Pulmonary vascular disease Flashcards
What is a pulmonary embolism (PE)?
Thrombus forms in the venous system, usually in the legs, and breaks off and travels through the venous system and R heart and into the pulmonary arteries.
What is the prognosis for PEs?
Minor = treated with anticoagulants and has very good prognosis
Major = often fatal
What are some risk factors of PEs?
Recent major trauma
Recent surgery
Cancer
Significant cardiopulmonary disease
Pregnancy
Inherited thrombophilia
Why does recent major trauma increase your risk for a PE?
You’re often immobile = blood pools
Blood clotting system is activated to prevent bleeding = more clots
How is pregnancy a risk factor for PE?
Clotting factors increase
Mechanical effect of enlarging foetus pressing on veins
What are the symptoms of a PE?
Pleuritic chest pain
Cough
Haemoptysis
Isolated acute dyspnoea
Syncope or cardiac arrest (massive PE)
How does pleuritic chest pain come about in a PE?
With small peripheral thrombus causing a large infarction.
Gives inflammation of lung surface = pleuritic chest pain
How does syncope or cardia arrest come about in PE?
Large thrombus lodged in main pulmonary artery.
Present with collapse, syncope or even cardiac arrest.
Complete obstruction of blood.
What are some signs of a mild PE?
Pyrexia = fever
Pleural rub
Stony dullness to percussion at base (pleural effusion)
What are some signs of moderate PE?
Tachycardia
Tachypnoea
Hypoxia
What is a moderate PE?
Multiple small pulmonary emboli
What are some signs of a massive PE?
Tachycardia
Tachypnoea
Hypoxia
Hypotension
What is a pulmonary infarction?
Death of tissue as a result of partial loss of blood supply to that section
What tests can be done for a PE?
Wells score
- Includes symptoms, signs of VTE, previous VTE and risk factors
Revised Geneva score
- Based on risk factors, symptoms and signs
What investigations are done with PE?
FBC
Biochemistry
Tni (if elevated = strain on heart)
ABG
Chest X-ray
ECG
D-dimer
CT pulmonary angiogram
V/Q scan
Echocardiography
Consider CT abdomen and mammography
Consider thrombophilia testing
What is a D-dimer and what do results demonstrate?
Haematological test
If low/negative the PE is very unlikely
When is echocardiography useful and what does it look for?
Useful in suspected massive PE
Assess for right ventricular strain
What are treatment options for a PE?
*Oxygen
*Low molecular weight heparin
*Direct oral anticoagulants (DOAC)
*Thrombolysis
*Pulmonary embolectomy
Warfarin
What is an example of low molecular weight heparin and when are they given?
Dalteparin
Always give at start of treatment/straight away
Give 2 examples of DOACs?
Rivaroxaban
Apixaban
Give an example of a thrombolysis drug and how it has an effect?
Alteplase
Will dissolve the clot quickly so quick recovery
When is a pulmonary embolectomy done?
Very rarely
Only for massive PE
What is the prognosis of PEs and how can you work it out?
Mortality at 30-days 0-30%
PESI score
- Based on age, sex, comorbidity and physiological parameters
Define pulmonary hypertension?
Elevated blood pressure in the pulmonary arterial tree.
Defined as a mean pulmonary artery pressure of >20mmHg
Explain primary (idiopathic) arterial hypertension?
Rare: incidence of 1-2 per million
Untreated is rapidly progressive leading to premature death.
Explain the pathology of pulmonary hypertension?
Smaller pulmonary arteries get thickened, arteries constrict and pressure builds up, affects right side of heart (hypertrophy and eventual failure).
Increased blood pressure in your lungs.
What are the 5 groups of causes of pulmonary hypertension?
- Idiopathic
- Secondary to heart disease
- Secondary to chronic respiratory disease
- Chronic thromboembolic PH (CTEPH)
- Miscellaneous
What are the 5 groups of causes of pulmonary hypertension?
- Idiopathic
- Secondary to heart disease
- Secondary to chronic respiratory disease
- Chronic thromboembolic PH (CTEPH)
- Miscellaneous
What are some things that fall into group 1 (causes of PH)?
Collagen vascular disease
Portal hypertension
Congenital heart disease (L to R shunt)
HIV infection
Give an example of a group 5 condition causing PH?
Sarcoidosis
What are some symptoms of PH?
Exertional dyspnoea
Chest tightness
Exertional presyncope or syncope
Haemoptysis
What is a presyncope?
Light headedness on exercise
What are some signs of pulmonary hypertension?
Elevated JVP
Right ventricular heave
Loud pulmonary second heart sound
Hepatomegaly
Ankle oedema
What investigations are done for PH?
ECG
Lung function tests
CXR
Echocardiography
V/Q scan
CTPA
Right heart catheterisation (confirms PH)
How does right heart catheterisation work?
Allows direct measure of pulmonary artery pressure.
Measurement of wedge pressure (if elevated suggest left heart problem).
Measurement of cardiac output.
Vasodilator trail with nitric oxide.
What are the common treatments for PH?
Treat underlying condition
Oxygen
Anticoagulation (for IPAH only)
Diuretics
What are some specific treatments for PH?
Calcium channel antagonists - if +ve vasodilator trial)
Prostaglandins - iloprost
Prostacyclin agonist - selecipag
Phosphodiesterase inhibitors - sildenafil, tadalafil
Endothelin receptor antagonists - bosentan, ambrisentan
Riociguat (for CTEPH)
What are some other treatments for PH?
Thromboendarterectomy (CTEPH)
Lung or heart transplant
