Pulmonary vascular disease Flashcards
what is pulmonary embolism?
Thrombus that forms in the venous system, usually in deep veins of the legs and embolises to the pulmonary arteries.
the embolus not only prevents the exchange of O2 and CO2, but it also decreases blood supply to the lung tissue itself, potentially causing lung tissue to die
what is a minor PE treated with?
anticoagulation (drugs like warfarin)
what are the major risk factors of a venous thromboembolism (6)
recent major trauma recent surgery cancer significant cardiopulmonary disease like MI pregnancy inherited thrombophilia
name an inherited thrombophilia
Factor V leiden
- a variant (mutated form) of human factor V which causes an increase in blood clotting
symptoms of pulmonary embolism (3)
pleuritic chest pain, cough, haemoptysis (due to rupturing of pulmonary arteriole)
isolated acute dyspnoea (laboured breathing)
syncope or cardiac arrest (massive PE)
examples of pre-test probability ie tests to find out the probabilities of the presence of a condition (2)
wells score
revised geneva score
what is the wells score?
a score showing likelihood of having pulmonary embolism
includes symptoms and signs of Venous thromboembolism (VTE), previous VTE and risk factors
what is the revised geneva score based on?
risk factors, symptoms and signs (heart rate)
what investigations are done to determine a PE (9)
Full blood count, biochemistry, blood gases
Chest X-Ray
ECG
D-dimer
CT Pulmonary Angiogram (CTPA)
V/Q scan
Echocardiography
Consider CT abdomen and mammography
Consider thrombophilia testing
what is a V/Q scan?
scan that examines ventilation and perfusion of the lungs
mortality at 30 days from PE varies from 0 to X%?
25%
what is the PESI score
Pulmonary Embolism Severity Index
calculates risk based on age, sex, comorbidity and physiological parameters
treatment options for a PE (6)
- Oxygen
- Low molecular weight heparin e.g. dalteparin
- Warfarin
- Direct Oral Anticoagulants (DOAC)
rivaroxaban, apixaban - Thrombolysis - use Alteplase (rt-PA) to do this
- Pulmonary Embolectomy
what is pulmonary hypertension?
Elevated blood pressure in the pulmonary arterial tree
what is the mean pulmonary artery pressure during pulmonary hypertension
> 25 mmHg
Causes of pulmonary hypertension? main (4)
idiopathic (unknown)
secondary to chronic respiratory disease (arterioles constrict to find better ventilated alveoli)
secondary to left heart disease (or LHF can cause pulmonary hypertension- back log from heart to the lungs)
chronic thromboembolic PH
secondary pulmonary hypertension is…?
more common and tends to occur in an older age group
secondary- caused by another disease
miscellaneous causes of pulmonary hypertension
collagen vascular disease
portal hypertension
congenital heart disease (L to R shunt)
HIV
symptoms of hypertension (3)
exertional dyspnoea (occurs when engaged in a simple activity) chest tightness exertional presyncope (feeling faint during exercise) or syncope
signs of pulmonary hypertension (5)
- elevated JVP - higher pressure, collapses higher up the neck (can also be sign of RV failure which can be linked with PH)
- right ventricular heave - (murmur you can feel- lifting of chest) suggests RV hypertrophy due to narrowing of pulmonary arteries, pushing blood through is harder
- loud pulmonary second heart sound (closing of the pulmonary and aortic valves- sound of the blood rushing back to the ventricle after the valves close- more blood-louder noise as it hits the closed valve)
- Hepatomegaly - enlarged liver
- Ankle oedema - increased pressure pushes fluid out of arterioles
what is JVP
jugular venous pressure
blood pressure in the jugular vein
what is a right ventricular heave
visible or palpable pulsations of the chest wall
a ‘lift’
what investigations are undergone for pulmonary hypertension (7)
ECG
Lung function tests
Chest X-Ray
Echocardiography
V/Q scan
CTPA - CT pulmonary angiogram - shows pulmonary arteries
Right heart catheterisation - required to definitively diagnose pulmonary arterial hypertension (PAH)
what is right heart catheterisation?
catheter inserted into right side of heart and then into the pulmonary artery
it measures blood flow and pressure
what does a right heart catheterisation allow measurement of? (3)
pulmonary artery pressure
measurement of cardiac output
measurement of wedge pressure - pressure measured by catheter with an inflated balloon into a small pulmonary arterial branch. It estimates the LA pressure
what is a CTPA
CT pulmonary angiography - CT scan of pulmonary artery
what is an echocardiography test
sonogram of the heart
uses 2D, 3D and ultrasound to create image of heart
what is an ECG
electrocardiogram
a test that shows electrical activity generated by the heart as it contracts
general treatment of pulmonary hypertension
treat underlying condition
oxygen
anticoagulation
diuretics
specific treatment of pulmonary hypertension
Calcium channel antagonist e.g. Prostacyclin
Endothelin receptor antagonists e.g. Riociguat
Phosphodiesterase inhibitors
thromboendarterectomy CTEPH
surgery to remove thrombus from the pulmonary arteries
name 2 phosphodiesterase inhibitors
sildenafil
tadalafil
name 2 endothelin receptor antagonists
bosentan
ambrisentan
what is a split S2 sound?
A split S2 is a finding upon auscultation of the S2 heart sound
causes of a fixed split S2 are pulmonary hypertension, right sided heart failure and atrial septal defect
why is low molecular weight heparin the better option over warfarin for DVT
You need to be loaded with warfarin before it has a therapeutic effect therefore it would not be the immediate treatment
direct oral anticoagulants have taken the place of which other drugs for treatment of DVT
warfarin and daltaparin (LMWH)
