Pulmonary heart disease

Question 1

What is pulmonary hypertension?

Answer 1

Elevated pulmonary artery pressure (>25mmHg at rest) and secondary right ventricular failure

Question 2

What is the aetiology of pulmonary hypertension?

Answer 2

Increase in pulmonary vascular resistance
OR
Increase in pulmonary blood flow

Question 3

What are the causes of pulmonary hypertension?

Answer 3

Hereditary
Idiopathic
SLE
Rheumatoid arthritis
HIV
Drugs: long term use of cocaine and amphetamines
Portal hypertension
Congenital heart disease
Chronic haemolytic anaemia

Question 4

What are the initial symptoms of pulmonary hypertension?

Answer 4

Exertional dyspnoea
Lethargy
Fatigue

Question 5

As right ventricular failure develops, what other symptoms may be seen in pulmonary hypertension?

Answer 5

Peripheral oedema

Abdominal pain from hepatic congestion

Question 6

What signs are seen on examination in pulmonary hypertension

Answer 6

Right ventricular heave
Elevated JVP with prominent V wave
Hepatomegaly
Pulsitile liver
Peripheral oedema
Ascites
Pleural effusion

Question 7

What investigations should be done in suspected pulmonary hypertension. What will they show?

Answer 7

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

Question 8

What is the initial treatment in pulmonary hypertension?

Answer 8

Oxygen
Warfarin due to high risk of intrapulmonary thrombosis
Diuretics for oedema
Calcium channel blocker as pulmonary vasodilators

Question 9

Where do emboli in PE usually arise from?

Answer 9

Thrombi in iliofemoral veins (DVT)

Question 10

How do small/medium PE’s present?

Answer 10

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

Question 11

How do massive PE’s present?

Answer 11

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

Question 12

What is a massive PE?

Answer 12

PE which obstructs the RV outflow tract and therefore suddenly increases pulmonary vascular resistance, causing acute right heart failure

Question 13

What is a submassive PE?

Answer 13

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

Question 14

How is the revised Geneva score used to predict PE?

Answer 14

Low risk: score 0-3
Medium risk: score 4-10
High risk: score ≥11

Question 15

What are the risk factors for PE listed on the Revised Geneva score and what are their scores?

Answer 15

Age >65: +1
Previous DVT or PE: +3
Surgery or fracture within 1 month: +2
Active malignancy: +2

Question 16

What are the symptoms of PE listed on the Revised Geneva score and what are their scores?

Answer 16

Unilateral leg pain: +3

Haemoptysis: +2

Question 17

What are the clinical signs of PE listed on the Revised Geneva score and what are their scores?

Answer 17

Heart rate 75-94: +3
Heart rate ≥95: +4
Pain on leg deep vein palpation and unilateral oedema: +4

Question 18

What features of PE may be seen on an ECG>

Answer 18

Sinus tachycardia
New onset atrial fibrillation
Features of right heart strain:
-Tall peaked P waves
-Right axis deviation
-RBBB

Question 19

What features of massive PE may be seen on an ABG?

Answer 19

Hypoxaemia

Hypocapnia

Question 20

In what conditions might D-dimers be elevated?

Answer 20

PE
Cancer
Pregnancy
Post-operatively

Question 21

What are plasma D-dimers

Answer 21

Fibrinogen degradation products released into the circulation when a clot begins to dissolve

Question 22

What is the diagnostic test of choice for patients with suspected PE?

Answer 22

CT pulmonary angiography (CTPA)

Question 23

What is a V/Q scan?

Answer 23

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

Question 24

How is PE managed?

Answer 24

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

Question 25

What is the most common caused of maternal death in the developed world? How is it managed?

Answer 25

PE
Initial investigation is compression ultrasonography of the legs.
CTPA requried if ultrasound is normal- delivers a lower dose of radiation to the foetus than V/Q scanning
Treated with LMWH as warfarin is teterogenic