Pulmonary Embolism and Pulmonary Hypertension

Question 1

Name two thromboembolic diseases?

Answer 1

DVT

PE

Question 2

What is a PE?

Answer 2

Pulmonary Embolism

- blockage of a pulmonary artery dueto a blood clot, fat, tumor or air

Question 3

What is Pulmonary Infarction?

Answer 3

If blood flow and hence oxygen supply to lung tissue is comprimised then the tissue may die

Question 4

Is a proximal or distal DVT more likely to embolise?

Answer 4

proximal

Question 5

What is the clinical presentation of a DVT?

Answer 5

Whole leg or calf:
swollen
red
hot and tender

Question 6

What are the investigations of DVTs?

Answer 6

Ultrasound Doppler leg scan - non invasive

CT scan of ileo femoral veins, IVC and pelvis

Question 7

What is the clinical presentation of each size of PE?

Answer 7

–Large: cardiovascular shock, low BP, central cyanosis, sudden death
–Medium: pleuritic pain, haemoptysis, breathless
–Small recurrent: progressive dyspnoea, pulmonary hypertension and right heart failure

Question 8

What are the investigations of PEs?

Answer 8

ECG - acute right heart strain pattern
D-dimers - usually raised
Isotop lung scan - V/P
CT pulmonary angiogram
leg and pelvic ultrasound to detect silent DVT
Echocardiogram - measure pulmonary artery pressure

Question 9

What are the risk factors for DVTs and PEs?

Answer 9

thrombophillia
contraceptive pill
pregnancy
trauma
surgery
immobility
malignancy 
pulmonary hypertension
obesity

Question 10

What are the treatment options for DVTs and PEs?

Answer 10

anticoagulation to prevent clot propagation
- heparin (3-5days) and warfarin (3-6months)
- target range for warfarin 2.5-3.5
for life threatening PE - thrombolysis
IVC filter to prevent embolism from ileofemoral clot

Question 11

How do you reverse warfarin action?

Answer 11

Vitamin K

Question 12

How do you reverse heparin action?

Answer 12

Protamine

Question 13

What is normal pulmonary arterial pressure?

Answer 13

12-20mmHg

Question 14

What figure constitutes pulmonary hypertension?

Answer 14

> 25mmHg

Question 15

What can cause Pulmonary Venous Hypertension? - left side

Answer 15

Left Ventricular Systolic Dysfunction
Mitral Regurgitation/Stenosis
Cardiomyopathy

Question 16

What can cause Pulmonary Arterial Hypertension? - right side

Answer 16

Hypoxia
Multiple PEs
Vasculitis
Drugs
HIV
Cardiac left -> right shift
Primary pulmonary hypertension

Question 17

What is Cor Pulmonale?

Answer 17

fluid retention due to hypoxia

- right sided HF which is secondary to a lung disease i.e. COPD

Question 18

What are the clinical signs of Pulmonary Hypertension?

Answer 18

central cyanosis
dependant oedema
raised JVP
tricuspid region murmur
enlarged liver

Question 19

What are the investigations of Pulmonary Hypertension?

Answer 19

ECG
CXR
SaO2 and arterial blood gases
Pulmonary function incl DLCO (diffusion capacity)
Echocardiogram – estimate right ventricular systolic pressure (RVSP)
Cardiac Catheterisation – measure mean pulmonary arterial pressure (mPAP)
D dimers and VQ scan if PE suspected
CT Pulmonary Angiogram
Cardiac MRI
Auto-antibodies if vasculitis suspected

Question 20

What is Primary Pulmonary Hypertension?

Answer 20

Progressive SOB

Signs of right heart failure

Question 21

What is the treatment for primary pulmonary hypertension?

Answer 21

CA Channel Blockers
Endothelin antagonists
PDES - inhibitors
Lung transplant

Question 22

What is Chronic Thromboembolic Pulmonary Hypertension (CTEPH)?

Answer 22

recurrent pulmonary embolisms which lead to chronic pulmonary hypertension

Question 23

What is the treatment for CTEPH?

Answer 23

Riociguat – pulmonary arterial vasodilator
Pulmonary endarterectomy –curative (2% op. mortality)
Balloon angioplasty