Pulmonary Embolism and Hypertension Flashcards
what two conditions compose thromboembolic disease
deep vein thrombosis, pulmonary embolism
what is a pulmonary embolism
blockage of a pulmonary artery by a blood clot, fat, tumour or air
what is a pulmonary infarction
when blood flow and oxygen to the tissue is compromised (tissue may die)
what are the two locations of DVT
proximal (ileo-femoral), Distal (polpiteal)
a proximal DVT is a higher risk than a distal DVT as it is more likely to… (2)
most likely to;
- embolise
- lead to chronic venous insufficiency and venous leg ulcers
what is the clinical presentation of a DVT
whole leg or half calf involved depending on site; swollen, hot, red, tender
what are the differential diagnosis of a DVT
popliteal synovial rupture, superficial thrombophlebitis, calf cellulitis
how is a DVT investigated
ultrasound doppler leg scan, CT scan
how can a DVT turn into a pulmonary embolism
predisposing DVT may be silent, sub clinical, and can embolise
what does the clinical presentation of a pulmonary embolism depend on
the size of the clot
how does a large pulmonary embolism present
cardiovascular shock, low BP, central cyanosis, sudden death
how does a medium pulmonary embolism present
pleuritic pain, haemoptysis, breathless (goes out to periphery (lungs))
how does a small recurrent pulmonary embolism present
progressive dyspnoea (difficult breathing), pulmonary hypertension and right heart failure
what are the risk factors for DVT and PE
thrombophilia (abnormality of blood clotting), contraceptive pills (particularly in smokers), hormone replacement therapy, pregnancy, pelvic obstruction, trauma, surgery, immobility (Venastasis), malignancy, pulmonary hypertension, obesity
what is the history of a presenting complaint in PE
breathlessness, chest pain, haemoptysis, leg pain/swelling, collapse/ sudden death
what are the clinical features of a PE
tachycardia, tachyponea, cyanosis, fever, low BP, crackles, pleural effusion
describe the arterial blood gases of of a patient with a PE
decreased PaO2 and SaO2 (type one resp failure: PaCO2 normal or low)
describe the chest x ray of someone with a PE
basal atelectasis (lung collapse), consolidation, pleural effusion
how is a DVT prevented
early post-op mobilisation, compression stockings, calf muscle exercises, subcutaneous heparin pre-op, direct oral anticoagulant medication
what does an ECG show that helps to diagnose a PE
acute right heart strain pattern
what happens to D-dimers in PE
usuallt raised
what does an isotope lung scan show that helps to diagnose a PE
ventilation/ perfusion; sensitive for small peripheral emboli. Perfusion defect before infarction, p + v matched defect after infarction
what does a PESI score mean
pulmonary embolism severity index- calculates risk
how can troponin and BNP show that the heart is under strain
troponin rises, BNP/ pro-BNP present
how is a low risk PE managed
ambulatory pathway to home
describe the clinical factors of a low risk PE
-ve troponin, low PESI, no oxygen, no co-morbidities
what are the clinical factors of a high risk PE
cardiovascular compromise
how is a high risk PE managed
may require thrombolysis (breakdown of clots), BP monitoring, medical high dependency unit
how is a intermediate/intermediate-high risk PE treated
ward or MHDU
how does anticoagulant prevent DVT/PE
prevents clot propagation, tips balance to thrombolysis, body dissolves clot
describe how heparin is administered
subcutaneous low mol weight (rarely IV) once daily
what drug is started at the same time as heparin to treat a DVT/PE
warfarin
how does warfarin prevent a DVT/PE
blocks the formation of vitamin K clotting factors. antagonises vit k dependant prothrombin
what anti clotting treatment is as effective as heparin + warfarin
DOACs- direct oral thrombin inhibitor (dabigatran) or factor x inhibitor (rivaroxaban) (use both solely from start)
how long does warfarin take to work
3 days
what should happen after 3-5 days on a herparin + warfarin combo when the patient’s INR>2
stop heparin, or use NOAC (novel oral) without LMWH
how long should the warfarin be administered for
3-6 months
how is warfarin use monitored
with INR- target range
what substances can interact with warfarin
alcohol, antibiotics, aspirin, NSAIDS, amiodarone, cimetidine, omeprazole, grapefruit.
what is a thrombolysis
treatment to dissolve clots- tissue plasminogen activator (tPA- tenecteplase)
what are the features of a life threatening PE
low bp, severe hypoxaemia due to main pulmonary artery occlusion
when is a thrombolysis used
in life threatening PEs
what is used to prevent embolisation from large ileofemoral/ IVC clot (in recurrent PEs)
IVC filter (inferior vena cava)
what are the relative risks of a PE and how should they be treated be treated
pregnancy/ post partum
what anticoagulant drugs have long half lives
low MW heparin, warfarin
when does the use of anticoagulant need to stop and effect reversed
if bleeding
how is warfarin reversed
with vitamin K
how is heparin reserved
protamine
how are NOACs reversed
no reversal agents
what does the duration of treatment depend on?
balance of risk (rpt clot) vs bleeding
how should intravenous drug users or people with active cancer be treated
fragmin only
when is life long treatment necessary
recurrent DVT/PE
describe the flow and pressure of a healthy pulmonary circulation system
high flow, low pressure
what is normal mean pulmonary arterial blood pressure
12-20 mmHg
when is mPAP pulmonary hypertension
> 25 mmHg
how is mPAP measured
right heart catheter
how can systolic pulmonary pressure be estimated
with an ECHO doppler
what is left heart disease
pulmonary venous hypertension
what can cause primary pulmonary hypertension
hypoxia, multiple PE, vasculitis, drugs, HIV, cardiac left to right shunt
what is cor pulmonale
right heart disease secondary to lung disease
what are the components of cor pulmonale
fluid retention due to hypoxia +/- right heart failure
what can cor pulmonale complicate
COPD, fibrotic lung disease, chronic PE, chronic ventilatory failure
what are the clinical signs of pulmonary hypertension and right heart failure
central cyanosis (if hypoxic), dependant oedema (influenced by gravity), raised JVP, enlarged liver
how is pulmonary hypertension investigated
ECG, CXR, SaO2 and ABGs, pulmonary function with DLCO, echo, cardiac catherterisation, D-Dimers, VQ scan, CTPA, cardiac MRI, auto-antibodies (if vasculitis suspected)
what is primary pulmonary arterial hypertension a disease of
pulmonary arteries/arterioles
what is a symptom of primary pulmonary arterial hypertension
progressive exertional breathlessness
what is the prognosis of primary PAH without treatment
3 years
how is primary PAH treated
prophylactic anticoagulant (warfarin), O2 if hypoxic, pulmonary vasodilators- (primary disease only), lung transplant
how is chronic thromboembolic pulmonary hypertension treated
ricoiguat (pulmonary arterial vasodilator), pulmonary endarterectomy (surgical procedure to unblock a carotid artery)
