Pulmonary vascular disease + thromboembolic disease

Question 1

What are the causes of pulmonary venous hypertension?

Answer 1

causes are cardiac:
LV hypertrophy (most common)
Mitral regurgitation or stenosis
cardiomyopathy
these cause a build up of pressure on the left atrium which creates a bag pressure on the pulmonary venous system

Question 2

What are the causes of pulmonary arterial hypertension?

Answer 2

• HYPOXIA (main cause) - can be due to COPD, obstructive sleep apnoea, fibrosing alveolitis
• multiple pulmonary emboli
• pulmonary vasculitis eg. due to SLE, systemic sclerosis
• drugs eg appetite lowering drugs (amphetamines)
• cardiac left to right shunt - VSD, ASD
• primary pulmonary hypertension = idiopathic

Question 3

What are the signs of pulmonary hypertension?

Answer 3

• if the cause is hypoxia - central cyanosis
• peripheral oedema
• raised JVP secondary to tricuspid regurgitation (due to RV hypertrophy)
• RV heave at left parasternal edge
• tricuspid regurgitation murmur
• large (pulsatile) liver - due to back pressure on systemic venous system

Question 4

What are some causes of hypercoagulability?

Answer 4

Genetic
physiological eg pregnancy
oral contraceptive pill (risk of DVT directly proportional to oestrogen levels)
malignancy
post MI

Question 5

What is the clinical presentation of DVT?

Answer 5

hot, swollen, red calf/leg

may be silent

Question 6

What are the differential diagnoses for DVT?

Answer 6

popliteal synovial rupture, superficial thrombophlebitis, cellulitis (inflammation of subcutaneous tissue)

Question 7

What investigations can you do for a DVT?

Answer 7

Doppler ultrasound of leg

D-dimers

Question 8

What investigations can you do for PE?

Answer 8

ECG, V/Q scan, CT pulmonary angiogram, echo, CXR, D-dimer, ABGs (look for hypoxia/hypercapnia)

Question 9

What are the signs of PE?

Answer 9

tachycardia, tachypnoea, low PB, crackles, rub, pleural effusion, ABGs show low PO2, low SaO2 and normal PCO2 (type 1 respiratory failure)

Question 10

What are the clinical presentations of PE?

Answer 10

Large: shock (obstructive), low BP, central cyanosis sudden death
Moderate: haemoptysis, pleuritic chest pain, SOB
Small recurrent: progressive dyspnoea, pulmonary hypertension, right ventricular failure

Question 11

What is the treatment for PE?

Answer 11

If it is a massive PE, give immediate thrombolysis or consider sending for surgery
otherwise, start anticoagulation with LMWH eg. fragmin (the body will break down the clot) and warfarin. Warfarin will take 2-3 days to take effect - continue heparin with warfarin until the INR > 2 then stop heparin. Continue warfarin for 3-6 months - aim for INR 2-3.

Question 12

How do you prevent PE?

Answer 12

Give heparin to all immobile patients
Surgery - Compression stockings and early mobilization
Stop HRT and the Pill before surgery
Calf muscle exercises
Low does LMWH peri-operatively