood clot
EKG of pulm embolism
RV strain (inverted T wave Sinus Tachy
S1 QIII TIII
is D-dimer sensitive for pulm embolsm
sensitive but NOT SPECIFIC
sepsis
pregnancy could also raise D-dimer
what is gold standard of pulm embolism
pulm angiography but invasive
The catheter is placed through the vein and carefully moved up into and through the right-sided heart chambers and into the pulmonary artery, which leads to the lungs
what is most widely used modality for pulm embolism diagnosis
CT pulm angiography
how does pulm embolism appear in nuclear ventilation/perfusion studies
decr perfusion and normal ventilation
Blood gas measurement of pulm embolsm
increased A-a gradient
is D-dimer sensitive for pulm embolsm
sensitive but NOT SPECIFIC
sepsis
pregnancy could also raise D-dimer
what is gold standard of pulm embolism
pulm angiography but invasive
The catheter is placed through the vein and carefully moved up into and through the right-sided heart chambers and into the pulmonary artery, which leads to the lungs
what is most widely used modality for pulm embolism diagnosis
CT pulm angiography
how does pulm embolism appear in nuclear ventilation/perfusion studies
decr perfusion and normal ventilation
how do you assess severity of cardiac injury due to PE
echo
how do you prevent pulm embolism
1) avoid stasis
2) take prophylactic anticoagulants
3) devices to incr blood flow
how do you treat DVT cause of PE
heparin then warfarin for at least 6 months
how do you treat PE itself
1) heparin + warfarin
2) thrombolytic therapy (maybe)
3) IVC filter for high risk patients
4) acute surgical thromboectomy in extreme
A patient with possible pulmonary hypertension undergoes right heart catheterization and the following measurements are made: mPAP = 45 mmHg PCWP = 20 mmHg CO = 5 L/min PVR = 5 WU What does this patient have?
A. WHO Group 1 Pulmonary Arterial Hypertension
B. WHO Group 2 PH Due to Left Heart Disease
C. WHO Group 3 PH Due to Lung Diseases and/or Hypoxia
D. WHO Group 4 Thromboembolic Pulmonary Hypertension
B = WHO group 2 PH due to Left heart disase
PVR incr but more importantly, PCWP incr
For PCWP > 15 so pulm venous hypertension
V/Q scan
preferred for pregnancy
1) patient inhale radioactive Xenon
see where gas goes in lung
find regions ventilated
2) use macroaggregated albumin IV not getting thru capillaries
uniformly diffuse throughout lung
with PE, get wedge defects in lung
CT angiography
inject bolus of dye into antecubital vessels
time the CT scan as bolus going through lung
look for where dye not able to go
if submassive stable PE, how do you treat
Parenteral Anticoagulation
Heparin: Unfractionated or low molecular weight
Oral Anticoagulation - warfarin
if unstable hypotensive, RV failure = massive, how do you treat
1) Heparin
2) Consider thrombolysis (tPA) (contraindicated if brain tumor due to poor blood vessels or GI bleeding if small ulcer)
3) Consider IVC Filter (noncompressibility of vessel due to clot so put iVC filter to prevent blood clot from leg into lung)
4) Consider surgical thrombectomy
A patient presents 1 week after left hip surgery with a swollen left leg and acute onset of shortness of breath and pleuritic chest pain. What would be an UNEXPECTED finding in this patient?
A. An incompressible deep vein in the leg on ultrasound.
B. A large infiltrate on chest x-ray.
C. An elevated plasma d-dimer.
D. An intraluminal filling defect on CT chest with contrast.
Answer = B. A large infiltrate on chest x-ray.
Has risk factors for DVT
now SOB due to blood clot embolize to lungs
get irritation of pleura –> pleuritic chest pain
exception = Hampton’s hump
PAH Hemodynamic and Clinical Course
NYHA class 1
CO
PAP incr
PVR incr
NYHA II decr CO PAP incr PVR incr symptomatic b/c cardiac output decr, SOB, and dizzy when walk (not enough blood flow to brain because blood flow to legs and not go to brain)
NYHA III decr CO BNP (out of RV not LV) incr PAP incr PVR
Class IV
Fall of of PAP because heart not able to push blood thru lungs
CO drops
CXR over time
RV becoming more dilated over time
PAH physical exam
distended neck vein
normal lung auscultation (NO RALES)
loud P2, murmur of tricuspid regurg
edema in extremities
A 25 year old female presents with 6 months of progressive dyspnea. She has edema and a loud P2. An echocardiogram suggests a dilated right ventricle and a right ventricular systolic pressure of 80mmHg. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Start sildenafil.
D. Obtain a right heart catheterization.
Answer = D
Obtain a right heart catheterization
no suggestion of blood clot, no swollen leg
no Calcium channel blockers
haven’t confirmed diagnosis, you have suggestion so don’t start sildenafil
Right heart cath is definitive test to determine pulm vascular resistance and can’t calculate based on echo
The right heart catheterization shows the following: mPAP = 45 mmHg
PCWP = 10 mmHg
CO = 5 L/min
PVR = 7 WU
There is no response to inhaled nitric oxide. A V/Q scan is negative. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Start sildenafil.
D. Surgical lung biopsy.
Answer = C start Sildenafil
elev MPAP
low PCWP
meet criteria for WHO class 1 no blood clot b/c V/Q is negative
during right heart cath, inhale NO vasodilator, acute drop in blood pressure –> candidate for calcium channel blocker (best prognosis)
She does well for 2 years, but then the shortness of breath returns plus she has fainting spells. A repeat right heart catheterization finds:
mPAP = 43 mmHg
PCWP = 10 mmHg
CO = 3 L/min
PVR = 11 WU
A V/Q scan is negative. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Change sildenafil to tadalafil.
D. Add intravenous epoprostenol.
Answer = D
aDD IV epoprostenol
no blood clot because V/Q scan negative
not vasodilator responsive so calcium channel blocker not sensitive–> need to have positive NO vasodilator response to have effect
tadalafil longer acting sildenafil
use epoporostenol open up –> most potent vasodilator
contemplate lung transplatn
A 55 year old man with a history of severe mitral regurgitation presents with shortness of breath. Right heart catheterization reveals: mPAP = 26 mmHg PCWP = 20 mmHg CO = 3 L/min PVR = 2 WU What should you do next?
A. Start a beta blocker.
B. Start diuretics.
C. Start sildenafil.
D. Start salt tablets.
Answer = B
start diuretics
beta blockers = slow HR, disadvantage for patient with HF –> make them worse
Diuretics = pee out fluid
wedge pressure elev –> cardiogenic pulm edema
lower wedge pressure
sildenafil = don't start PAH salt = cause more fluid retention
A patient with possible pulmonary hypertension undergoes right heart catheterization and the following measurements are made: mPAP = 45 mmHg PCWP = 20 mmHg CO = 5 L/min PVR = 5 WU What does this patient have?
A. WHO Group 1 Pulmonary Arterial Hypertension
B. WHO Group 2 PH Due to Left Heart Disease
C. WHO Group 3 PH Due to Lung Diseases and/or Hypoxia
D. WHO Group 4 Thromboembolic Pulmonary Hypertension
B = WHO group 2 PH due to Left heart disase
PVR incr but more importantly, PCWP incr
For PCWP > 15 so pulm venous hypertension
V/Q scan
preferred for pregnancy
1) patient inhale radioactive Xenon
see where gas goes in lung
find regions ventilated
2) use macroaggregated albumin IV not getting thru capillaries
uniformly diffuse throughout lung
with PE, get wedge defects in lung
CT angiography
inject bolus of dye into antecubital vessels
time the CT scan as bolus going through lung
look for where dye not able to go
if submassive stable PE, how do you treat
Parenteral Anticoagulation
Heparin: Unfractionated or low molecular weight
Oral Anticoagulation - warfarin
A patient presents 1 week after left hip surgery with a swollen left leg and acute onset of shortness of breath and pleuritic chest pain. What would be an UNEXPECTED finding in this patient?
A. An incompressible deep vein in the leg on ultrasound.
B. A large infiltrate on chest x-ray.
C. An elevated plasma d-dimer.
D. An intraluminal filling defect on CT chest with contrast.
Answer = B. A large infiltrate on chest x-ray.
Has risk factors for DVT
now SOB due to blood clot embolize to lungs
get irritation of pleura –> pleuritic chest pain
exception = Hampton’s hump
PAH Hemodynamic and Clinical Course
NYHA class 1
CO
PAP incr
PVR incr
NYHA II decr CO PAP incr PVR incr symptomatic b/c cardiac output decr, SOB, and dizzy when walk (not enough blood flow to brain because blood flow to legs and not go to brain)
NYHA III decr CO BNP (out of RV not LV) incr PAP incr PVR
Class IV
Fall of of PAP because heart not able to push blood thru lungs
CO drops
CXR over time
RV becoming more dilated over time
A 25 year old female presents with 6 months of progressive dyspnea. She has edema and a loud P2. An echocardiogram suggests a dilated right ventricle and a right ventricular systolic pressure of 80mmHg. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Start sildenafil.
D. Obtain a right heart catheterization.
Answer = D
Obtain a right heart catheterization
no suggestion of blood clot, no swollen leg
no Calcium channel blockers
haven’t confirmed diagnosis, you have suggestion so don’t start sildenafil
Right heart cath is definitive test to determine pulm vascular resistance and can’t calculate based on echo
The right heart catheterization shows the following: mPAP = 45 mmHg
PCWP = 10 mmHg
CO = 5 L/min
PVR = 7 WU
There is no response to inhaled nitric oxide. A V/Q scan is negative. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Start sildenafil.
D. Surgical lung biopsy.
Answer = C start Sildenafil
elev MPAP
low PCWP
meet criteria for WHO class 1 no blood clot b/c V/Q is negative
during right heart cath, inhale NO vasodilator, acute drop in blood pressure –> candidate for calcium channel blocker (best prognosis)
She does well for 2 years, but then the shortness of breath returns plus she has fainting spells. A repeat right heart catheterization finds:
mPAP = 43 mmHg
PCWP = 10 mmHg
CO = 3 L/min
PVR = 11 WU
A V/Q scan is negative. What should you do next?
A. Start unfractionated heparin drip.
B. Start calcium channel blockers.
C. Change sildenafil to tadalafil.
D. Add intravenous epoprostenol.
Answer = D
aDD IV epoprostenol
no blood clot because V/Q scan negative
not vasodilator responsive so calcium channel blocker not sensitive–> need to have positive NO vasodilator response to have effect
tadalafil longer acting sildenafil
use epoporostenol open up –> most potent vasodilator
contemplate lung transplatn
A 55 year old man with a history of severe mitral regurgitation presents with shortness of breath. Right heart catheterization reveals: mPAP = 26 mmHg PCWP = 20 mmHg CO = 3 L/min PVR = 2 WU What should you do next?
A. Start a beta blocker.
B. Start diuretics.
C. Start sildenafil.
D. Start salt tablets.
Answer = B
start diuretics
beta blockers = slow HR, disadvantage for patient with HF –> make them worse
Diuretics = pee out fluid
wedge pressure elev –> cardiogenic pulm edema
lower wedge pressure
sildenafil = don't start PAH salt = cause more fluid retention
