Pulm HTN/ Cor. Pulm highlights Flashcards
Define pulmonary HTN
PH = mean pulmonary arterial pressure > 20 mmHg @ rest during RH catheterization
OR
Mean pulmonary arterial pressure > 35 mmHg via non-invasive estimate (Transthoracic ECHO)
List the WHO Classifications for pulmonary hypertension by group
Group 1: Pulmonary Arterial Hypertension (PAH)
Group 2: PH 2nd to left heart disease
Group 3: PH 2nd to lung disease and hypoxia
Group 4: PH 2nd to chronic PE
Group 5: PH 2nd to multifactorial
True or false: There is no data to support screening for PH (pulmonary HTN) in general population
True
What do you have to go through to get to the right heart?
“might ask this again”
A vein
Who should do annual screening for PAH?
1) Asymptomatic patients at increased risk
2) Symptomatic patients at increased risk
Do any of the following have screenings for the general population?
1) Asthma
2) COPD
3) Lung CA
4) Colonoscopy
1) No
2) No
3) If smoker or certain risks
4) Yes, if over 45
Give an example of a symptomatic pt at an increased risk for pulmonary HTN
Portal HTN
(Congenital heart disease, HIV, Methamphetamine use, SSD)
Pulmonary HTN: What is the CC?
Dyspnea with minor exertion and fatigue, light headedness, pre-syncope or syncope
What past medical history is important for pulmonary hypertension Dx?
1) Family history: of PH
2) Personal hx: of HIV, SSD, methamphetamine or cocaine use, or PE
Second heart sound (S2):
1) Is created by the closing of the _____________ and _________ valves.
2) It occurs at the end of _____________ and marks the beginning of _____________.
3) S2 is normally split because the which valve closes slightly before the pulmonary valve (P2)?
1) Aortic and pulmonary valves.
2) systole; diastole.
3) Aortic valve (A2) closes slightly before the pulmonary valve (P2)
What will a PFT show with pulmonary HTN?
probably something you need to remember
Totally normal (b/c just bad diffusion)
1) What is the gold standard for diagnostic evaluation in a pt with dyspnea who you suspect pulmonary HTN (PH) in?
2) Referral to specialist is indicated when?
1) Right heart catheterization (> 20 mm Hg)
2) If any combination of work up suggests PH
List 4 conditions you should ID and treat underlying cause for with HTN
1) HF
2) COPD:
3) PE:
4) Treat underlying systemic disease
________________is defined as an alteration in the structure and function of the right ventricle (RV) of the heart caused by a primary disorder of the respiratory system (chronic COPD, or acute PE)
Cor Pulmonale
Which heart chamber is the closest to the anterior of the chest?
Right ventricle
Pulmonary hypertension is often the common link between lung dysfunction and the heart inwhat condition?
Cor Pulmonale
Venous thromboembolism: List 2 types
1) Deep venous thrombosis (DVT)
2) Pulmonary emboli (PE)
Most serious presentation of venous thromboembolism (VTE) is what?
Pulmonary emboli (PE)
Pulmonary emboli:
1) Incidence increases with _____.
2) Most common source (85%) is _______________.
3) 10-60% occur in ________________ patients
1) age
2) lower extremity DVT
3) hospitalized
1) 10-60% of pulmonary emboli occur in hospitalized pts; who is at highest risk?
2) How many pregnancies does it occur in?
Orthopedic procedures and cancer patients (joint replacement)
1:1,000 pregnancies (baby sitting on iliac veins)
What is the Virchow triad for?
PE (pulmonary embolism)
What is the Virchow triad?
1) Circulatory stasis (prolonged immobility, HF)
2) Vessel endothelial injury (trauma, disease, prior DVT)
3) Hypercoagulable state: transient or permanent … contraceptives, pregnancy, cancer, genetic
List the OLDCARTS for a PE (embolism)
Onset, duration, timing – acute onset, persistent symptoms, associated with risk factors (Virchow Triad)
Location: Lower extremity for DVT, usually unilateral
PE symptoms associated with pulmonary symptoms, syncope
Character : Lower extremity DVT with pitting edema, tenderness
PE varies from mild to severe cardiopulmonary instability
Aggravating/alleviating – n/a
Radiation – lower extremity DVT emboli to pulmonary artery leading to acute right heart strain/failure
Associated symptoms – cardiopulmonary – may be asymptomatic to unstable
What is a key part of PE (embolism) exam to differentiate between admitting a pt and not?
hypotensive/unstable
Differential diagnoses for chest pain & dyspnea:
1) List a pulmonary DDx
2) List 2 cardiovascular DDxs
1) Pulmonary embolism
2) ACS + aortic dissection
What is a resource for medical calculators (like Wells score), equations, scores, and guidelines?
MDCalc
After your evaluation, if your clinical gestalt for PE is low, what do you do?
May perform PERC test; if other than Zero obtain Well’s score
After your evaluation, if your clinical gestalt for PE is high, what do you do? (i.e. what is the gold standard for PE?)
CTPA or V:P scan
After your evaluation, if your clinical gestalt for PE is uncertain, what do you do?
Obtain Well’s score
Well’s score:
1) What if this score shows low probability?
2) What abt intermediate?
3) What abt high probability?
1) If low probability – perform PERC test, if ZERO, then done
2) D-dimer
D-dimer positive then CTPA
D-dimer negative then done
3) CTPA or V:P scan
What is a common result of a clinical exam for PE?
Provider is uncertain
(not high probability, not low probability)
Pulmonary emboli diagnosis: Most EKGs will be normal, but what would abnormal be?
(said we don’t need to know yet)
RBBB & S1Q3T3 pattern
RSR’
Deep S wave in lead I
Q wave in III
Inverted T wave in III
List the radiology findings with a PE
1) CXR – most are normal …but classic findings are:
a) Hampton’s hump – peripheral lung infact
b) Westermark sign – hypovolemic PA beyond clot
2) Ultrasound – r/o DVT
3) V/Q scan
4) CT Pulmonary angiography (Gold Standard)
What is the gold standard radiology for PE?
CT Pulmonary angiography
Define each of the following:
1) Westermarck’s sign
2) Fleischer’s sign
3) Hampton’s hump
“put a star on this, do need to know”
1) Hypovolemia and collapsed pulmonary artery distal to PE
2) Distension of the pulmonary artery proximal to a PE
3) Peripheral, pleural-based opacification in the lung most commonly due to PE & lung infarction
PE treatment summary from 2019 guideline ECS
Long-term Rx for PE includes ________________ therapy for at least 3-6 months, longer if elevated risk of recurrence.
important to know
anticoagulant
If you Dx a pt with a PE, put them on an oral anticoagulant for _________ months
3-6
What is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling?
Pleuritic Chest pain
Westermark sign, oligemia, Fleishner’s sign, and Hampton’s hump are all signs of what?
PE
