Pulmonary embolism and hypertension Flashcards
Pulmonary embolism
Blockage of a pulmonary artery by blood clot, fat, tumour or air
Pulmonary infarction
If blood flow and oxygen to the lung tissues is compromised the lung tissue may die
Thromboembolic disease (2)
Pulmonary embolism
Deep venous thrombosis
Proximal (ileo-femoral) DVT
Most likely to embolise
Most likely to lead to chronic venous insufficiency and venous leg ulcers
Distal (polpiteal) DVT
Least likely to embolise
Clinical presentation of DVT
Whole leg or calf
Swollen, hot, red, tender
Differential diagnosis of DVT
Popliteal synovial rupture (baker’s cyst)
Superficial thrombophlebitis
Calf cellulitis
Investigation for DVT
Ultrasound-doppler leg scan
CT scan
Clinical presentation of large pulmonary emboli
Cardiovascular shock
Low BP
Central cyanosis
Sudden death
Clinical presentation of medium pulmonary emboli
Pleuritic pain
Haemoptysis
Breathless
Clinical presentation of small recurrent pulmonary emboli
Progressive dyspnoea
Pulmonary hypertension
Right heart failure
Risk factors for pulmonary embolism and DVT
Thrombophilia - Family history, age, frequency, site
Contraceptive pill (especially if smokes)
Hormone replacement therapy
Pregnancy
Pelvic obstruction e.g. uterus, ovary, lymph nodes
Trauma- RTA
Surgery- pelvic, hip, knee
Immobility- long haul flight, bed rest
Malignancy
Pulmonary hypertension/ vasculitis
Obesity
Clinical features and diagnosis of PE (symptoms)
Tachycardia Tachypnoea Cyanosis Fever Low BP Crackles Rub Pleural effusion
Clinical features and diagnosis of PE (ABGs)
Low PaO2 and low SaO2
PaCo2 normal/ low
Clinical features and diagnosis of PE (CXR)
CXR normal early on before infarction
Pleural effusion
Basal atelectasis, consolidation
Investigations for PE
ECG: Acute Right heart strain pattern D-dimers usually raised V/Q Isotope lung scan: Sensitive for small peripheral emboli Perfusion defect before infarction Perfusion + ventilation matched defect after infarction CT Pulmonary angiogram Leg and pelvic ultrasound Echocardiogram: Acute RV dilatation
Prevention of DVT
Early post-op mobilisation
Compression stockings
Calf muscle exercises
Subcutaneously low-dose low mol wt heparin perioperatively (Dalteparin)
Novel Oral AntiCoagulant medication
-Dabigatran - direct thrombin inhibitor
- Rivaroxaban/Apixaban- Factor X inhibitor
Treatment for PE/DVT
A. Low mol wt low dose Heparin
Start warfarin at same time as heparin
B. OR Oral thrombin inhibitor (dabigatran)/ Factor X inhibitor (Rivaroxaban) on own from start
C. OR NOACs without LMWH
D. Tissue plasminogen activator (tPA)- tenecteplase
For large life threatening PE
E. IVC filter for recurrent PEs
F. Thrombo-electomy
Action if over-anticoagulation
Address underlying cause Stop anticoagulant Reverse warfarin with vitamin K1 Reverse heparin with protamine May need cover with prothrombin complex concentrate or fresh frozen plasma
Normal mean pulmonary arterial pressure (mPAP)
12-20mmHg
mPAP in Pulmonary hypertension
> 25mmHg
Pulmonary Venous Hypertension
Left heart disease
Pulmonary Arterial Hypertension
Walls of the smaller branches of the pulmonary arteries become thick and stiff
Causes of pulmonary venous hypertension
Left Ventricular Systolic Dysfunction - Ischaemic
Mitral regurgitation/ Stenosis
Cardiomyopathy eg alcohol, viral
Causes of secondary pulmonary hypertension
Hypoxic - COPD, OSA, Pulmonary fibrosis Multiple PE- chronic thromboembolic PH Vasculitis- SLE, systemic sclerosis Drugs - appetite suppressants HIV Cardiac left to right shunt Primary pulmonary hypertension
Cor pulmonale
Right heart disease secondary to lung disease
Fluid retention due to hypoxia +/- right heart failure
Clinical signs of pulmonary hypertension and right heart failure
Central cyanosis if hypoxic Dependent oedema Raised JVP with V waves Right ventricular heave at left parasternal edge Murmur of tricuspid regurgitation Enlarged liver Load P2
Investigation of pulmonary hypertension
ECG CXR SaO2 and arterial blood gases Pulmonary function incl diffusion capacity Echocardiogram Cardiac Catheterisation – measure mPAP D dimers and VQ scan if PE suspected CT Pulmonary Angiogram Cardiac MRI Auto-antibodies if vasculitis suspected
Diagnosis of primary pulmonary hypertension
Diagnosis by exclusion of other secondary causes
Progressive SOBOE and signs of right heart failure
Treatment of primary pulmonary hypertension
Prophylactic anticoagulation (warfarin)
O2 if hypoxic
Pulmonary vasodilators
-Ca2+ channel blockers (oral nifedipine, diltiazem)
-Endothelin antagonist (oral bosentan, macitentan)
-PDE5 inhibitor (oral sildenafil, tadalafil)
-Prostanoids (IV Epoprostenol, or inhaled iloprost)
-Soluble Guanylate Cyclase Stimulator (oral riociguat)
Lung transplant
Treatment for chronic thromboembolic pulmonary hypertension (CTEPH)
Pulmonary arterial vasodilator - Riociguat
Pulmonary endarterectomy
Balloon angioplasty
Risk factors for PE
Factors in vessel wall
Abnormal blood flow
Hypercoaguable blood
