pulmonary heart disease - pulmonary hypertension, PE Flashcards
what is mean pulmonary artery pressure
14
what is pulmonary hypertension
mPAP >25 mmHg
when is pulmonary hypertension measured
on right heart catheterisation
what changes are seen in pulmonary arteries of pulmonary hypertension
- hypertrophy
- proliferation
- fibrotic changes
what mutations cause pulmonary hypertension
boen morphogenetic protein receptor type 2
what drugs cause pulmonary hypertension
- fenfluramine
- dexfenfluramine
- toxic rapeseed oil
- anorectic agents aminorex and benfluorex
symptoms of pulmonary hypertension
- SOB
- fatigue
- weakness
- angina
- syncope
- abdominal distension
sings of pulmonary hypertension
- left parasternal heave
- loud P2 heart sound
- soft pan systolic murmur
- tricuspid regurgitation
- early diastolic murmur
- pulmonary regurgitation
what does right heart failure lead to
- jugular venous distension
- ascites
- peripheral oedema
- hepatomegaly
what investigation can be done for pulmonary hypertension
- blood test
- CXR
- ECG
- echo
- liver ultrasound
- right heart catheterisation
what is seen on blood test for pulmonary hypertension
check for underlying rheumatic disease, HIV, hepatitis
what is seen on CXR for pulmonary hypertension
- enlargement of pulmonary arteries
- marked tapering of peripheral arteries
- lung fields are Lucent
- right atrial enlargement
what is seen on ECG of pulmonary hypertension
- right ventricular hypertrophy
- right atrial enlargement
what is seen on echo of pulmonary hypertension
- tricuspid regurgitation
what is on ultrasound for pulmonary hypertension
exclude liver cirrhosis and portal hypertension
what is done to confirm diagnosis
right heart catheterisation
what is done as treatment for pulmonary hypertension
- anticoagulation
- diuretics
- digoxin
- calcium channel blockers
- prostanoids
- PDE 5 inhibitor
- ballon atrial septostomy
- cardiac transplantation
what is done for physical treatment of pulmonary hypertension
remain physically active but avoid exertion
what precaution during pregnancy for pulmonary hypertension
there is a high mortality rate
should be counselled on conception
what precautions during travel for pulmonary hypertension
supplementary oxygen
what vaccination should be given for a patient with pulmonary hypertension
influenza and pneumococcal pneumonia
what precautions during surgery for patient with pulmonary hypertension
anaesthesia
when are diuretics used in pulmonary hypertension
when patients haver right heart failure and fluid overload
when is digoxin given in pulmonary hypertension
people with tachyarrhythmias
what is prostanoids
potent vasodilator that inhibits platelet aggregation and cell proliferation
what can prostanoids increase in patients iwht pulmonary hypertension
exercise capacity
what is endothelin-1
potent vasoconstrictor
what do PDE-5 inhibitor produce
vasodilatation in pulmonary vasculature
is cardiac transplantation give a good prognosis for pulmonary hypertension
not really 5 year survival is only 50%
where does pulmonary embolism thrombus form and where do they dislodge
in systemic veins
rarely in the right heart
- dislodge and embolism into pulmonary arterial system
where do most clots come from that cause PE
pelvic and abdominal veins
why do clots form
as a result of combination of sluggish blood flow, local injury or compression of the vein and a hypercoaguable state
think Virchow’s triad
what can emboli occur from
- tumour
- fat
- amniotic fluid
- foreign material during IV misuse
what happens to lung tissue after PE
lung tissue is ventilated but not perfused producing intrapulmonary dead space
what does the lung no longer produce if it is not perfused
surfactant
how can right ventricular ischaemia be detected
with elevations of troponin and creatine kinase
what does distal embolisation lead to
alveolar haemorrhage with haemoptysis, pleural inflammation and effusion
symptoms of PE
- sudden onset SOB (unexplained)
- pleuritic chest pain
- haemoptysis
what is usually the only symptoms present in PE
SOB
what is seen on examination of PE
- tachypnoeic
- localised pleural rub
- coarse crackles
- fever
what can develop because of PE
exudative pleural effusion (blood stained)
what happens to patient if there is a massive PE
- sudden collapse
- severe central chest pain
- shocked
- pale
- sweaty
- syncope
- death
what JVP wave is seen in massive PE
prominent a-wave
what is cardiovascular signs of massive PE
- right ventricular heave
- gallop rhythm
- split second heart sound
what investigation are done for PE
- CXR
- ECG
- blood gases
- cardiac troponin
- D-dimer
- V/Q scan
- ultrasound
- CTPA
- MRI
- echo
what is seen on CXR for PE
- often normal
but
- linear atelectasis
- blunting of costophrenic angle
- wedge shaped pulmonary infarct
what is seen on ECG of PE
- sinus tachycardia
- right atrial dilatation
- tall peak P waves in lead II
- right ventricular strain with right axis deviation
- T wave incursion in right precordial leads
when are cardiac troponin elevated in PE
when it is severe
when is plasma D-dimer elevated in PE
when patients have thromboembolism
elevated doesn’t always mean there is a PE as it can be elevated by cancer, pregnancy, elderly
what is a good diagnostic investigation for PE
V/Q mismatch
what can ultrasound detect in PE
clots in pelvic or iliofemoral veins
what is another good investigation that can exclude PE
CTPA
what should be done for a pregnant mother
CTPA exposes the mother to greater radiation risk than V/Q scan but delivers lower radiation to the foetus
what can be seen in echo for PE
good for evidence of right ventricular dysfunction
what is first line investigation if no shock for PE
D-dimer
if D-dimer is positive what is done next for PE
CT angiography
what is useful when CTPA cannot be done for PE
echo
what is done for a massive PE
thrombolysis
what are treatments for PE
- high flow oxygen
- initial anticoagulation
- IV fluids
- thrombosis
- surgical embolectomy
who should get oxygen in PE
everyone unless significant chronic lung disease
what anticoagulation should be given for PE
LMWH or fondaparinux
or IV heparin
what can improve perfusion quicker than anticoagulant
thrombolysis
is surgical embolectomy necessary
rarely
what is given to precent further emboli
anti coagulated with vitamin K antagonist = warfarin for 3-6 months
or
dabigatran, rivaroxaban are used in patients with venous thromboembolism (they are safer than warfarin)
what is given to pregnant ladies and those with cancer to precent emboli
long term LMQH
what is given to patients when anticoagulation is contraindicated
vena cava filter inserted via the femoral vein to above the level of the renal veins
what type of respiratory failure is a PE
type 1 respiratory failure
what are the ABG’s for PE
respiratory acidosis
