pulmonary hypertension Flashcards
define pulmonary hypertension:
elevated blood pressure in the pulmonary arterial tree usually secondary to chronic lung disease (e.g. COPD)
-> leads to right heart failure known as Cor Pulmonale
what mean pulmonary artery pressure is considered pulmonary hypertension?
≥ 25 mmHg at rest
list some presentations of pulmonary hypertension:
Exertional dyspnoea and syncope (fainting)
Chest tightness
Peripheral oedema
Haemoptysis (uncommon)
Mean pulmonary artery pressure of ≥ 25 mmHg
give some signs of pulmonary hypertension on examination:
Fluid retention (e.g. Ankle oedema, Ascites, Elevated JVP)
Loud pulmonary second heart sound (P2) and splitting of S2
Right ventricular parasternal heave (due to right ventricular hypertrophy)
Clubbing
Hepatomegaly
what are the causes of pulmonary hypertension?
Idiopathic
Left Heart Disease (e.g. Left ventricular systolic/diastolic failure, Mitral stenosis)
Chronic Respiratory Disease (e.g. COPD, Interstitial lung disease, Sleep apnoea)
Chronic Arterial Stenosis (e.g. Chronic unresolved pulmonary embolism, Congenital pulmonary artery stenosis)
Multifactorial (e.g. Haemolytic anaemia, Sarcoidosis, Chronic kidney disease, Connective tissue disease)
describe the pathophysiology of pulmonary hypertension in COPD:
Pulmonary vasoconstriction (due to hypoxia, intimal muscular hypertrophy and fibrosis which reduces the lumen’s diameter)
Loss of capillary bed due to emphysema’s destruction of tissue.
Secondary polycythaemia (increased number of RBC’s increases blood viscosity)
women with pulmonary hypertension should avoid pregnancy as it is associated with a 15% maternal death rate
what investigations are used to definitively diagnose pulmonary hypertension?
Right heart catheterisation (right heart catheter with pulmonary capillary wedge pressures)
Vasodilator Trial (patient inhales nitric oxide during catheterisation to assess the vasculature)
what is the treatment of different conditions in pulmonary hypertension?
peripheral oedema - diuretics
lung disease/ hypoxia - oxygen/ long term oxgen therapy
thrombosis - anticoagulation (LMWH, DOACS)
what are the results of vasodilator trial?
Reactive (pulmonary vessels relax and the PAP falls)
Fixed (shows a fixed obstruction with no change following vasodilator)
what is the management of pulmonary hypertension if reactive or fixed pulmonary vasculature following vasodilator?
reactive
Give high-dose CCB (e.g. diltiazem) or prostaglandin (e.g. iloprost)
fixed
Phosphodiesterase inhibitors (e.g. slidenafil, tadalafil)
Endothelin receptor antagonists (e.g. bosentan, ambrisentan)
Continuous IV Prostanoids
what is used to manage chronic thromboemolic pulmonary hypertension?
Riociguat
It works by increasing cyclic guanosine monophosphate which results in vasodilation and acts on the nitic oxide pathway
This acts to reduce shortness of breath
