Pulmonary Vascular Disease Flashcards
How does a pulmonary embolism occur?
- A thrombus (clot) forms in the venous system (usually in the deep veins of the leg)
- It embolises through the veins through the heart and lodges in the pulmonary arteries
Whats the prognosis for a minor PE?
Very good if treated with anticoagulation
Whats the mortality rate for PE?
At 30 days mortality is between 0-25% (closer to 25% in a massive PE)
How do we determine the risk of mortality?
Using a PESI score based on:
- Age
- Sex
- Comorbidity
- Physiological Parameters
What are the Major Risk Factors for a Pulmonary Embolism?
- Recent Major Trauma
- Recent Surgery
- Cancer
- Significant cardiopulmonary disease e.g. MI
- Pregnancy
- Inherited Thrombophilia
What is a thrombophilila?
An inherited disorder with a predisposition to produce clotting factors (e.g. Factor V Leiden)
What happens if you get a small PE in a peripheral artery??
A section of the lung is infarcted.
This leads to local tissue inflammation, necosis and rubbing against the pleura
What are the signs and symptoms of a small Peripheral PE?
Symptoms:
Pleuritic Chest Pain (from rubbing)
Cough and Haemoptysis
Signs:
Pyrexia
Stony Dullness to percussion at base (due to pleural effusion)
What happens if there multiple small PEs?
Several areas are infarcted
This means perfusion of the lung in general becomes low
What are the signs and symptoms of multiple small PEs?
Symptoms:
pleuritic chest pain, cough, haemoptysis, isolated acute dyspnoea
Signs:
Tachycardia, Tachpnoea, Hypoxia
What happens during a massive PE?
A general lack of pulmonary blood flow leads to hypoxia and loss of blood pressure
What are the signs and symptoms of a massive PE?
The loss of blood pressure can lead to syncope or even cardiac arrest.
Signs:
Tachycardia, Hypotension, Tachypnoea, Hypoxia
How do we determine how likely someone is to get a PE?
By various scoring systems:
- Wells Score
- Revised Geneva Score
What early tests do we do when we suspect a PE?
- A full blood count, blood gases & biochemistry.
- A CXR (rules out other conditions)
- ECG (shows tachycardia)
- D-dimer (-ve indicates unlikely to have a PE)
What is the main test we use to determine a PE?
A CT pulmonary Angiogram (CTPA)
What test would we use to determine if the right ventricle is under strain?
An echocardiograph
What the use of a V/Q scan?
To show areas of ventilation and perfusion.
A PE would be indicated by normal ventilation but areas (or whole thing) of reduced perfusion
Why would we consider doing abdomen CTs and mammography?
In the case of a PE in someone with little clinical risk we would use these tests to see if the cause is occult cancer.
When would we do thrombophilia testing?
If the person had a PE without much clinical risk wed test for inherited disease
What treatments do we use for someone with a minor PE?
- Oxyegn
- BloodThinners
- Direct Oral Anticoagulatants (DOAC)
What treatment would we add for a massive PE?
Thrombolysis
If contraindicated then a pulmonary embolectomy is performed
Name some blood thinners?
- Low Molecular Weight Heperarin (e.g. dalteparin)
- Warfarin
Name some Direct Oral Anticoagulants (DOAC)?
- Rivaroxaban
- Apixaban
In what situation do we put someone on permanent anticoagulants?
IF they have a very high risk of future PE
Name an agent of thrombolysis?
Alteplase (rt-PA)
What is the level of pressure in pulmonary hypertension?
Pressure in pulmoary arterial tree >25mmHg
What is the incidence of primary PH?
1-2/million (very rare)
In what age group does secondary PH normally occur?
The elderly
Name some causes for Pulmonary Hypertension?
- Idiopathic (Primary)
- Secondary to chronic respiratory disease
- Secondary to left heart disease
- Chronic Thromboembolic PH (CTEPH)
- Miscellaneous
How does a chronic respiratory disease lead to pulmonary hypertension?
The disease is bad enough it leads to hypoxia
That leads to pulmonary vasoconstriction
This leads to hypertension
What are the miscelaneous causes of Pulmonary Hypertension?
- Collagen Vascular Disease
- Portal Hypertension
- Congenital Heart Disease (L to R shunt)
- HIV infection
What are the symptoms of Pulmonary Hypertension?
Symptoms:
- Exertional Dyspnoea
- Chest Tightness
- Exertional Presyncope or syncope (i.e. lightheaded or passing out on exercise)
What are the signs of pulmonary hypertension?
- Elevated Jugular Venous Pressure (JVP)
- Right Ventricular Heave
- Loud pulmonary second heart sound
- Hepatomegaly
- Angle Oedema
What tests do we do in pulmonary hypertension to see if its secondary to pulmonary diseasE?
- ECG
- Lung Function Tests
- CXR
Whats the use of an echocardiograph in pulmonary hypertension?
The echocardiograph involves inducing a leak and measuring its velocity.
This way you can indirectly work out the arterial pressure to determine hypertension.
What scans do we use testing for pulmonary hypertension?
A V/Q scan
A CTPA
Why do we use a right heart catheterisation in pulmonary hypertension?
- Allows direct measure of pulmonary artery pressure
- Allows measurment of wedge pressure
- Allows measurement of cardiac output.
All these rule out heart disease as the cause
What is wedge pressure?
An indirect measure of pulmonary venous system pressure.
This tells us if theres a problem with the heart’s left side
What are the general treatments for Pulmonary hypertension?
- Treat underlying condition (if secondary)
- Oxygen (if hypoxic)
- Anticoagulation
- Diuretics (if theres oedema)
what are the specific treatments for PH?
- Calcium channel antagonist
- Prostacyclin (smooth muscle relaxant for vasodilation)
- Endothelial Receptor Antagonists
- Phosphodiesterase inhibitors
What are the surgical treatments for PH?
Thromboendoarterectomy (For chronic thromboembolic PH)
Lung or heart transplant
