Pulmonary Vascular Disease

Question 1

What happens in pulmonary embolism?

Answer 1

Thrombus forms in venous system, usually in the deep veins of the legs and embolises to the pulmonary arteries

Question 2

Major risk factors for VTE

Answer 2

Recent major trauma
Recent surgery
Cancer
Significant cardiopulmonary disease e.g.MI
Pregnancy
Inherited thrombophilia e.g. factor V Leiden

Question 3

Presentation of PE

Answer 3

Pleuritic chest pain 
Cough 
Haemoptysis 
Isolated acute SOB 
Syncope or cardiac arrest (Massive PE)

Question 4

Signs of PE

Answer 4

Pyrexia
Plerual rub 
Stony dullness to percussion at base (pleural effusion) 
Tachycardia
Tachypboea
Hypoxia
Hypotension

Question 5

Pre test probability for PE

Answer 5

Wells score

Revised Geneva score

Question 6

What does wells score look at?

Answer 6

Symptoms and signs of VTE
Previous VTE
RFs

Question 7

What does the revised Geneva score look at?

Answer 7

Risk factors

Symptoms and signs (HR)

Question 8

Investigations for PE

Answer 8

FBC, biochemisty, blood gases
CXR
ECG
D-dimer
CTPA
V/Q scan 
ECHO
CT of abdomen and mammography (consider)
Thrombophilia testing (consider)

Question 9

What score determines prognosis of PE

Answer 9

PESI score

Question 10

What does PESI score look at?

Answer 10

Based on age, sex, comorbidity and physiological parameters

Question 11

Treatment of PE

Answer 11

Oxygen 
LMWH (or fondaparinux) initially (continue for 5 days or INR >2)
Warfarin given within 24 hours 
DOAC 
Thrombolysis (if massive PE)
Pulmonary embolectomy

Question 12

Example of LMWH

Answer 12

Dalteparin

Question 13

Examples of DOAC

Answer 13

Rivaroxban

Apixaban

Question 14

Examples of thrombolysis

Answer 14

Altepase (rt-PA)

Question 15

What is pulmonary HTN?

Answer 15

Elevated BP in the pulmonary artery or tree

Question 16

What PMAP is defined as pulmonary HTN?

Answer 16

Pulmonary arterial pressure > 25 mmHg

Question 17

Causes of pulmonary HTN

Answer 17

Idiopathic
Secondary to chronic resp disease
Secondary to L heart disease
Chronic thromboembolic PH (CTPH)
Collagen vascular disease
Portal HTN
Congenital heart disease (L to R shunt)
HIV infection

Question 18

Presentation of Pulmonary HTN

Answer 18

Exertional SOB
Chest tightness
Exertional pre syncope or syncrope

Question 19

Signs of Pulmonary HTN

Answer 19

Elevated JVP
Right ventricular heave
Loud pulmonary second heart sound
Hepatomegaly 
Ankle oedema

Question 20

Investigations of Pulmonary HTN

Answer 20

ECG
LFTs
CXR
ECHO
V/Q scan
CTPA
Right heart catheterisation

Question 21

What does right heart catheterisation measure?

Answer 21

Pulmonary artery pressure
Wedge pressure
Cardiac output

Question 22

Treatment of pulmonary HTN

Answer 22

Treat underlying condition 
Oxygen 
Anticoagulation 
Diuretics 
CCBs e.g. amlodipine
Prostacyclin 
Endothelial receptor antagonists e.g. bosentan, ambrisentan 
Phosphodiesterase inhibitors - sildenafil, tadalafil 
Thromoendarterectomy (CTEPH)
Lung or heart transplant

Question 23

How long should warfarin be continued for after a PE?

Answer 23

3 months

Question 24

How long should LMWH be continued for after a PE in people with cancer?

Answer 24

6 months

Question 25

What is thrombolysis the gold standard for a PE treatment for?

Answer 25

Massive PE when there is circulatory failure (e.g. hypotension)

Question 26

Patients who have repeated PEs, despite anticoagulation, may be considered for what?

Answer 26

Inferior vena cava filters

Question 27

How does an IVC filter work?

Answer 27

Stop clots formed in the deep veins of the leg moving to the pulmonary arteries