Pulmonary Vascular Disease (Embolism & Hypertension)

Question 1

describe what a pulmonary embolism is.

Answer 1

its when a thrombus forms in a systemic vein then travels through the venous system to the pulmonary artery. This causes a blockage in the major pulmonary artery in the lung - an embolism.

Question 2

what is a common place for clots to form and why?

Answer 2

the legs because of the low flow system in deep veins.

Question 3

what are the major risk factors for a pulmonary embolism?

Answer 3

recent surgery (orthopaedic & abdominal)
recent major trauma
cancer (releases pro co-agulants)
inherited thrombophillia (factor V leiden)
pregnancy (foetus may lean on major vessels causing increased pressure therefore decreased flow)
significant cardiopulmonary disease i.e. MI

Question 4

what are the symptoms for a small thrombus?

Answer 4

cough
haemoptysis
pleuritic chest pain

Question 5

explain why small clots cause such symptoms.

Answer 5

small clots cause infarction of that area of the lung. the dead tissue causes inflammation of the surface of the lung causing the pleuritic pain.
Cough up blood as there is bleeding into the tissue which can reach the bronchial tree.

Question 6

what are the symptoms for many small clots?

Answer 6

isolated acute breathlessness

Question 7

explain why patients with multiple small emboli present with such symptoms.

Answer 7

many small emboli cause a ventilation perfusion mismatch therefore causing breathlessness as there isn’t enough oxygen getting into the lungs. the patient may also become hypoxic due to this mis match.

Question 8

wha are the symptoms for a massive embolism?

Answer 8

syncope, collapse, cardiac arrest, MI

Question 9

explain why patients with a massive pulmonary embolism present with such symptoms.

Answer 9

a massive embolism lodges into the main pulmonary artery and results in a loss of cardiac output. therefore no blood is being pumped to the organs or the brain.

Question 10

what are the signs on examination of a patient:

1) with a small embolism?
2) many small emboli?
3) a massive embolism?

Answer 10

1) Pleural rub , pyrexia, may have a stony dullness on percussion at base if they have a pleural effusion.

2) tachypnoea, tachycardia and hypoxia
3) hypoxia, tachycardia, tachypnoea, hypotension

Question 11

explain the 3 steps in the diagnosis of a pulmonary embolism.

Answer 11

1- severe risk factors
2- pre test susceptibility i.e. Wells and revised Geneva score
3- Investigations: chest Xray, full blood count, Echocardiograph, ECG, D-dimer, CT pulmonary angiography, thrombophillia testing, V/Q scan , CT abdomen and mammography

Question 12

What is the prognosis with a pulmonary embolism?

Answer 12

mortality rate after 30 days is 0-25%
(survival after 30 days is 75-100%)
PESI sure used to assess severity and to see how long patients need monitoring in hospital etc.

Question 13

what are the treatments for pulmonary embolism?

Answer 13

high flow oxygen
Anti co-agulants: Low molecular weight heparin (Dalteparin) , maybe warfarin
Direct oral anti coagulants (DOAC) i.e. Rivaroxiban and Apixaban
Thrombolysis therapy
Thrombectomy (rarely used now)
IV fluids and inotropic agents for severe patients who need to improve pumping of right heart.

Question 14

what is pulmonary hypertension?

Answer 14

elevated blood pressure in the pulmonary arterial tree.

Question 15

what value indicates high blood pressure?

Answer 15

pressure > 25 mmHg

Question 16

describe the epidemiology of pulmonary hypertension.

Answer 16

primary - rare. occurs in 1-2 per million of population.

secondary- more common. mostly in the older population

Question 17

what is aetiology of pulmonary hypertension?

Answer 17

idiopathic
secondary to chronic respiratory disease
secondary to left heart disease
secondary to a thromboembolism (CTPH)
other causes i.e. collagen vascular disease, portal hypotension, congenital heart disease, HIV.

Question 18

what are the symptoms of pulmonary hypertension?

Answer 18

exersional dyspnoea
tight chest
syncope

Question 19

what are the clinical signs of pulmonary hypertension?

Answer 19

elevated jugula venous pressure
right ventricular heave
loud pulmonary second heart sounds
hepatomegaly
ankle oedema

Question 20

what investigations will be carried out in the diagnosis of pulmonary hypertension?

Answer 20

ECG, lung function tests, Chest X ray, echocardiograph, V/Q scan, CTPA, right heart catheterisation.

Question 21

why is right heart catheterisation useful in the diagnosis of pulmonary hypertension?

Answer 21

it allows direct measurement of the pulmonary arterial pressure by direct measurement of the wedge pressure and cardiac output.

Question 22

what is the general and specific treatment for pulmonary hypertension?

Answer 22

general treatment - 
treat underlying condition
oxygen
anti coagulants
diuretics

specific treatment- 
calcium channel antagonist,
prostacyclin
endothelia receptor antagonists
phosphodiesterase inhibitors

other therapies -
thrombendarterectomy
lung or heart transplant

Question 23

What is the virchows triad?

Answer 23

The 3 categories of factors which contribute to thrombosis;
1- reduced blood flow
2- abnormal vessels
3- hypercoagubility