Pulmonary Vascular Disease Flashcards
What is a pulmonary embolism?
Thrombus forms in venous system (usually deep veins of legs), all/part of it propagates + travels up IVC to heart and ends up in a pulmonary artery
What are risk factors for PE?
Recent major trauma/surgery
Cancer (large tumour pressing on veins –> venous stasis)
Significant cardiopulmonary disease, e.g. MI
Pregnancy
Inherited thromophilia
COPD
Why do major surgery/trauma predispose to PE?
Clotting system is activated and immobilisation/stasis
What are potential features of a PE?
Chest pain (pleuritic) SoB Haemoptysis Tachycardia Tachypnoea
Why do you get haemoptysis in PE?
Blood clot in pulmonary artery –> tissue infarction (so cough up necrotic tissue)
Why do you get pleuritic chest pain in PE?
Inflamed lung rubs against chest wall
How might a massive PE present?
Syncope or cardiac arrest (e.g. if clot in main pulmonary artery)
What are signs of a small clot causing a PE?
Pyrexia, pleural rub (sounds like walking on snow), stony dullness to percuss at base (pleural effusion)
What are signs of a bilateral PE?
Tachycardia, tachypnoea, hypoxia
What are signs of a massive PE?
Shock - hypotension, tachycardia, tachypnoea, hypoxia
All patients presenting with signs/symptoms suggestive of a PE should have what?
CXR to exclude other pathology
What key change was made to the investigation and management of VTE in 2020?
Use of the pulmonary embolism rule out criteria - this should be used if there is low possibility of PE but you want more reassurance it is not a PE
Low probability is <15% if higher than this move straight to a two level PE wells score
What is the two level PE well score?
Clinical sx/sx of DVT (minimum of leg swelling + pain on palpation of deep veins) -3
Alt diagnosis less likely - 3
HR >100bpm - 1.5
Immobilisation >3 days/surgery in prev 4 weeks - 1.5
Prev. DVT/PE - 1.5
Haemopytsis - 1
Malignancy (on treatment, treated in last 6 months or palliative) - 1
What wells score indicates PE is likely?
> 4 points
If PE is likely what should you do?
Arranged immediate CTPA (if delay then start interim therapeutic anticoagulation until scan is performed)
What interim therapeutic anticoagulation is given for PE?
DOACs, e.g. apixiban or rivaroxiban
What should you do if PE is unlikely?
Arrange D-dimer
If +ve –> immediate CTPA (interim anticoagulation if unable to get it immediately)
If -ve –> PE unlikely, consider alt diagnosis
If the patient has an allergy to contrast/renal impairment what should be done instead of a CTPA?
V/Q scan
What are the classic ECG changes seen in PE?
Large S wave in lead I, large Q wave in lead III and inverted T wave in lead III (S1Q3T3)
Right bundle branch block + right axis deviation
Sinus tachycardia
What do you typically see on CXR in PE?
Usually normal
What (other than a current PE) may cause a V/Q mismatch on a V/Q scan?
Old PEs, AV malformations, vasculitis, prev. RT
What is the gold standard investigation for diagnosing PE?
Pulmonary angiography
List all the investigations that should be considered qfor a suspected PE
FBC, biochemistry, ABG CXR ECG D-dimer CTPA VQ scan ECHO Thrombophilia testing?
What is the PESI score?
PE severity index, based on age, sex, comorbs, physiological parameters
What is the first line treatment for most people with VTE?
DOACs
Where might patients with low risk PEs be managed?
As outpatients (assess risk using PESI score, with key requirements being haemodynamic stability, lack of comorbs and support at home)
What DOACs are offered first line after a PE?
Apixiban or rivaroxaban
What should be used if DOACs are not suitable for treating a PE?
LMWH followed by dabigatran or edoxaban or LMWH followed by vit K antagonist, e.g. warfarin
What should be used to treat PE in severe renal impairment?
LMWH then UFH or LMWH then VKA
What should be used to treat PE in those with antiphospholipid syndrome?
LMWH followed by VKA
How long should all patients with PE be anticoagulated?
Min 3 months
What is the first line treatment for massive PE with circulatory failure?
Thrombolysis
What treatment can be given to those with recurrent PEs despite adequate anticoagulation?
IVC filters (these work by stopping clots formed in deep veins of leg moving to the pulmonary arteries)
What is pulmonary hypertension?
Elevated BP in pulmonary artery tree (pulmonary arterial pressure >25mmHg)
Who is primary PHT seen in ?
Young people - it is very serious and rare and requires treatment
What are causes of pulmonary HTN?
Primary - idiopathic 2ndary to chronic resp disease - any disease severe enough to cause bad hypoxia --> constriction of pulmonary capillary bed --> inc. pulmonary artery pressure Secondary to L heart disease Chronic thromboembolic PH (due to web and scar tissue formation) Collagen vascular disease Portal HTN Congenital heart disease HIV
What are symptoms of PHT?
Exertional SoB
Chest tightness
Exertional presyncope or syncope
What are signs of PHT?
Elevated JVP, RV heave, loud pulmonary 2nd heart sound, hepatomegaly, ankle oedema (due to inc. venous pressure in leg)
What investigations are used in PHT?
ECG, LFTs, CXR, echo, VQ scans, CTPA, right heart catheterisation (allows direct measurement of arteral pressure)
How is PHT managed?
Treat underlying condition Oxygen Anticoagulation Diuretics (if lots of oedema) CCB, e.g. amlodipine Prostacycline (inhibits platelet activation and vasodilator) Phosphodiesterase inhibitors Endothelin receptor antagonists
What surgery might be offered for organised thrombosis?
Thromoendarectomy (CTEPH) resection of organised thrombosis
