Pulmonary Vascular Disease

Question 1

What is a thrombus?

Answer 1

Blockage of blood vessel - usually in the veins of the lower limb

Question 2

What percentage of hospitalisations as caused by pulmonary embolism?

Answer 2

1%

Question 3

How is minor PE treated?

Answer 3

Anticoagulants

Question 4

What are the major risk factors for PE?

Answer 4

• Recent major trauma/surgery
• Cancer
• Significant cardiopulmonary disease
• Pregnancy
• Inherited thrombophila e.g. Factor V Leiden

Question 5

What are the symptoms of PE?

Answer 5

• Pleuritic chest pain
• Cough
• Haemoptysis
• Isolated acute dyspnoea
• Syncope or cardiac arrest

Question 6

What are the signs of PE?

Answer 6

• Pyrexia
• Pleural rub
• Pleural effusion
• Tachycardia
• Tachypnoea
• Hypoxia

Question 7

What two pre-test probability scores do we use to predict someones susceptibility to PE?

Answer 7

Wells Score (Includes symptoms of VTE and risk factors) and Revised Geneva Score (includes symptoms, signs and heart rate)

Question 8

What investigations may be useful for pulmonary embolism diagnosis?

Answer 8

• Full blood count/gases
• Chest X-ray
• ECG
• D-dimer
• CTPA
• V/Q scan
• Echocardiography
• (Consider CT abdomen, mammography and throombophilia testing)

Question 9

How does the prognosis of PE vary?How is this measured?

Answer 9

Mortality in 30 days varies from 0-25%

PESI (Pulmonary embolism severity index) - based on age, sex, comorbidity and physiological parameters

Question 10

What are the treatment options for PE?

Answer 10

• Oxygen
• Low MR heparin (e.g dalteparin)
• Warfarin
• Direct oral anticoagulants (DOAC) - e.g. rivaroxaban, apixaban
• Thrombolysis (Alteplase (rt-PA))
  Pulmonary embolectomy

Question 11

What is the definition of pulmonary hypertension?

Answer 11

A mean pulmonary artery pressure of >25mmHg

Question 12

Which is more common, primary PH or secondary PH?

Answer 12

Secondary PH

Primary has an incidence of 1-2 per million population

Question 13

What are the causes of PH?

Answer 13

• Idiopathic (spontaneous)
• Secondary to respiratory infection/left heart disease
• Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
• Misc. Collagen vascular disease, portal hypertension, congenital heart disease, HIV infection

Question 14

What are the symptoms of PH?

Answer 14

• Exertional dyspnoea
• Chest tightness
• Exertional pre syncope/syncope

Question 15

What are the signs of PH?

Answer 15

• Elevated JVP (Jugular venous pressure)
• Right ventricle heave
• Loud pulmonary second heart sound
• Hepatomegaly
• Ankle oedema

Question 16

What investigations maybe useful in the diagnosis of PH?

Answer 16

ECG
Lung Function tests
Chest X-ray
Echocardiography 
V/Q scan 
CTPA 
Right heart catheterisation (wedge pressure, cardiac output and direct pulmonary artery pressure)

Question 17

What general treatments are there for PH?

Answer 17

• Treat underlying -condition
• Oxygen
• Anticoagulation
• Diuretics (ferosimide)

Question 18

What specific treatments are there for PH?

Answer 18

• Calcium channel antagonists (amlodipine)
• Prostacyclin (vasodilator)
• Endothelin receptor antagonist (bosentan, ambrisentan)
• Phosphodiesterase inhibitors - relaxes blood vessels (sildenafil. tadalafil)

Question 19

What other surgical treatments may be considered?

Answer 19

Thromboendarterectomy

Lung/heart transplant