pulmonary vasculature Flashcards
what MAP classifies pulmonary HTN?
> 25mm Hg at rest
differentiate primary pulmonary HTN from secondary pulmonary HTN
primary: 30-40 y/os, familial, unknown etiology
secondary: RHF from COPD, PE, sickle cell, HIV, cirrhosis, portal hypertension, appetite suppressive medication
what are drugs and toxins that could cause pulmonary arterial hypertension (Group 1)?
appetite suppressants, rapeseed oil and benfluorex (definite)
amphetamines
cocaine
SSRIs
what are causes of pulmonary venous hypertension (Group 2)
left heart disease
LV systolic/diastolic dysfunction
valvular heart disease
What is the most common cause of group 3 pulmonary hypertension?
COPD (lung disease or hypoxemia)
what is the most common cause of group 4 pulmonary HTN?
chronic thromboembolism
what are the causes of group 5 pulmonary arterial HTN?
hematologic
metabolic
systemic (sarcoidosis)
miscellaneous (tumor embolization, ESRD on HD)
what are the classes of pulmonary HTN per NYHA based on symptoms and functional status?
class I: no limitation of physical activity, no symptoms class II: pulm HTN slight limitation and ordinary physical activity causes dyspnea, fatigue, chest pain, or near syncope class III: pulm HTN marked limitation of physical activity and no symptoms at rest but less than ordinary activity class IV: pulm HTN with inability to perform physical activity, evidence of RHF, dyspnea and fatigue at rest
what is the number one sign and symptom of pulm HTN?
exertional dyspnea
what is a classic sign after exertion or warm shower with pulmonary HTN?
syncope
what may you see on physical exam for pulm HTN?
JVD paradoxical split of S2 loud P2 of S2 right-sided third heart sound tricuspid regurgitation murmur (holosystolic) heard along the LSB hepatomegaly ascites abdominal distension lower extremity edema
what is carvallo’s sign?
a louder murmur heard from inspiration with tricuspid regurgitation
what sign occurs from shunting?
cyanosis from right-to-left shunt due to increased right atrial pressure
what would you see on EKG with pulm HTN?
typically normal
may see peaked P wave in the inferior and right-sided leads
what might you see on the ABGs for pulm HTN?
low PaO2 and SaO2
what is the gold standard for diagnosing pulm HTN?
right-sided cardiac catheterization
what is the transpulmonary gradient
drop in pressure across the pulmonary circulation which can be assessed by cardiac catheterization in order to differentiate arterial hypertension from venous hypertension
what is considered a significant acute vasodilator response with right heart cath?
drop in MAP of greater than 10 mm Hg (or 20%) to less than 40 mm Hg
what findings on PFTs is suggestive of pathologically increased pulmonary arterial pressure?
decreased single-breath diffusing capacity
normal FVC on spirometry
normal TLC on lung volume measurement
increased wasted ventilation on cardiopulmonary exercise
what diagnostic test would be used for group 4 pulmonary HTN?
pulmonary angiography - most definitive diagnostic procedure for defining the distribution and extent of disease in chronic thromboembolic pulmonary HTN
how would you treat group 1 PAH?
treat underlying cause
no primary therapies available
could try diltiazem or nifedipine, but only give to pts with positive acute vasodilator response
what are you treating in group 2 PVH?
treat left heart failure
how are you treating in group 3 PH?
supplemental O2 for 15 hours or more per day
how do you treat group 4 PH?
anticoagulation thromboendarterectomy recommended if surgically accessible for pts with class IV and have no response to other therapies
how do you treat group 5 PH?
treat underlying etiology
if pt is class I with PH, and no acute vasodilator response, how do you treat?
observation
if pt is class II with PH, and no acute vasodilator response, how do you treat?
ambrisentan plus tadalafil
if pt is class III with PH, and no acute vasodilator response, how do you treat?
ambrisentan plus tadalafil
if pt is class IV with PH, and no acute vasodilator response, how do you treat?
epoprostenol IV
what are examples of PDE5 inhibitors?
sildenafil and tadalafil
what is a C/I to PDE-5 inhibitors?
concomitant use of PDE-5 inhibitors with any drug serving as a NO donor, which can lead to significant arterial hypotension
what are examples of ERAs? (endothelin receptor antagonists)
ambrisentan (selective ETa receptor antagonist)
bosentan (dual endothelin receptor antagonist)
what are examples of prostacyclins?
epoprostenol
treprostinil
never stop _______ in chronic patients suddenly
prostacyclins
what medications are used in treating the symptoms of pulmonary HTN?
furosemide for swelling
warfarin (ASA in children) for preventing blood clots in lungs
O2
exercise
Cor pulmonale is most commonly caused by?
COPD
define pneumoconiosis
general term given to any lung disease caused by inhaled dust deposited deep in the lungs
Severe lung disease can be a cause of ______
low cardiac output
RV volume and function differed depending on the degree of ______ present in pts with COPD
emphysema
what are symptoms of cor pulmonale?
chest pain exertional dyspnea wheezing cough palpitations fatigue syncope or pre-syncope dependent edema *no symptom is 100% specific
what are signs of cor pulmonale?
cyanosis clubbing JVD tricuspid regurg RV heave and/or gallop RUQ pain ascites
give details of cardiac chest pain
accompanied by a sense of anxiety or uneasiness
retrosternal or left precordial
pressure to the throat, lower jaw, shoulders, inner arms, upper abdomen or back
feeling of impending doom
nausea
diaphoresis
what does the HEART score stand for and what is its purpose?
History EKG Age Risk factors Troponin *helps distinguish coronary chest pain in ED from non-coronary causes
what will you see in vitals with cor pulmonale?
SpO2 decreased
may see elevated CVP
what labs will you see in cor pulmonale?
polycythemia (CBC)
hypoxemia +/- hypercarbia (ABG)
oximeter monitors __________ and not oxygen tension
hemoglobin saturation
what will you see on the CXR for cor pulmonale?
pulmonary artery enlarged
right atrium dilated
what do you see in right heart cath for cor pulmonale?
increased pulmonary artery pressure
increased vascular resistance
what are the treatments for cor pulmonale?
CPAP for sleep apnea anticoagulation for blood clots long-term O2 for hypoxic COPD pts diuretics for RV volume overload CCBs, prostacyclin analogues and ERAs for PAH
what is the most common EKG finding for PE?
sinus tachycardia
differentiate DVT vs PE
DVT is a blood clot in a deep vein
PE is an obstruction of the pulmonary artery or one of its branches by material that originated elsewhere in the body
what does virchow’s triad consist of?
vessel wall injury
venous stasis
hypercoagulability
what is the most common risk factor for VTE (venous thromboemoblisms)
recent surgery (within last 3 months) due to virchow's triad hip fracture repair most common
what are the two most common hypercoagulable states with VTEs?
factor V leiden mutation
prothrombin gene mutation
the use of _____ or _____ increases your risk for VTEs
oral contraceptives or hormone replacement therapy
what are other risk factors for VTEs?
antithrombin III deficiency catheters CHF COPD drug-induced lupus anticoagulant immobilization postpartum period pregnancy protein C/S deficiency trauma venous stasis warfarin
what may you see on physical exam for DVT?
swollen, discolored UE/LE
tenderness to palpation
superficial venous dilation
positive homan’s sign (calf tenderness with dorsiflexion of foot)
what are complications of DVT?
PE
post-thrombophlebitic syndrome
what risk factor is commonly associated with UE DVT?
catheter placement
what is the purpose of Wells criteria and what do different scores mean?
tells you the probability of having a DVT
0 or less = low
1-2 moderate
3 or more = high
what is a highly sensitive test for DVT diagnosing?
D-dimer
what are causes of elevated D-dimer?
DVT PE post-operative state malignancy pregnancy
what is the test of choice in imaging for DVTs?
compression ultrasonography (US)
what is the most common cause of PE?
DVT
what are the three PE classifications for hemodynamic effect?
massive PE (SBP <90 or drop in SBP > 40 from baseline for a period > 15 min; go into obstructive shock)
submassive PE
nonmassive
what are the major S&S of PE?
SOB or DOE
plueritic pain
tachypnea
Wells criteria better for PE or DVT?
PE
use US for DVT
list the Wells criteria
clinical symptoms of DVT other dx less likely than PE HR > 100 immobilization >3 days or previous sx in past 4 weeks previous VTE hemoptysis malignancy
how to treat a stable vs unstable pt with PE?
stable - proceed with further diagnostic work-up
unstable - oxygen, IV fluids, BP support, ICU, consider thrombolytics
what labs do you get for PE?
same as DVT CBC/BMP PT/INR aPPT D-dimer
what cardiac biomarker may be increased in pt with PE?
troponin
what are most common EKG findings with PE?
sinus tachycardia
non-specific T wave changes
what is the “classic” EKG with PE?
S1Q3T3
US and CXR are _____ for PE
non-diagnostic
define Hampton’s Hump
CXR finding specific to PE
pleura-based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface
define Pulmonary Wedge Sign
10% of PE cause pulmonary infarction, resulting in wedge sign
what is a positive V/Q Scan?
scan is + if there is 1 or more “mismatch”
what is the most common way to diagnose PE?
CTA - diagnostic when intraluminal pulmonary arterial filling defect is surrounded by contrast
what is the gold standard for diagnosing PE?
angiogram - reserved for pts who have had non-diagnostic tests for PE and treatment with anticoagulants is controversial
what may you find on an echo with PE?
RV dilatation, hypokinesis or failure
increased RV pressure
marked tricuspid regurgitation
what are the main treatments of VTE?
IV/oral anticoagulants
thrombolytics
what are the types of anticoagulants?
IV unfractionated heparin LMWH fondaparinux warfarin NOACs
which anticoagulant do you give in initial treatment of VTE?
IVUH
how do we reverse IVUH?
protamine
what are we monitoring in IVUH?
CBC, aPTT, anti-Xa
what is the indication for LMWH (lovenox)?
outpatient tx of DVT and stable PE
do you monitor LMWH?
no
what reverses LMWH?
protamine
which populations is LMWH indicated for?
CrCl <30, elderly, obese
what is warfarin indicated for?
long-term treatment of VTE
what do you monitor in warfarin?
PT/INR
what is the therapeutic INR range?
2.0-3.0
how to reverse warfarin?
vitamin K, fresh frozen plasma
pt should remain on heparin a minimum of _____ days or ____ days after their INR is therapeutic
5 days
2 days
what is the indication for NOACs?
DVT/PE and nonvalvular Afib
which of the NOACs can do dialyses?
dabigatran (pradaxa)
how long should the duration of tx be for VTEs?
1st VTE if provoked: 3 months
1st idiopathic VTE: 3-6 months
recurrent VTEs: indefinite
thrombolytics used for ______ with PE
unstable pts examples: massive PE/cardiogenic shock severe hypoxemia substantial perfusion deficit on V/Q scan RV dysfunction extensive DVT
what are examples of thrombolytics?
streptokinase
urokinase
r-tPA
what are the indications for doing IVC filters?
absolute C/I to anticoagulation
recurrent PE despite adequate anticoagulation
complication of anticoagulation
hemodynamic or respiratory compromise
what are prophylactic measures against DVTs?
sequential compression devices (SCDs) TED hose (thromboembolic deterrent) low dose SQ heparin and lovenox in hospital
can a clinically stable pt with DVT or PE be treated as an outpatient?
yes, lovenox or NOACs are appropriate for outpt treatment of DVT and stable PE
who is responsible for monitoring pt’s anticoagulation?
PCP, cardiologist, or anticoagulation clinic
