Pulmonary Circulation Disorders Flashcards
The Pulmonary Circuit of the
cardiovascular system is
responsible for _____
oxygenating blood
Any condition that affects the blood
vessels along the route between the
heart and lungs can:
○ Change pulmonary arterial blood pressure.
○ Change pulmonary venous pressure.
○ Stress the heart and rest of the
cardiovascular system
Pulmonary Embolism
A Pulmonary Embolism (PE) is a mechanical obstruction of the pulmonary vasculature, usually from a blood clot from a Deep Vein Thrombosis (DVT)
Virchow’s Triad
○ Venous stasis
○ Vessel wall injury
○ Hypercoagulable state
PEs are also sometimes referred to as:
■ Pulmonary Thromboembolism
■ Venous Thromboembolism (VTE)
Risk Factors for a pulmonary embolism
○ Prior VTE
○ Thrombophilia
○ Surgery
○ Cancer
○ Pregnancy
○ Oral contraceptives
○ Immobilization
○ Trauma
○ Obesity
○ Central venous access
Inherited risk factors for a pulmonary embolism
Factor V Leiden
Prothrombin G20210A
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Are community or hospitalized patients at greater risk for a PE?
Hospitalized
____ is by far the most common cause of a PE.
DVT
Less common causes of PE:
○ Septic Embolism
○ Air Embolism
○ Fat Embolism
○ Amniotic Fluid Embolism
○ Intravascular Foreign Bodies
○ Tumor Embolism
25% occlusion by a PE may cause ____
increased pulmonary arterial
pressure and decrease in arterial oxygen tension
35%-40% occlusion with a PE may cause _____
increased right atrial pressure
PE signs and symptoms
○ Symptoms usually have rapid onset, but may occasionally
progress over several weeks.
○ Pay attention to onset
○ Classics presentation:
■ Dyspnea
■ Tachypnea
■ Tachycardia
■ Pleuritic chest pain
■ Cough
■ Fever
Diagnostic Approach for PE if high risk
● Get CT Angio or Transthoracic Echo right away
● If referred to cath lab, consider Pulmonary Angio if acute coronary syndrome is excluded
Diagnostic Approach for PE If hemodynamically stable:
■ Initial evaluation using the PERC Score
■ Then two main options for risk scoring-
● Revised Geneva Scoring System
● Wells Clinical Prediction Rule (more common)
Important Diagnostic Studies Used for PE
○ High-sensitivity D-Dimer
○ CT Pulmonary Angiography
○ Pulmonary Angiography
○ V-Q (Ventilation-Perfusion) Scan
○ Lower Extremity Venous Ultrasound
○ Echocardiogram
○ Chest X-ray- If patient is hypoxic and CXR is
normal then suspect a PE.
○ Electrocardiogram (EKG)
Considered the diagnostic study of choice for PE.
CT Pulmonary Angiogram
CT angio findings that are positive for PE:
● Images will be positive for filling
defects within the vasculature
V-Q Scan
● The Ventilation-Perfusion Scan is a nuclear medicine
imaging study (scintigraphy) that is a less sensitive/specific
test for PE that utilizes radioactive isotopes.
● Much less radiation exposure than CT Pulm Angio.
● Preferred imaging study in:
○ Young patients (esp female)
○ Pregnant patients
○ Patients with contrast allergies
○ Patients with severe renal failure
○ Patient with hyperproteinemia
Use of Lower Extremity Venous Ultrasound in PE diagnostics
○ LE compression ultrasonography may contribute to the
diagnosis of PE, but negative test may not exclude PE.
Use of Echocardiogram in PE diagnostics
○ Can be used in the ER with high-risk PE patients who are hemodynamically unstable.
○ Signs of right ventricular dysfunction and pressure overload in setting of hypotension or severe hypoxemia justify emergent reperfusion treatment for PE if CT pulm angio not feasible.
Chest X-Ray use in PE diagnostics
○ Limited utility in Pulmonary Embolism
○ May see pleural effusion or evidence of atelectasis
○ May see Westermark Sign
■ Focal oligemia
○ May see Hampton Hump
EKG use in PE
○ Limited value in diagnosis of PE because abnormal findings are nonspecific and generally found only in severe PEs.
○ May see signs of right ventricular strain- S(I) Q(III) T(III) pattern
■ Prominent S wave in lead 1, Q wave in lead
III and inverted T wave in lead III.
■ T wave inversion in leads V1- V4
Hemodynamic instability in PE is defined as
■ Systolic BP under 90 mmHg
■ On vasopressors to maintain BP
■ Drop of SBP by > 40 mmHg in HTN patient
■ Hypoxia not resolving with supplemental O2
Initial Management of PE if Unstable
○ Start IV Unfractionated Heparin for anticoagulation
○ Unless there are contraindications and high-risk for bleeding, thrombolytics should be strongly considered
■ Alteplase (tPA) is preferred
Treatment of Hemodynamically Stable Pts with PE
○ Systemic anticoagulation should be started right away.
○ LMWH
■ Enoxaparin (Lovenox)- preferred if renal insufficiency
○ Direct oral anticoagulants (DOAC) - Become first line
■ Dabigatran (Pradaxa)
■ Rivaroxaban (Xarelto)
■ Apixaban (Eliquis)
A patient with a first thromboembolic event occurring in the
setting of reversible risk factors, such as immobilization, surgery,
or trauma, should receive anticoagulation for at least _____
3 months, potentially 6 months
Complications of PEs include _____
pulmonary hypertension,
cor pulmonale (which may lead to shock and death), and arrhythmias (A-Fib/A-Flutter).
○ Elevated troponin levels are associated with increased short-term mortality in patients with acute pulmonary embolism.
Pulmonary Hypertension is a complex problem characterized
by _____
pathologic elevation in pulmonary arterial pressure.
Normal systolic pressure in the pulmonary artery at rest is _____
8 - 20 mmHg
Pathophysiology of Pulm HTN
○ The primary pathologic mechanism is an increase in pulmonary
vascular resistance that leads to an increase in pulmonary
systolic pressure to greater than 30 mmHg or the mean pressure
(mPAP greater than 20 mmHg). ↓cardiac output
Group 1 Pulmonary Hypertension
Pulmonary Arterial Hypertension (PAH)
● Localized directly to the pulmonary artery- increases proliferation of inflammation (ie vasculopathy)
● → Intimal fibrosis, smooth muscle hypertrophy, pulmonary arterial precapillary remodeling
Group 2 Pulmonary Hypertension
Pulmonary Venous Hypertension
● ↑ left atrial pressure → pulmonary venous hypertension
● Left heart dysfunction, valvular disease, heart failure
● Chronic venous hypertension can lead to reactive PAH
Group 3 Pulmonary Hypertension
PH associated with lung disease
● Derived from Hypoxia
● Specific to the lung tissue and disease of oxygen exchange (eg. COPD, interstitial lung disease)
● Sleep-disordered breathing
Group 4 Pulmonary Hypertension
Thromboembolic disease
● Recurrent embolism, may not after a single event of an acute PE
Group 5 Pulmonary Hypertension
Miscellaneous
● Group of varying etiologies
● Lymphatic obstruction, sarcoidosis, sickle cell
S/S of Pulmonary Hypertension
○ There are no signs or symptoms specific to pulmonary
hypertension
○ Patients often present with…
■ Dyspnea
■ Chest discomfort
■ Cough (often non-productive)
■ Malaise
■ Fatigue
■ Syncope- more advanced disease
○ On rare occasion, patients may present with hemoptysis
Physical Examination for Pulmonary Hypertension may include:
■ Jugular Venous Distention
■ Hepatomegaly
■ Lower extremity edema
■ Accentuated Pulmonary valve
component of the S2
■ Right-sided S3 may be heard
■ Murmur of Tricuspid
regurgitation
Pulmonary Hypertension Diagnostics
○ Chest X-ray often suggests enlargement of the main pulmonary arteries.
■ In advanced disease, right ventricular and right atrial enlargement can be seen
○ Pulmonary Function Tests (PFTs)
○ If Pulmonary Hypertension is
suspected, an Echocardiogram with
Doppler should be performed.
○ Right-Sided Cardiac Catheterization
remains the Gold Standard for diagnosis
Right-Sided Cardiac Catheterization
remains the Gold Standard for diagnosis of
Pulmonary Hypertension
Pulmonary Hypertension Treatment
○ Primary treatment is directed and the underlying cause (heart failure, oxygen therapy, etc.)
○ Advanced therapy is treatment aimed at PH
■ Should be prescribed by Pulm or Cardiologist and may include
● CCB
● Phosphodiesterase inhibitors (ex: Sildenafil)
○ Lung transplantation may be an option
The presence of _____ carries a poor survival
outcome regardless of the underlying cause of Pulmonary Hypertension
Cor Pulmonale
Cor Pulmonale
The term “Cor Pulmonale” refers to Right
Ventricular systolic and diastolic failure
resulting from PH secondary to pulmonary
disease and/or PH induced altered structure.
_____ (Emphysema or Chronic
Bronchitis) is the most common cause
of Cor Pulmonale
COPD
Pathophysiology of Cor Pulmonale
○ Cardiac damage due to pulmonary hypertension.
■ Specifically right ventricular hypertrophy, dilation, or both with resultant right heart failure
Cor Pulmonale S/S
○ The clinical presentation of compensated Cor Pulmonale is dependent on or related to their underlying pulmonary disorder (may include cough, dyspnea, fatigue, etc).
○ As the Cor Pulmonale progresses, the RV function declines and signs of right-sided heart failure arise:
■ Jugular venous distention
■ Peripheral edema
■ Hepatomegaly (with RUQ pain)
■ Tricuspid Regurgitation
■ RV heave
CXR Findings for Cor Pulmonale
■ Will like show signs of underlying pulmonary
disease, such as signs of COPD, etc.
■ May demonstrate enlarged, bulging pulmonary artery even in early disease.
■ As the disease progresses, may see enlarged RV
CBC and serum BNP findings for Cor Pulmonale
○ CBC and vitals may reveals Polycythemia and/or hypoxemia.
○ Serum BNP may be elevated due to RV injury.
EKG findings for Cor Pulmonale
EKG may show evidence of RV failure and hypertrophy.
■ Tall, peaked P waves in Lead II- “P-Pulmonale” pattern
■ Right Axis Deviation
■ Right Ventricular Hypertrophy
Echo findings for Cor Pulmonale
■ Should demonstrate normal LV size and function, thereby
excluding it as cause of right heart failure.
■ Will likely show RV and RA dilation and RV dysfunction
Treatment of Cor Pulmonale
○ Most treatment efforts are focused on the treating the
underlying pulmonary condition (like COPD).
■ Most often involves oxygen therapy
○ Otherwise, heart failure management. May include:
■ Salt and fluid restriction
■ Diuretic therapy (such as Furosemide)
■ Inotropic drugs often used during decompensation
(such as Digoxin)
once signs of heart failure appear,
the average life expectancy is ____
2-5 years
