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Foundations II (Cholley) > Pulmonary Vasculature > Flashcards

Pulmonary Vasculature Flashcards

1
Q

Define pulmonary HTN

A

Elevation in pulmonary arterial pressure

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2
Q

WHO grouping (5)

A
  1. Pulmonary arterial HTN (PAH) secondary to various disorders
  2. Due to left heart dz
  3. Due to lung dz &/or hypoxia
  4. Due to chronic thromboemboli
  5. Miscellaneous
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3
Q

In pulmonary htn, what is mean pulmonary pressure at rest?

A

> 25

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4
Q

WHO - Group 1

A

Diseases that localize directly to the pulmonary aa –> structural changes, SM hypertrophy, & endothelial dysfxn

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5
Q

What are definite RFs for PAH?

A
  • Appetite suppressants
  • Rapeside oil
  • Benfluorex
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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

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7
Q

WHO - Group 2 includes what conditions?

A
  • LV systolic & diastolic dysfxn
  • Valvular heart dz
  • Congenital/acquired obstruction & CMs
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8
Q

WHO - Group 3 is secondary to what?

A

Lung dz or hypoxemia

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9
Q

What causes lung dz & hypoxemia?

A

Advanced obstructive & restrictive lung disease:

  • COPD
  • ILD
  • Pulmonary fibrosis
  • Bronchiectasis
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10
Q

WHO - Group 4 is secondary to what?

A

Chronic thromboembolism

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11
Q

What classification is no longer included in group 4?

A

Pts w/ non-thrombotic occlusion (tumors, FB)

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12
Q

WHO - Group 5 is secondary to what?

A

Hematologic, systemic, metabolic, or miscellaneous causes

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13
Q

What are examples of hematologic disorders?

A
  • Chronic hemolytic anemia
  • Myeloproliferative disorders
  • Splenectomy
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14
Q

What are examples of systemic disorders?

A
  • Sarcoidosis
  • Vasculitis
  • Neurofibromatosis type 1
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15
Q

What are examples of metabolic disorders?

A
  • Glycogen storage dz
  • Gaucher disease
  • Thyroid disease
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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
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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
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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

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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
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20
Q

What are other signs of pulmonary HTN?

A

Cyanosis due to shunting

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21
Q

How do you dx pulmonary HTN?

A
  • EKG

- Elevated RV systolic pressure on echo

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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
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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

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24
Q

What is the transpulmonary gradient?

A

Drop in pressure across pulmonary circulation

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25
Q

What imaging is used for pulmonary HTN?

A

Radiographs & CTs of chest

- PFTs are useful in determining cause of htn for pts in Group 3

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26
Q

On PFTs, what combo suggests increased pulmonary arterial pressure?

A
  • Decreased single-breath
  • Normal FVC
  • Normal TLC
  • Increased wasted ventilation
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27
Q

What is considered the definitive dx procedure for defining the distribution & extent of disease in chronic thromboembolic pulmonary htn?

A

Pulmonary angiography

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28
Q

What test differentiates chronic thromboembolic pulmonary htn from idiopathic pulmonary arterial htn?

A

V/Q scan

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29
Q

What is 1st line therapy for group 1?

A

CCBs (Diltiazem, nifedipine)

*Should only be given to pts w/ + acute vasodilator response

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30
Q

How do you tx group 3?

A

Supplemental O2 for 15 hrs or more per day

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31
Q

How do you tx group 2 & 5?

A

Treat underlying condition

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32
Q

How do you tx group 4?

A
  • Anticoag

- Thromboendarterectomy if no response to other therapies

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33
Q

What phosphodiesterase 5 inhibitors have been approved for the tx of pulmonary htn?

A
  • Sildenafil

- Tadalafil

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34
Q

What is the MOA of phosphodiesterase 5 inhibitors?

A

cGMP accumulation –> decreased muscular tone

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35
Q

What is contraindicated w/ PDE-5 inhibitors?

A

Any drug serving as a nitric oxide donor

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36
Q

How do you tx the sx of pulmonary htn?

A
  • Diuretics: Furosemide
  • Warfarin (or ASA in children)
  • O2
  • Exercise
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37
Q

Pregnant women w/ PAH, should be tx w/ what?

A

A prostanoid

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38
Q

Define: Cor Pulmonale

A

RV alteration due to pulmonary dz &/or hypoxia that may progress to RV failure

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39
Q

What are the etiologies of cor pulmonale?

A
  • COPD
  • Pulmonary htn
  • idiopathic pulmonary fibrosis
  • thromboembolic disease
  • ARDs
  • Pneumoconiosis or kyphoscoliosis (less common)
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40
Q

Cor pulmonale has ____ pulmonary vasoconstriction & ____ pulmonary vascular bed.

A
  • Increased

- Decreased

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41
Q

Define: pneumoconiosis

A
  • Inhaled dust deposited deep in lungs

- An occupational lung dz

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42
Q

Pneumoconiosis includes what subcategories?

A
  • Coal workers’ pneumoconiosis (black lung dz)
  • Asbestosis
  • Silicosis
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43
Q

In pts w/ COPD, RV volume & fxn differs depending on what?

A

The degree of emphysema

- Greater degree = smaller RV volume & lower RVEF

44
Q

What are sx of cor pulmonale?

A
  • CP
  • Dyspnea, wheezing, cough
  • Palpitations
  • Syncope, pre-syncope
  • Fatigue
  • Edema
  • No sx is 100% specific. Depends on entire picture
45
Q

What are signs of cor pulmonale?

A
  • Cyanosis
  • Clubbing
  • JVD
  • Tricuspid regurg
  • RV heave/gallop
  • Enlarged/tender liver
  • Ascites
46
Q

What is a frequent cause of chest pain? What is it usually described as?

A
  • MI

- Pressure, tightness, squeezing, gas

47
Q

Ischemic sx are 1st noted w/…

A

exercise or cardiac stress

48
Q

What represents unstable angina?

A

Progressive sx or sx @ rest

- Due to plaque rupture or thrombosis

49
Q

CP may be accompanied by what other sx?

A
  • SOB
  • Dizziness
  • Feeling of impeding doom
  • Vagal sx
50
Q

Who has a higher frequency of atypical angina?

A

Women!

- Depression can mask sx

51
Q

The HEART score is composed of what?

A
  • History
  • EKG
  • Age
  • RFs
  • Troponin
52
Q

What is the purpose of the HEART score?

A

Distinguish CP from non-coronary causes

53
Q

In cor pulmonale, what labs are used for dx?

A
  • CBC: Polycythemia present
  • ABG: Hypoxemia +/- hypercarbia
  • BNP
54
Q

What dx test provies an inexpensive noninvasic alternative means for monitoring hemoglobin sat w/ O2?

A

Oximetry

55
Q

What imaging is used for dx of cor pulmonale?

A
  • CXR: enlarged pulmonary artery, dilated R atrium
  • CT
  • Echo
56
Q

What other dx tests are used in cor pulmonale?

A
  • PFT & spirometry
  • Lung biopsy
  • EKG
  • Right heart cath
57
Q

How do you tx cor pulmonale?

A
  • Reverse hypoxia
  • Improve RV contractility
  • CPAP for pts w/ sleep apnea
  • Phlebotomy
  • Longterm O2 for COPD pts
58
Q

What meds are used to tx cor pulmonale?

A
  • Anticoag pts w/ thromboembolic dz
  • Diuretics
  • CCBs, prostacyclin analogues, endothelin-receptor antagonists for PAH
  • Theophylline
59
Q

What is the avg life expectancy for pts w/ cor pulmonale?

A

2-5 yrs

- Those w/ COPD, have 30% chance of survival

60
Q

What is the most common EKG finding for PE? What is considered the “classic” EKG?

A
  • Sinus tach = most common

- S1Q3T3 = classic

61
Q

Define: DVT vs PE

A
  • Both types of VTE
  • DVT: blood clot in deep vein
  • PE: obstruction of pulmonary artery
62
Q

What causes PE?

A

Over 90% are due to emboli originating from LE DVTs

63
Q

What makes up virchows triad?

A
  • Vessel wall injury
  • Venous stasis
  • Hypercoagulability
64
Q

What are RFs for VTE?

A
  • 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
Q

What are sx of DVT?

A
  • Unilateral swollen UE or LE
  • Pain
  • Discoloration
66
Q

What do you see on PE for DVT?

A
  • Tenderness to palpation
  • Erythema
  • SF venous dilation
  • Palpable cord: + Homan’s
67
Q

What are complications of a DVT?

A
  • PE

- Post-thrombophlebitic syndrome (abnormal blood pooling)

68
Q

UE DVT is associated w/ what?

A

Catheter placement

69
Q

What scoring system is used in both DVT & PE?

A

Wells Criteria

70
Q

What labs are used for dx of DVT?

A
  • CBC, BMP
  • PT/INR: measures extrinsic pathway of coagulation
  • aPPT: measures intrinsic pathway of coagulation
  • D-dimer: sensitive but not specific
71
Q

What can cause an elevated d-dimer?

A
  • VTE
  • Post-op states
  • Malignancy
  • Pregnancy
72
Q

What imaging is used for dx of DVT?

A
  • US *Test of choice

- Contrast venography

73
Q

Besides DVT, what else can cause a PE?

A
  • Fat or air emboli
  • Amniotic fluid
  • Talc
  • Parasite
74
Q

Describe: Massive PE

A
  • SBP < 90, or a drop in > 40

- Results in acute RV failure, shock, & possible death

75
Q

Describe: Submassive PE

A

RV dysfxn or myocardial necrosis

76
Q

What are the most common signs & sx of PE?

A
  • SOB or DOE

- Tachypnea

77
Q

What clinical features does the Wells Criteria include?

A
  • 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
Q

If the pt is unstable, how do you tx PE?

A
  • O2
  • IV fluids
  • BP support
  • ICU
  • Consider thrombolytics
79
Q

What labs do you use for dx of PE?

A

Same as DVT! Plus troponin

80
Q

Risk of inherited thrombophilia is greater in those w/…

A
  • Initial thrombosis prior to 50 yo
  • Family hx of VTE
  • Recurrent VTE
  • Hx of warfarin-induced skin necrosis (suggests protein c deficiency)
81
Q

What imaging is used for dx of PE?

A
  • US
  • CXR: Hampton’s hump (pathognomonic for PE), pulmonary wedge sign
  • CTA
  • Echo
82
Q

When is a V/Q scan considered + for PE?

A

If there ≥1 “miss match”

83
Q

What are the advantages of using a CTA for dx of PE?

A
  • Provides direct visualization
  • May provide alternative dx
  • Highly sensitive
  • Accessible
  • Non-invasive
84
Q

What are the disadvantages of using a CTA for dx of PE?

A
  • Interpreter dependent
  • IV contrast
  • May miss subsegmental emboli
85
Q

What is the gold standard dx test used for PE?

A

Angiogram

86
Q

What are the disadvantages of using an angiogram for dx of PE?

A
  • Invasive
  • High contrast
  • Technically demanding
  • Costly
87
Q

What is the initial tx for VTE? What is the MOA?

A

IV unfractionated heparin

  • Inhibits clotting cascade by inactivating thrombin
  • Used w/ warfarin
88
Q

What do you need to monitor in pts on IV unfractionated heparin?

A

CBC, aPTT or Anti-Xa

89
Q

What are side effects of heparin?

A

Bleeding

Thrombocytopenia

90
Q

What is the antidote for heparin?

A

Protamine

91
Q

What is used for outpatient tx of DVT & stable PE? What is the MOA?

A

Low molecular weight heparin (Enoxaparin)

  • Inhibits clotting cascade
  • used w/ warfarin
92
Q

What med is used for long-term tx of VTE?

A

Warfarin (coumadin)

93
Q

What do you need to monitor in pts on warfarin?

A

PT/INR

94
Q

What are side effects of warfarin?

A

Bleeding

Skin necrosis

95
Q

What is the antidote for warfarin?

A

Vitamin K

Fresh frozen plasma (FFP)

96
Q

How long should pts remain on heparin?

A

Min of 5 days or 2 days after INR btwn 2-3.

97
Q

What is the MOA of NOACs?

A

Factor Xa or direct thrombin inhibitor

98
Q

What are the side effects of NOACs?

A
  • Bleeding

- Irreversibility

99
Q

What is the duration of tx for someone w/ 1st VTE?

A

3 months

100
Q

What is the duration of tx for someone w/ 1st idiopathic VTE?

A

3-6 months

101
Q

What is the duration of tx for someone w/ recurrent VTE or inherited coagulopathy?

A

Indefinite

102
Q

What is the MOA of thrombolytics (used in unstable PE)?

A

Ex. streptokinase, urokinase, recombinant tissue plasminogen activator
- Activate plasminogen –> plasmin –> lysis of thrombi

103
Q

What is the name of a mechanical device that is used to remove clots from veins?

A

Thrombectomy/embolectomy

104
Q

When are IV filters indicated?

A
  • Recurrent PE despite anticoagulation
  • Complication of anticoagulation
  • Hemodynamic or respiratory compromise
105
Q

Where are IV filters placed?

A

In IVC

- Prevents DVT from propagating to lungs

106
Q

What are prophylactic measures for VTE?

A
  • SCDs

- TED hose

Foundations II (Cholley) (25 decks)

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