Pulmonary vascular disease

Question 1

Explain what happens in a pulmonary embolism

Answer 1

-Thrombus formation from venous system ( normally from deep veins in legs) and embolises to the pulmonary arteries

Question 2

Treatment of minor PE

Answer 2

-anticoagulation

Question 3

Risk factors of thromboembolism

Answer 3

• trauma
• recent surgery
• cancer
• cardiopulmonary disease ( MI)
• pregnancy
• inherited thrombophilia ( Factor V Leiden)

Question 4

Symptoms of PE

Answer 4

• pleuritic chest pain, cough + haemoptysis
• isolated acute dyspnoea
• syncope/cardiac arrest ( major PE)

Question 5

Clinical signs of PE

Answer 5

• pyrexia(high temp)
• pleural rub( rubbing of pleural membranes, grating low pitched sound)
• dull percussion at base ( pleural effusion)
• tachycardia, tachypnoea, hypoxia, hypotension (major)

Question 6

What is well’s/ Modified geneva test?

Answer 6

-test to assess risk of PE

Wells score= symptoms, signs of VTE(venous thromboembolism), previous VTE + risk factors

Revised Geneva score= based on risk factors, symptoms + signs(HR)

4 points/< = unlikely
>4 points= PE likely

(see slide 12)

Question 7

PE investigations

Answer 7

• FBC, biochemsitry, TnI?, Blood gases
• CXR
• ECG
• D-dimer ( a fibrin degradation product (small protein fragment) present in the blood after a blood clot is degraded by fibrinolysis.
• CT pulmonary angiogram
• V/Q scan
• Echocardiography

Consider: CT abdomen/mammography, /thombophillia testing

Question 8

What is the PESI score

Answer 8

• determines mortality of patients who have been diagnised with PE.
• dependernt on age, sex, comorbidity and physiological parameters

Question 9

Treatment for PE

Answer 9

• Oxygen
• lower molecular weigh heparin ( dalteparin, warfarin)
• Direct oral anticoagulants ( rivaroxaban, apixaban)
• thrombolysis ( Alteplase ( rt-PA)
• Pulmonary embolectomy

Question 10

What is pulmonary hypotension?

Answer 10

• high BP in the pulmonary arterial tree
• can be primary/secondary to other conditions
• defined as mean pulmonary artery pressure of >25mmHg

Question 11

Explain features of primary and secondary PH

Answer 11

Primary= rare, if left untreated can lead to premature death

Secondary - most common, occurs in older age groups

Question 12

Causes of PH

Answer 12

• idiopathic ( group 1 )
• Secondary to left heart disease ( 2)
• Secondary to chronic respiratroy disease ( 3)
• Chronic thomboembolic PH ( 4)
• Miscellaneous
• collagen vascular disease (1)
• portal hypertension (1)
• congenital heart disease ( L to R shunt) (1)
• HIV infection (1)
• sarcoidosis ( group 5 )

Question 13

Symptoms of PH

Answer 13

• dyspnoea
• chest tightness
• presyncope/syncope

Question 14

Clinical signs of PH

Answer 14

• high JVP(jugular venous pressure)
• right ventricular heave
• loud pulmonary second heart sound
• hepatomegaly
• ankle oedema

Question 15

Investigation of PH

Answer 15

• ECG
• Lung function tests
• CXR
• echocardiography
• V/Q scan
• CTPA (ct pulmonary angiogram)
• Right heart catherisation;
• allows direct measure of pulmonary artery pressure
• measurement of wedge pressure
• measurement of CO

Question 16

General treatment of PH

Answer 16

• treat udnerlying condition
• Oxygen
• anticoagulation
• diauretics

Question 17

Specific treatment of Ph

Answer 17

• Calcium channel antagonist ) amlodipine)
• prostacyclin
• endothelin receptor antagonist ( bosentan, ambrisentan)
• Ricociguat
• Phosphodiesterase inhibitors(Sildenafil, tadalafil)

Question 18

Other treatments of PH

Answer 18

• thromboendarterectomy (CTEPH)

- heart/lung transplant