Pulmonary Vascular Disease

Question 1

Where does a thrombus form?

Answer 1

In the venous system, usually in deep veins of the legs

Question 2

Where does a thrombus normally embolise in a pulmonary embolism?

Answer 2

Embolises to the pulmonary arteries.

Question 3

What is mortality rate for pulmonary embolism?

Answer 3

Massive PE fatal, although minor PE treated with anticoagulation has a very good prognosis.

Question 4

What are major risk factors for venous thromboembolism?

Answer 4

Recent major trauma Recent surgery (Body responds by increasing clotting factors after surgery, immobilised so blood flow to the legs is less) Cancer - blood more likely to clot, tumour can obstruct blood flow Significant cardiopulmonary disease Pregnancy Inherited thrombophilia

Question 5

What are the symptoms for pulmonary embolism?

Answer 5

Pleuritic chest pain, cough and haemoptysis (cough up blood due to dead and dying lung tissue) Isolated acute dyspnoea (difficult or laboured breathing) Syncope or cardiac arrest

Question 6

When do you feel the pain in pleurisy?

Answer 6

Pain in the chest when taking a deep breath

Question 7

How does PE affect V/Q mismatch?

Answer 7

Ventilation fine, perfusion reduced

Question 8

What are the signs of PE?

Answer 8

Pyrexia Pleural rub Pleaural effusion Tachycardia Tachypnoea Hypoxia Hypotension

Question 9

What tests are used to determine the likelihood of PE?

Answer 9

Wells score Revised Geneva score

Question 10

What things does the revised geneva score take into consideration?

Answer 10

Previous pulmonary embolism or deep vein thrombosis Heart rate Recent surgery or immobilisation Clinical signs of deep vein thrombosis Alternative diagnosis less likely than pulmonary embolism Haemoptysis Cancer

Question 11

What are the relevant PE investigations?

Answer 11

Full blood count, biochemistry, blood gases Chest X-ray ECG - Tachycardia D-dimer - product of clotting cascade CT pulmonary angiogram V/Q scan Echocardiography Consider CT abdomen and mammography Consider thrombophilia testing

Question 12

What is a CT pulmonary angiogram?

Answer 12

Medical diagnostic test that uses computed tomography to obtain an image of the pulmonary arteries

Question 13

What is an ECG?

Answer 13

An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical activity of your heart.

Question 14

What is echocardiography?

Answer 14

Echocardiography, is a painless test that uses sound waves to create moving pictures of your heart. The pictures show the size and shape of your heart. They also show how well your heart’s chambers and valves are working.

Question 15

What is a V/Q scan?

Answer 15

A ventilation–perfusion (VQ) scan is a nuclear medicine scan that uses radioactive material to examine ventilation and perfusion in the lungs. The aim of the scan is to look for evidence of any blood clot in the lungs, called pulmonary embolism.

Question 16

What do the results of a V/Q scan look like?

Answer 16

Question 17

What test assesses morbidity and mortality of PE?

Answer 17

The PESI score (pulmonary embolism severity index)

Question 18

What is mortality at 30 days for pulmonary embolism?

Answer 18

Mortality at 30 days varies from 0 - 25%

Question 19

What is treatment for PE?

Answer 19

Oxygen

Low molecular weight heparin (dalteparin) - anticoagulant, also naturally produced by basophils and mast cells

Warfarin

Direct oral anticoagulants (rivaroxaban, apixaban) - newer fancier drugs

Thrombolysis (alterplase - direct lysis of the clot)

Pulmonary emolectomy

Question 20

What is pulmonary hypertension?

Answer 20

Elevated blood pressure in the pulmonary atrterial tree

(Mean pulonary arterial pressure of > 25 mmHg)

Can be a primary condition or a secondary condition

Question 21

Is pulmonary hypertension common or rare?

Answer 21

Rare, incidence of 1-2 per million population

Question 22

Is pulmonary hypertension a fatal illness?

Answer 22

Yes, •Untreated it is a rapidly progressive condition that leads to premature death.

Question 23

Which is more common, primary or seconday pulmonary hypertension?

Answer 23

Secondary, Tends to occur in an older age group

Question 24

What are the causes of pulmonary hypertension?

Answer 24

Idiopathic

Secondary to chronic respiratory disease

Secondary to left heart disease

Chronic Thromboembolic PH (High blood pressure resulting from embolism that cannot be reabsorbed by the body. 2 to 4 percent of people with PE develop CTEPH. It is a relatively rare disease.)

Miscelaneoud reasons

Question 25

What are the symptoms of Pulmonary Hypertension?

Answer 25

Exertional Dyspnoea

Chest tightness

Exertional presyncope or syncope

Question 26

What are the signs of Pulmonary Hypertsion?

Answer 26

Elevated jugular venous pressure

Right ventricular heave

Loud pulmonary second heart sound

Hepatomegaly (abnormal enlargement of the liver)

Ankle oedema

Question 27

What are the relevant investigations for pulmoary hypertension?

Answer 27

ECG

Lung function tests

Chest X-ray

Echocardiography

V/Q scan

CTPA

Right heart catheterisation

Question 28

What is treatment for Pulmonary Hypertension?

Answer 28

Treat underlying condition

Oxygen

Anticoagulation

Diuretics

Question 29

What is specific treatment for Pulmonary Hypertension?

Answer 29

Calcium channel antagonist

Prostacyclin - relaxes smooth muscle in the pulmonary arteries causing vasodilation

Question 30

Other treatments?

Answer 30

Thromboendarterectomy

Lung or heart lung transplant