Pulmonary HTN Flashcards
Pulmonary Hypertension is defined by what?
mPAP > 20 mmHg
Pre-capillary PH is defined as?
mPAP > 20 mmHG
PAWP </= 15 mmHg
PVR > 2WU
Isolated Post-capillary PH is defined as?
mPAP > 20 mmHg
PAWP > 15 mmHg
PVR </= 2 WU
Combined pre and post capillary PH is defined as?
mPAP > 20 mmHg
PAWP > 15 mmHg
PVR > 2 WU
Exercise PH is defined as?
mPAP/CO slope between rest and exercise > 3 mmHg/L/min
Risk Factors for PH
age > 65 years old
Left Heart Disease
COPD
CHD
Some infectious diseases (schistosomiasis, HIV)
high altitude
Clinical Presentation of PH
Early
Dyspnea on Exertion
Fatigue and rapid exhaustion
Dyspnea when bending forward
Palpitations
Hemoptysis
Exercise-induced abdominal distension and nausea
Weight gain d/t fluid retention
Syncope (during or shortly after physical exertion
Clinical Presentation of PH
Late
Exertional chest pain: dynamic compression of the left main coronary artery
Hoarseness (dysphonia): compression o fthe left laryngeal recurrent nerve)
SOB, wheezing, cough, lower respiratory tract infection, atelectasis: compression of the bronchi
The cardinal symptom of PH is
dyspnea on progressively minor exertion
Signs of PH
Central, peripheral or mixed cyanosis
accentuated pulmonary component of the second heart sound
RV third heart sound
Systolic murmur of the tricuspid regurgitation
Diastolic murmur of pulmonary regurgitation
Signs of RV backward failure
Distended and pulsating jugular veins
Abdominal distention
Hepatomegaly
Ascites
Peripheral edema
Signs pointing towards underlying cause of PH
Digital Clubbing
Sclerodactyly
Raynaud’s Phenomenon
digital ulceration
GORD
Signs pointing towards underlying cause of PH
Digital Clubbing
Cyanotic CHD, fibrotic lung disease, bronchiectasis, PVOD, or liver disease
Signs pointing towards underlying cause of PH
Differential clubbing/cyanosis
PDA/Eisenmenger’s syndrome
Signs pointing towards underlying cause of PH
Auscultory findings
crackles or wheezing
murmurs
Lung or heart disease related
Signs pointing towards underlying cause of PH
Sequelae of DVT, venous insufficiency
CTEPH
Signs pointing towards underlying cause of PH
Telangiectasia
Hereditary Hemorrhagic Telangiectasia or systemic sclerosis
Signs pointing towards underlying cause of PH
Sclerodactyly, Raynaud’s Phenomenon, digital ulceration, GORD
systemic sclerosis
Signs of RV forward failure
Peripheral cyanosis (blue lips and tips)
Dizziness
Pallor
Cool Extremities
Prolonged Cap refill
Typical ECG abnormalities in PH
P pulmonale (P > 0.25 mV in lead II)
R or sagittal axis deviation
RV hypertrophy (R/S > 1, w/ R > 0.5 mV in V1; R in V1 + S in lead V5 > 1mV)
RBBB
RV strain pattern (ST depression/ T-wave inversion in the right pre-cordial V1-4 and inferior II, III, aVF)
Prolonged QTc
Radiographic Signs of PH and concomitant abnormalities
R heart enlargement
PA enlargement
Pruning of the peripheral vessels
‘Water-bottle’ shape of cardiac silhouette
Radiographic Signs of LHD/Pulmonary Congestion
Central air space opacification
Interlobular septal thickening ‘Kerley B’ lines
Pleural effusions
LA enlargement
LV dilation
Radiographic signs of lung disease
Flattening of diaphragm (COPD/Emphysema)
Hyperlucency (COPD/Emphysema)
Lung volume loss (fibrotic lung disease)
Reticular opacification (fibrotic lung disease)
PFT findings in patients w/ PAH
usually normal or may show mild restrictive, obstructive or combined abnormalities.
More severe PFT abnormalities are occasionally found in patients w/ ?
PAH associated w/ CHD
A severely reduced Diffusing Capacity for Carbon Monoxide (<45% of predicted value) in the presence of otherwise normal PFTs can ve found in what patients?
PAH w/ Systemic Sclerosis
Patients w/ PAH have what PaO2 levels?
slightly reduced or normal
Severe reduction of PaO2 in PAH might raise suspicion of what?
patent foramen ovale
hepatic disease
other abnormalities w/ R-to-L shunt (e.g. septal defect)
low-DLCO- associated conditions
Patients w/ PAH have what PaCO2 levels?
typically lower than normal d/t hyperventilation
Elevated PaCO2 is very unusual in PAH and reflects what?
What is recommended in this case?
alveolar hypoventilation, which may be a cause of PAH in itself
Overnight oximetry or polysomnography for suspicion of sleep d/o breathing or hypoventilation
Echo Signs of RV dysfunction on four chamber view
Dilated RV
Enlarged RA area (> 18 cubic cm)
Presence of pericardial effusion
Echo Signs of RV dysfunction on parasternal long axis view
Enlarged RV