Pulmonary heart disease Flashcards
What is pulmonary hypertension?
Elevated pulmonary artery pressure (>25mmHg at rest) and secondary right ventricular failure
What is the aetiology of pulmonary hypertension?
Increase in pulmonary vascular resistance
OR
Increase in pulmonary blood flow
What are the causes of pulmonary hypertension?
Hereditary Idiopathic SLE Rheumatoid arthritis HIV Drugs: long term use of cocaine and amphetamines Portal hypertension Congenital heart disease Chronic haemolytic anaemia
What are the initial symptoms of pulmonary hypertension?
Exertional dyspnoea
Lethargy
Fatigue
As right ventricular failure develops, what other symptoms may be seen in pulmonary hypertension?
Peripheral oedema
Abdominal pain from hepatic congestion
What signs are seen on examination in pulmonary hypertension
Right ventricular heave Elevated JVP with prominent V wave Hepatomegaly Pulsitile liver Peripheral oedema Ascites Pleural effusion
What investigations should be done in suspected pulmonary hypertension. What will they show?
CXR: shows emlarged proximal pulmonary arteries which taper distally. May also reveal underlying cause e.g. emphysema; calcified mitral valve
ECG: shows right ventricular hypertrophy and peaked P waves
Echocardiography: shows RV dilatation and/or hypertrophy
What is the initial treatment in pulmonary hypertension?
Oxygen
Warfarin due to high risk of intrapulmonary thrombosis
Diuretics for oedema
Calcium channel blocker as pulmonary vasodilators
Where do emboli in PE usually arise from?
Thrombi in iliofemoral veins (DVT)
How do small/medium PE’s present?
Breathlessness
Pleuritic chest pain
Haemoptysis if there is pulmonary infarction
May be tachypnoeic
May have pleural rub
An exudative and occasionally blood stained pleural effusion can develop
How do massive PE’s present?
Medical emergency Severe central chest pain and suddenly becomes shocked, pale and sweaty with marked tachypnoea and tachycardia Syncope and death may follow rapidly O/E -Shock -Central cyanosis -Raised JVP -RV heave -Accentuation of the second heart sound and a gallop rhythm may be heard
What is a massive PE?
PE which obstructs the RV outflow tract and therefore suddenly increases pulmonary vascular resistance, causing acute right heart failure
What is a submassive PE?
Impacts in a terminal, peripheral pulmonary vessel and may be clinically silent unless it causes pulmonary infarction. Lung tissue is ventilated but not perfused causing impaired gas exchange
How is the revised Geneva score used to predict PE?
Low risk: score 0-3
Medium risk: score 4-10
High risk: score ≥11
What are the risk factors for PE listed on the Revised Geneva score and what are their scores?
Age >65: +1
Previous DVT or PE: +3
Surgery or fracture within 1 month: +2
Active malignancy: +2
What are the symptoms of PE listed on the Revised Geneva score and what are their scores?
Unilateral leg pain: +3
Haemoptysis: +2
What are the clinical signs of PE listed on the Revised Geneva score and what are their scores?
Heart rate 75-94: +3
Heart rate ≥95: +4
Pain on leg deep vein palpation and unilateral oedema: +4
What features of PE may be seen on an ECG>
Sinus tachycardia New onset atrial fibrillation Features of right heart strain: -Tall peaked P waves -Right axis deviation -RBBB
What features of massive PE may be seen on an ABG?
Hypoxaemia
Hypocapnia
In what conditions might D-dimers be elevated?
PE
Cancer
Pregnancy
Post-operatively
What are plasma D-dimers
Fibrinogen degradation products released into the circulation when a clot begins to dissolve
What is the diagnostic test of choice for patients with suspected PE?
CT pulmonary angiography (CTPA)
What is a V/Q scan?
Ratio of ventilated lung to perfused lung. In PE lung tissue is ventilated but not perfused so V/Q is increased. PE is excluded in patients with a normal scan but there is a high incidence of non-diagnostic scans
How is PE managed?
High flow oxygen if hypoxaemic
Thrombolysis if indicated
Analgesia: morphine IV to relieve pain and anxiety
Prevention of further thrombi: LMWH and oral warfarin
IV fluids to raise filling pressure for patients presenting with moderate to severe embolism
In patients who are cardiovascularly stable with no co-existent serious medical pathologies, treat at home with anti-coagulation (warfarin) for 6w to 6 months depending on the likelihood of recurrence of thromboembolism. Life long treatment is indicated for recurrent emboli
Thrombolysis is only indicated for massive PE with persistent hypotension
