Pulmonary Vascular Disease Flashcards
A patient has a CTPA after presenting to the ambulatory care unit with chest pain. There is no pulmonary embolus and it is thought that the pain is musculoskeletal. There is an incidental pulmonary arteriovenous malformation (PAVM) and you are asked for advice on what to tell the patient and advise the GP.
Which ONE of the following is the single most accurate statement about PAVMs?
A. Antibiotics are not required to cover dental procedures
B. Dyspnoea on exertion is a common presenting symptom
C. Embolisation should be offered to all patients, regardless of size of PAVM
D. PAVMs create a left to right shunt
E. Screening for iron deficiency is recommended in all patients with PAVM
C. Embolisation should be offered to all patients, regardless of size of PAVM
PAVMs are structurally abnormal vascular connections between pulmonary arteries and veins which create a continuous right-to-left shunt. They are often asymptomatic, but are important due to the risks they pose if untreated: >1 in 4 patients will have a paradoxical embolic stroke, abscess or myocardial infarction while life-threatening haemorrhage affects 1 in 100 women in pregnancy. All PAVMs should therefore be considered for embolisation, regardless of size. Dental procedures should be covered by antibiotics due to the risk of bacteriaemia and septic emboli.
A 57 year old previously fit and independent man presents to the emergency department with a two day history of pleuritic chest pain and breathlessness on exertion. He has osteoarthritis and underwent arthroscopic knee surgery 3 weeks ago. Observations show P 109/min BP 100/65 RR 24 SpO2 95% on air T 37.1. Examination reveals no significant findings. She receives an initial dose of treatment dose low molecular weight heparin whilst waiting for a CTPA. This shows a large R main pulmonary artery embolus with further segmental clot on the right. There is some peripheral consolidation suggestive of a pulmonary infarct. There are no CT signs of RV strain.
Which ONE of the following is the most appropriate management plan?
A. Admit to high dependancy unit and give catheter directed thrombolysis
B. Admit to high dependency unit and give systemic thrombolysis
C. Admit to ward bed and continue low molecular weight heparin
D. Outpatient management with direct oral anticoagulant
E. Outpatient management with warfarin
D. Outpatient management with direct oral anticoagulant
Although you might not feel confident to send this patient home on a DOAC, if you risk assess this patient using PESI you will find they are low risk (PESI score 67 class II low risk and sPESI score 0) . Both ERS/ESC guidelines on PE and BTS guidelines on outpatient management of PE would support you to send the patient home. You may feel better with a low Troponin or BNP result but the evidence says you do not need this to follow an outpatient pathway.
