Pulmonary Vasculature Flashcards
1
Q
Define pulmonary HTN
A
Elevation in pulmonary arterial pressure
2
Q
WHO grouping (5)
A
- Pulmonary arterial HTN (PAH) secondary to various disorders
- Due to left heart dz
- Due to lung dz &/or hypoxia
- Due to chronic thromboemboli
- Miscellaneous
3
Q
In pulmonary htn, what is mean pulmonary pressure at rest?
A
> 25
4
Q
WHO - Group 1
A
Diseases that localize directly to the pulmonary aa –> structural changes, SM hypertrophy, & endothelial dysfxn
5
Q
What are definite RFs for PAH?
A
- Appetite suppressants
- Rapeside oil
- Benfluorex
6
Q
WHO - Group 2 is secondary to what? What is it referred to as?
A
L heart dz
- Referred to as pulmonary venous htn or “post-capillary” pulmonary htn
7
Q
WHO - Group 2 includes what conditions?
A
- LV systolic & diastolic dysfxn
- Valvular heart dz
- Congenital/acquired obstruction & CMs
8
Q
WHO - Group 3 is secondary to what?
A
Lung dz or hypoxemia
9
Q
What causes lung dz & hypoxemia?
A
Advanced obstructive & restrictive lung disease:
- COPD
- ILD
- Pulmonary fibrosis
- Bronchiectasis
10
Q
WHO - Group 4 is secondary to what?
A
Chronic thromboembolism
11
Q
What classification is no longer included in group 4?
A
Pts w/ non-thrombotic occlusion (tumors, FB)
12
Q
WHO - Group 5 is secondary to what?
A
Hematologic, systemic, metabolic, or miscellaneous causes
13
Q
What are examples of hematologic disorders?
A
- Chronic hemolytic anemia
- Myeloproliferative disorders
- Splenectomy
14
Q
What are examples of systemic disorders?
A
- Sarcoidosis
- Vasculitis
- Neurofibromatosis type 1
15
Q
What are examples of metabolic disorders?
A
- Glycogen storage dz
- Gaucher disease
- Thyroid disease
16
Q
What are examples of miscellaneous causes for group 5?
A
- Tumor embolization
- External compression of pulmonary vasculature
- End-stage renal disease on dialysis
17
Q
What are signs & sx of pulmonary HTN?
A
- Asx for years
- # 1 = exertional dyspnea
- fatigue/weakness
- CP
- Syncope
- Nonproductive cough
- R ventricular hypertrophy & HF in advanced dz
18
Q
What sx is rare but a life-threatening event for pulmonary HTN? What is it caused by?
A
Hemoptysis
- Caused by rupture of pulmonary artery
19
Q
What is seen on PE for pulmonary HTN?
A
- JVD
- Paradoxical split of S2
- Accentuated pulmonary valve component of the 2nd heart sound
- R sided 3rd heart sound
- Tricuspid regurg murmur (at parasternal line)
- Strong R. ventricular impulse
- Hepatomegaly, abdominal distension, & ascites
- LE edema
20
Q
What are other signs of pulmonary HTN?
A
Cyanosis due to shunting
21
Q
How do you dx pulmonary HTN?
A
- EKG
- Elevated RV systolic pressure on echo
22
Q
What can you use for dx of pulmonary HTN?
A
- Routine blood work
- Arterial blood gas
- Sleep study
- Screening for HIV & collagen vascular dz
23
Q
What is the gold standard for dx of pulmonary htn? When should you perform this?
A
R-sided cardiac cath
- Perform prior to initiation of advance therapies
24
Q
What is the transpulmonary gradient?
A
Drop in pressure across pulmonary circulation
25
What imaging is used for pulmonary HTN?
Radiographs & CTs of chest
| - PFTs are useful in determining cause of htn for pts in Group 3
26
On PFTs, what combo suggests increased pulmonary arterial pressure?
- Decreased single-breath
- Normal FVC
- Normal TLC
- Increased wasted ventilation
27
What is considered the definitive dx procedure for defining the distribution & extent of disease in chronic thromboembolic pulmonary htn?
Pulmonary angiography
28
What test differentiates chronic thromboembolic pulmonary htn from idiopathic pulmonary arterial htn?
V/Q scan
29
What is 1st line therapy for group 1?
CCBs (Diltiazem, nifedipine)
| *Should only be given to pts w/ + acute vasodilator response
30
How do you tx group 3?
Supplemental O2 for 15 hrs or more per day
31
How do you tx group 2 & 5?
Treat underlying condition
32
How do you tx group 4?
- Anticoag
| - Thromboendarterectomy if no response to other therapies
33
What phosphodiesterase 5 inhibitors have been approved for the tx of pulmonary htn?
- Sildenafil
| - Tadalafil
34
What is the MOA of phosphodiesterase 5 inhibitors?
cGMP accumulation --> decreased muscular tone
35
What is contraindicated w/ PDE-5 inhibitors?
Any drug serving as a nitric oxide donor
36
How do you tx the sx of pulmonary htn?
- Diuretics: Furosemide
- Warfarin (or ASA in children)
- O2
- Exercise
37
Pregnant women w/ PAH, should be tx w/ what?
A prostanoid
38
Define: Cor Pulmonale
RV alteration due to pulmonary dz &/or hypoxia that may progress to RV failure
39
What are the etiologies of cor pulmonale?
- COPD
- Pulmonary htn
- idiopathic pulmonary fibrosis
- thromboembolic disease
- ARDs
- Pneumoconiosis or kyphoscoliosis (less common)
40
Cor pulmonale has ____ pulmonary vasoconstriction & ____ pulmonary vascular bed.
- Increased
| - Decreased
41
Define: pneumoconiosis
- Inhaled dust deposited deep in lungs
| - An occupational lung dz
42
Pneumoconiosis includes what subcategories?
- Coal workers' pneumoconiosis (black lung dz)
- Asbestosis
- Silicosis
43
In pts w/ COPD, RV volume & fxn differs depending on what?
The degree of emphysema
| - Greater degree = smaller RV volume & lower RVEF
44
What are sx of cor pulmonale?
- CP
- Dyspnea, wheezing, cough
- Palpitations
- Syncope, pre-syncope
- Fatigue
- Edema
* No sx is 100% specific. Depends on entire picture
45
What are signs of cor pulmonale?
- Cyanosis
- Clubbing
- JVD
- Tricuspid regurg
- RV heave/gallop
- Enlarged/tender liver
- Ascites
46
What is a frequent cause of chest pain? What is it usually described as?
- MI
| - Pressure, tightness, squeezing, gas
47
Ischemic sx are 1st noted w/...
exercise or cardiac stress
48
What represents unstable angina?
Progressive sx or sx @ rest
| - Due to plaque rupture or thrombosis
49
CP may be accompanied by what other sx?
- SOB
- Dizziness
- Feeling of impeding doom
- Vagal sx
50
Who has a higher frequency of atypical angina?
Women!
| - Depression can mask sx
51
The HEART score is composed of what?
- History
- EKG
- Age
- RFs
- Troponin
52
What is the purpose of the HEART score?
Distinguish CP from non-coronary causes
53
In cor pulmonale, what labs are used for dx?
- CBC: Polycythemia present
- ABG: Hypoxemia +/- hypercarbia
- BNP
54
What dx test provies an inexpensive noninvasic alternative means for monitoring hemoglobin sat w/ O2?
Oximetry
55
What imaging is used for dx of cor pulmonale?
- CXR: enlarged pulmonary artery, dilated R atrium
- CT
- Echo
56
What other dx tests are used in cor pulmonale?
- PFT & spirometry
- Lung biopsy
- EKG
- Right heart cath
57
How do you tx cor pulmonale?
- Reverse hypoxia
- Improve RV contractility
- CPAP for pts w/ sleep apnea
- Phlebotomy
- Longterm O2 for COPD pts
58
What meds are used to tx cor pulmonale?
- Anticoag pts w/ thromboembolic dz
- Diuretics
- CCBs, prostacyclin analogues, endothelin-receptor antagonists for PAH
- Theophylline
59
What is the avg life expectancy for pts w/ cor pulmonale?
2-5 yrs
| - Those w/ COPD, have 30% chance of survival
60
What is the most common EKG finding for PE? What is considered the "classic" EKG?
- Sinus tach = most common
| - S1Q3T3 = classic
61
Define: DVT vs PE
* Both types of VTE
- DVT: blood clot in deep vein
- PE: obstruction of pulmonary artery
62
What causes PE?
Over 90% are due to emboli originating from LE DVTs
63
What makes up virchows triad?
- Vessel wall injury
- Venous stasis
- Hypercoagulability
64
What are RFs for VTE?
- Recent surgery (within last 3 months)
- Immobilization/prolonged bed rest
- Pregnancy
- Malignancy
- Hypercoagulable states: Factor V & prothrombin mutation
- Use of contraceptives or HRT
- LE trauma
- Prior episode
65
What are sx of DVT?
- Unilateral swollen UE or LE
- Pain
- Discoloration
66
What do you see on PE for DVT?
- Tenderness to palpation
- Erythema
- SF venous dilation
- Palpable cord: + Homan's
67
What are complications of a DVT?
- PE
| - Post-thrombophlebitic syndrome (abnormal blood pooling)
68
UE DVT is associated w/ what?
Catheter placement
69
What scoring system is used in both DVT & PE?
Wells Criteria
70
What labs are used for dx of DVT?
- CBC, BMP
- PT/INR: measures extrinsic pathway of coagulation
- aPPT: measures intrinsic pathway of coagulation
- D-dimer: sensitive but not specific
71
What can cause an elevated d-dimer?
- VTE
- Post-op states
- Malignancy
- Pregnancy
72
What imaging is used for dx of DVT?
- US *Test of choice
| - Contrast venography
73
Besides DVT, what else can cause a PE?
- Fat or air emboli
- Amniotic fluid
- Talc
- Parasite
74
Describe: Massive PE
- SBP < 90, or a drop in > 40
| - Results in acute RV failure, shock, & possible death
75
Describe: Submassive PE
RV dysfxn or myocardial necrosis
76
What are the most common signs & sx of PE?
- SOB or DOE
| - Tachypnea
77
What clinical features does the Wells Criteria include?
- Active cancer
- Paralysis, paresis, recent immobilization of LE
- Recently bedridden or major surgery w/in 4 wks
- Localized tenderness along deep venous system
- Entire leg swollen
- Calf swelling > 3cm when compared to asx LE
- Pitting edema
- Collateral SF veins
*Alternative dx likely or more likely than DVT (subtract 2 points)
78
If the pt is unstable, how do you tx PE?
- O2
- IV fluids
- BP support
- ICU
- Consider thrombolytics
79
What labs do you use for dx of PE?
Same as DVT! Plus troponin
80
Risk of inherited thrombophilia is greater in those w/...
- Initial thrombosis prior to 50 yo
- Family hx of VTE
- Recurrent VTE
- Hx of warfarin-induced skin necrosis (suggests protein c deficiency)
81
What imaging is used for dx of PE?
- US
- CXR: Hampton's hump (pathognomonic for PE), pulmonary wedge sign
- CTA
- Echo
82
When is a V/Q scan considered + for PE?
If there ≥1 “miss match”
83
What are the advantages of using a CTA for dx of PE?
- Provides direct visualization
- May provide alternative dx
- Highly sensitive
- Accessible
- Non-invasive
84
What are the disadvantages of using a CTA for dx of PE?
- Interpreter dependent
- IV contrast
- May miss subsegmental emboli
85
What is the gold standard dx test used for PE?
Angiogram
86
What are the disadvantages of using an angiogram for dx of PE?
- Invasive
- High contrast
- Technically demanding
- Costly
87
What is the initial tx for VTE? What is the MOA?
IV unfractionated heparin
- Inhibits clotting cascade by inactivating thrombin
- Used w/ warfarin
88
What do you need to monitor in pts on IV unfractionated heparin?
CBC, aPTT or Anti-Xa
89
What are side effects of heparin?
Bleeding
| Thrombocytopenia
90
What is the antidote for heparin?
Protamine
91
What is used for outpatient tx of DVT & stable PE? What is the MOA?
Low molecular weight heparin (Enoxaparin)
- Inhibits clotting cascade
- used w/ warfarin
92
What med is used for long-term tx of VTE?
Warfarin (coumadin)
93
What do you need to monitor in pts on warfarin?
PT/INR
94
What are side effects of warfarin?
Bleeding
| Skin necrosis
95
What is the antidote for warfarin?
Vitamin K
| Fresh frozen plasma (FFP)
96
How long should pts remain on heparin?
Min of 5 days or 2 days after INR btwn 2-3.
97
What is the MOA of NOACs?
Factor Xa or direct thrombin inhibitor
98
What are the side effects of NOACs?
- Bleeding
| - Irreversibility
99
What is the duration of tx for someone w/ 1st VTE?
3 months
100
What is the duration of tx for someone w/ 1st idiopathic VTE?
3-6 months
101
What is the duration of tx for someone w/ recurrent VTE or inherited coagulopathy?
Indefinite
102
What is the MOA of thrombolytics (used in unstable PE)?
Ex. streptokinase, urokinase, recombinant tissue plasminogen activator
- Activate plasminogen --> plasmin --> lysis of thrombi
103
What is the name of a mechanical device that is used to remove clots from veins?
Thrombectomy/embolectomy
104
When are IV filters indicated?
- Recurrent PE despite anticoagulation
- Complication of anticoagulation
- Hemodynamic or respiratory compromise
105
Where are IV filters placed?
In IVC
| - Prevents DVT from propagating to lungs
106
What are prophylactic measures for VTE?
- SCDs
| - TED hose
