PULMONARY HEART DISEASE

Question 1

Pulmonary Hypertension (2)

Answer 1

1- Normal pulmonary artery pressure (PAP) is 10-14 (very low compared to systemic)
2- In pulmonary HTN, there is increase in PAP to more than 25 at rest —> RHF

Question 2

Pathology

Answer 2

Pulmonary HTN is due to increase in the pulmonary vascular resistance and increase in the pulmonary blood flow

Question 3

Presentation (5)

Answer 3

1- Exertional dyspnea
2- Lethargy and fatigue (decreased CO)
3- Loud pulmonary S2 sound
4- Right parasternal heave
5- RHF (peripheral edema, hepatomegaly, distended JVP, prominent V wave)

Question 4

Diagnosis (2)

Answer 4

1- Right heart catheterization —> determines pulmonary wedge pressure (PWP) and confirms increased PAP
2- CXR, ECG, Echo to know underlying cause

Question 5

Treatment

Answer 5

Oxygen, Warfarin, Diuretics, oral CCB, and treat underlying cause

Question 6

Causes of Pulmonary artery prominence (3)

Answer 6

1- High volume —> Left to right shunt (VSD, ASD, PDA)
2- High pressure —> Pulmonary HTN
3- Post-stenotic dilatation —> Pulmonary stenosis

Question 7

High volume (Left to right shunt) (8)

Answer 7

1- Plethoric lung field
2- QP: QS > 2:1
3- Frequent, severe chest infections
4- Cardiac overactivity
5- ASD —> LPH
6- VSD, PDA —> hyperdynamic apex
7- Cardiomegaly, plethora
8- No murmur or symptoms until regression of pulmonary vascular resistance after the newborn period (after 4 weeks)

Question 8

High Pressure (Pulmonary HTN) (4)

Answer 8

1- Oligemic lung field
2- Causes:
- Left heart disease
- Eisenmenger (reversal of L-R shunt to a cyanotic R-L shunt)
- Chronic lung disease
- Recurrent pulmonary TE
- CT disease (SLE, scleroderma)
- Peripheral pulmonary artery stenosis
3- Treatment —> bosentan, sildenafil
4- On examination:
- Loud P2, left parasternal heave (RVH)
- Graham steel murmur (early diastolic)
- PR and TR murmurs
- JVP —> prominent a from RVH, prominent V from TR

Question 9

Post stenotic dilatation (Pulmonary stenosis) (5)

Answer 9

1- Oligemic lung field
2- Young, asymptomatic
3- Dilatation only in valvular PS —> starts acyonotic then becomes R-L shunt
4- Mostly congenital
5- On examination: Heave, systolic thrill, JVP: Prominent a, ejection systolic best at inspiration, Soft P2 and delayed