Vascular Flashcards
PE definition
Obstruction part or entire part pulmonary artery
60 per 100,000
100 deaths per million
PE aetiology
75% DVT
MI
Paradoxical embolus
Septic embolism eg central line or sbe
PE risk factors
Major
Surgery
Pregnancy or post partum
Malignancy
Varicose veins
Flight
Previous
Minor
CHF htn
Central line
OCP
Neurodegenrative
Myeloproliferative
Obese
IBD
Nephrotic syndrome
Bender
PE presentation
Acute pain cough Haemoptysis collapse 30% die
Chronic sob collapse af RHF pleural effusion
OE
Tachycardia
AF
Pleural rub
Loud P2
Hypoxia raised A-a
Fever
DVT
RHF and reduced CO Low venous
Haemodynamic effects PE
Pulmonary artery occluded
Raised PAP
Raised RV diastolic pressure
RHF
Reduced blood to PA
Reduced LV preload
Reduced systemic blood flow and hence coronary blood flow
Death
Hypoxia
1) Reduced CO
Low venous pao2 to KHPoor oxygenation
2) VQ mismatch
3) R to L shunt in 1/3 due to PFO
Hypoxia out of proportion PE extent
PE presentation
Acute pain cough Haemoptysis collapse 30% die
Chronic sob collapse af RHF pleural effusion
OE
Tachycardia
AF
Pleural rub
Loud P2
Hypoxia raised A-a
Fever
DVT
RHF and reduced CO
D dimer
Over 50 use age cutoff
High NPV
Increased large PE
Massive PE Ix
Raised trop and bnp
CTPA
Clot extent eg saddle
Rv dilation or reflux contrast Ivc or rv clot
Echo
TAPSE less than 16
RV to LV more than 1 is mcconnells sign
Flat septum
Distended ivc
TVV more than 3.6
R heart thrombus
Throbophilia scree indication PE
Recurrent VTE
Less than 40
Pregnant or OCP or hurt
Cerebral or mesenteric or portal vein
PE ix
Wells score less than 4 low
D dimer raised then ctpa or VQ vs low then alternative
High risk ctpa and if positive treat if negative no treatment
PESI identifies 30d mortality
Age number
Sex 10
Cancer 30
HF 10
CLD 10
HR over 110 is 20
SBP less than 100 is 30
RR over 30 is 20
T less than 36 is 20
Reduced GCS is 60
Sats less than 90 is 20
Very low less than 65
Low 66-85 low
Intermediate 86-105
High 106-123
V high over 123
Simplified
Age over 80
Cancer
Cp disease
Hr over 110
SBP less than 100
Sats less than 90
PE severity tx
4 strata
High
Unstable
PESI 3-5
RV dysfunction
Raised trop
Intermediate High
Stable
PESI 3-5
Rv dysfunction
Raised trop
Intermediate low
Stable
PESI 3-5
Rv dysfunction OR raised trop
Low
Stable
PESI 1-2
No rv dysfunction
Normal trop
Stable in PE
SBP less than 90
Drop 40mmhg
End organ hypoperfusion eg oliguria or raised lactate or deranged lft or drowsy
Ambulation
Yes
Low less
Written info
Access HCP
Info on ooh contact
Not suitable
Sats less than 90
SBP <100
Chest pain despite opiates
Bleeding
Over 150 kg
HIIT
Circle less than 30
INR2 at diagnosis
Barrier ambulation
Management PE
Intermediate and High
Anticoagulants pre ctpa
Confirm decision DOAG depending on stability
AC UFH vs LMWH
UFH egfr less than 30/pre procedure/high risk bleed
Low risk early discharge and home on DOAG 3m (Apix then rvx, cancer or over 180kg esp GIT then lmwh and check anti xa)
Unstable
Intermediate low LMWH then D3 doag
Intermediate High LMWH then D3 doag
High thrombolysis then D5 doag
Warfarin
Antiphos or V Leiden or protein C or S def
Renal failure
INR 2-3
DOAG
Dabigatran thrombin inhx or xa rest
Good no labs / reduced interaction/ prevent recurrence/ reduced bleeding
X not for renal failure / not BF or pregnancy
Management of high risk PE
O2 to correct VQ and shunt
IVF gentle 500ml in 30m
Thrombolysis
Avoid intubation
Vasopressin NA or dobutamine
VA Ecmo cardiac arrest or max support deteriorating
Thrombolysis
Indication large PE + high risk or int high
Risk
10% major bleeding .2% ICH
Contra indication ABSOLUTE
Internal bleeding
Cva 3m
SOL or spinal injury
Prev ich
Coagulopathy
Trauma or surgery or head injury 3w
CI relative
Over 65
TIA 6m
By over 180/110
Oral AC
Pregnancy or 1week pp
Non compressive puncture or recent sx
Cva over 3m
Traumatic resuscitation
Liver disease
SBE
Peptic ulcer
Pericardial effusion
Diabetic retinopathy
Greatest benefit first 2d but up to 6-14d
Evidence thrombolysis reduced mortality 7d and rv perfusion
Alternative
Catheter directed thrombectomy indication failed thrombolysis
vs surgery ecmo failed thrombolysis/thrombectomy or CI
IVC filter indication failed thrombolysis and thrombectomy or CI or recurrent on AC or AC CI
Ivc filter con no change recurrence or survival, penetration, migration
Poor prognosis PE
SBP<90
RR>20
Cancer
PH definition
mPAP over 20
Dx RHC
PVR= (mPAP- pawn) / CO
RVSP measure estimate mPAP
4(TRV squared) + RAP
On echo
(0.61x PASP) +2 is mPAP estimate
Pathogenesis PH
Intimimal proliferation
Vasoconstriction and remodel pa vessel wall
Medial hypertrophy PA and fibrosis
PLEXIFORM LESIONS HALLMARK PAH - proliferation endothelial cells form plexus at arterial branching point
Thrombosis
RHF
Reduced NO
Reduced prostacyclin
Increased thromboxane A2
Endothelin
Presentation PH
Clinical
Exertional sob
Chest pain
Fatigue
Syncope late
Palpitations
Peripheral oedema
Examination
RV heave and thrill
S3
Split S2
TR
Raised JVP
Ascites oedema
Cyanosis
Systemic sclerosis or clubbing
Groups
G1 idiopathic genetic drugs CTD HIV CKD schisto VOD
G2 LHD
G3 lung
G4 cteph angiosarcoma PA stenosis parasite
G5 haem LAM metabolic
Pre capillary 1 3 4 5
Wedge less than equal 14
PVR >2
Post capillary 2
Wedge >=15
PVR less than 3
If 10-15 give bolus 500ml and if wedge above 15 then lhd
Pre cap
Low normal CO 1/3/4/5
High consider left to right shunt eg asd or vsd or pda
CpcPH
Wedge >15 and pvr >2
Ix PH
Bloods tsh ace ANCA anti sc70 RhF dsDNA trop bnp
Cxr en,argued PA/ large heart/ loss peripheral vessels
ECG rad rbbb Rvh
ABG hypoxia
Restrictive reduced TLCO
HRCT exclude lung
Vq cteph
Echo
En,argued RV so RV/LV more than 1
Flat septum
Ivc distended
TAPSE less than 16
TRV less than 2.8 low alt / 2.8-3.4 int echo/ more than 3.4 high RHC
SPAP
RVOT <105
cMRI cm
RHD diagnosis and vasoresponders
Treatment PH
Indication
Intermediate or high risk
On IV prostacyclin
PCH or SSc or PA induced
Liver or kidney dysfunction
Haem disordered
Generic tx
Ac not evidence based
LTOT if pao2 less than 8 helps reduce VQ mismatch + reduce shunt + in pfo
Diuretic
Iron help Do2
Immunisation Vaccine flu and pneumococcus
In flight o2 if pao2 less than 8 at sea level
Contraceptive young women
Complication PH
Infection
Arrhythmia
Anaemia
PE
Fluid overload
Haemoptysis dilation PA
Group 1
Distal PA so medial hyoertrophy proliferation then fibrosis
Adhesional thickening and thrombosis
PLEXIFORM BODIES
idiopathic 36F rare poor outcome
10% genetic BMPR2 most common / others (ALK1/endoglin/ BMPR1/SMAO9)
15% SySc PAH, other (RA SLE sj DM raynaud) — poor prognosis
Drugs meth and cocaine
HIV
Portal HTN 5% have PAH
CHD L to R shunt
Schisto portal HTN
Chronic haem anaemia
Haemangio idio vs EIF gene. CT interstitial oedema /GGO / thick septa/ nodularity)
Ix
Bloods inc RHF anti dsDNA complement ANA antiSCl70
SSC yearly echo and RHC if sob
CTD yearly echo
PE sob 3m VQ
1 degree family PH then echo
Mx
Vasodilator response to inhaled NO or inhaled epo or iv epo or iv adenosine
Yes if 10% or 40mmHG drop mPAP with same CO = SITBORN CRITERIA
Meds high dose nifedipine or diltiazem or amlodipine
SE leg oedema or hypotension
3m RHC ongoing sy and PH then 2nd agent
Non responder
Low risk PDE5 inhx
Int add ERA antagonist + sexipleg
High risk PDE5 inhx and ERA and IV Porostacyclin —> refer tx
Group 2
LV fails
Back flow PA so endothelial dysfunction
Vascular remodel
RV dysfunction
TR
Cause
HFrEF
HFpEF
Valvular
CHD
Mx
Underlying failure BB ACEi ald ant then entresto
ICD vs crt
Diuretic
LVAD
No evidence pulm vd
CHD
Balloon septotomy
Rot L shunt reversed
Prevent systemic blood bypassing lungs
Indication syncope or pre tx or prostanoid not tolerated
SE Desat
Group 3
Chronic hypoxia so pulmonary vc and vascular remodel
PA hyperplasia so mechanical stress and loss of capillaries
Smoke toxin vascular remodel
——
Air trapping
Physiological shunt so less perfusion to hyperventilated
Cause
25% Copd worse prognosis if pasp over 45 have 5year survival 10%
Ild
OSA
Alveolar hypop in nmd
Altitude
Developmental ab
Mx
Treat disease
LTOT or NIV
Smoking cessation
PR
Diuresis
Pulmonary VD if pvr more than 5 with iv TREPROSTENOL
Group 4
Symptomatic VQ mismatch 3 months post PE and wedge less than or equal 15
Thromboembolic doesn’t dissolve and forms organised thrombi so fibrotic web obstruction so microvascular remodel, collateral supply artery and raised PVR
Arteriopathic change non obstructed area
4 per 1000 PE
4% non fatal PE cause cteph
Aet
Abnormal clot
Endothelial cell abnormality
PH
RF
Acute previous VTE or large PE or echo phtn or cteph
Chronic shunt or lines or splenectomy or thrombophilia or hypothyroid or cancer or myelop or IBD or DM
Strongest risk factor splenectomy or staph ppm or non group o or VA shunt
Ix sOB at 3m post ac
VQ echo
RHC
MDT
Other ix
CT rings or webs/ slits/ chronic total occlusion
prognosis
10% at 5y
Worse non operable
Mx
PEA
Deep hypothermia and bypass
Proximal disease
PAP falls in 2d and less than 10%
5% mortality
BPA
Distal in 4-10 sessions
Se bleeding or lung injury or reperfusion injury
Riocigat
Enhances cGMP
Inoperable cteph
Pre PEA
1-2 Pdei then era vs ccb
3-4 iv prostanoid
Group 5
Haem SCA cml pv myelof et and haemolytic disease
LCH LAM NF
Sarcoid
Fibrosing mediastinitis
Metabolic eg gauchers thyroid glycogen storage
CKD
Pulmonary tumour thrombotic microangiopathy
PH meds non vasoreactive
PDE5 inhx eg sildenafil
Stops cGMP breakdown
Augments NO so PA VD
Increase exercise capacity
Indication NYHA 2-3 in G1 + G4
SE headache flush epistaxis nasal congestion
————————————————————————————————————
ERA so reduce pro inflam mediators and reduce SM proliferation
Bosentan
AB blocker
PO
G1
Y increase exercise capacity, HD, function
Ambisentan
A blocker
Y better lft/ symptoms / exercise
G1
SE lft or headache or peripheral oedema
Macentan
AB blocker
Y reduced mm/ increased exercise capacity/ better lft and leg swelling
——————————————————————————————————
Prostanoid
Increase cAMP so VD and inhibit plt aggregation and reduce proliferation
G1
EpoIV or iloprost IV/neb or ineprost iv/sc
Y improved survival
IV tunnelled line with dose increase
SE dv or headache or cough or chest pain or flush or blurred
—————————————————————-
Sexipleg
Po prostacyclin
Reduce death
—————————
Riocuguat
Enhance cGMP
G1 and cteph
Increase exercise / reduce progression / increase HD
Pathway
Low without com PDE5 inhx and ERA
Not improving add sexipleg or riociguat
Low with com then pde5 inhx or era
High then combo with iv prostacyclin and refer tx
Specific treatment
HIV
ARV
ERA or PDE5 inhx then combo
Portal htn
Echo pre tx
Monk then combo
Liver tx indication mPAP less than 35 and pvr less than 5
ASD or VSD or PDA
PVR more than 5 then closure not recommended, <3 then shunt closure
Once closed mono then combo then add uv prostanoid
Eisenmenger
Iv prostanoid and treat IDA
Lung transplant PH
NYHA 3-4 on medical therapy
Worsening RHF
RAP more than 20
CI less than 2
6WT less than 350m
PE pregnancy
Suspected
CXR
D dimer based on clinical risk no role
Bilateral Doppler if sysi
Proximal DVT then ac LMWH and mdt re PE
No DVT
Cxr normal then ctpa or VQ
Cxr abnormal then ctpa
VQ
Y low radiation breast and baby
No inconclusive Kate preg or cxr abnormal
CTPA
Y more accurate and low fetus radiation
N slightly higher breast radiation dose and x1.0003 lifetime cancer risk and not for renal failure
Mx pregnancy
3m or 6 weeks post partum
LMWH or UFH
Anti xa in renal failure or recurrent VTE or extremes body weight
Side effect HIT or bleeding
Labour
LMWH stop day before
Regional 4 hours after stop UFH
Catheter out 12h after stop UFH
Thrombolysis
Life threatening or arrest
Systemic kr Catheter thrombectomy
Bridge ecmo
Risk bleeding and teratogenic
PE anticoagulant special circumstances
CR less than 15 warfarin
15-50 apix rivarox or LMWH
Malignancy
3-6m then reassess
LMWH esp GI cancer higher risk bleeding
Antiphospholipid
Warfarin
Inr 2-3
Amniotic fluid embolism
CP
SOB hours list delivery
Rash dic
Arrest
2 per 100,000
Risk factors
CoM
Placenta Praevia
Polyhydromnios
Instrumental
Htn
ICU
Supportive
Small vessel vasculitis
Small vessel inflammation
Neutrophils then fibrinoid necrosis then vessel wall destruction then alveolar haemorrhage
MPA
PANCA
Equal gender in 50s white
Pulmonary 50% (pleurisy/ asthma/ Haemoptysis/ phaem) or Renal fsgs
Bx fsgs with fubrinoid necrosis and sparse immune deposits
Pred then cyclophos or ritux
———
GPA
CANCA
50s white
Nasal crusting or congestion or epistaxis or ulcer or saddle
Subglottic stenosis
Ild
Renal GN or nephrotic syndrome
Fever and weight loss
Rash scleritis proptosis visual loss
Mononeuritis
Ix
CANCA (negative esp if only lung)
Ct nodules consolidation or pulm infiltrates retic cavities infarct pleural effusion bre — dah or OP
Restrictive / reduced TLCO w raised kco
Ct sinus
Bal or tbb dah or neut+eo+lympth
Bx respiratory small and medium necrotising vasculitis
Bx Renal fs or diffuse necrotising GN
Urine microscopy red cell casts
Mx
Local pred then cyclo then mx aza or Mtx.
Relapse increased pred or severe mp then cyclo w plex
Severe 70mg pred then cyclo — maint ritux then aza
Life threatening iv methylpred then cyclophos w plex + dialysis —) aza
Refractory infliximab or ig or MMf or leflonumide
Maint 2y with pred + a aza or MMf
50% relapse risk
——-
Egpa granulomatous necrotising vasculitis
PANCA
Middle aged male 2x
Asthma /raised Eo / pulm infiltrate / sinus/ Mononeuritis and Eo on Bx
Other cm or myositis or pericarditis/ GI mesenteritis/ dah/ rare renal/ skin nodules/ myalgia/ fever and WL
Renal Bx fsgs
Phases asthma then blood tissue Eo then systemic vasculitis
CT gg /nodules/ bronchial wall thick / dah
Bronch marked eosinophilia
Bx extravasculad Eo, necrotising angitis, granulomata
Mx
Lung pred
DAH MP then high dose pred
Cardiac GI relapse or life threatening- iv methylpred then cyclophos
No benefit Plex
Maint pred and cyclophos
Pg good Resp disease
Polyarteritis Nodosa
Medium vessel vasculitis
Rare lung
Negative anca
Association pregnancy or hepatitis b/c
Goodpastures
IgG BM alveoli and nephrons
1 in a million
Young men 4x
Renal failure
Alveolar haemorrhage
Smoker
Viral precedes
Raised HLA DR2 in 70%
Anti GBM in blood sputum and renal Bx
Urine dip blood
Diffuse Patchy airspace shadowing in mid and lower zones
Restrictive w raised kco
Bx cresenteric GN nephrons and IgG linear deposition
Lung Bx alveolar haemorrhage with haemosiddherin laden macrophages
High dose steroid then cyclophos
Plex
Dialysis
If ab low and renal function refractory renal tx
Pg good if treated
Fatal if not treated
Relapse rare
Large vessel vasculitis
GPA
Neg anca
Headache /visual aum fugax/ UL scalp tender/ON
Rare lung
High esr
Dx temporal artery Bx
Takayasu
Anca negative
Frequent lung
Young Asian
Aorta and major branches and rarely pulmonary vessel arthritis
Fever and weight loss, absent pulses
Dx angiography
Tx pred don’t affect mortality. Some angioplasty
Generic vasculitis mx
Cxr pulmonary infiltrate
HRCT gg nodule dah
Bal Eo
Bx granulomatous necrotising polyangitis
Mx
Mild pred
Haemorrhage mp then cyclophos
Cardio or GI or life threatening then Cyclophos
Mepo il5 inhibition
Pulmonary veno occlusive disease
G1
Pulmonary vascular remodel
Gene E1F2AK
Hypoxia
CT
Enlarged mediastinal LN
Thickened septa
Central GG
L heart normal echo
Worse prognosis
Hepatopulmonary syndrome
Intrapulmonary shunt so raised A-a gradient
Sob when sit up
Insidious
Clubbing
Central cyanosis
Ix
ABG
Contrast echo
Mx liver tx
Assessment PH severity
6WT
BNP
Echo
Other
RHF
Syncope
Vo2 max less than 35%
BNP over 1500
Ra size over 26
Pericardial effusion
CI less than 2
Svo2 less than 60%
Sickle cell and the lung
AR
Valine to glycine so affects b globulin
HbSS less soluble so chronic haemolytic
Tissue infarct
Pneumonia
Strep chlamydia HiB mycoplasma legionella rsv
Acute chest crisis CX
Pen v prophylaxis
Asthma vo crisis
VTE increased risk of
Tonsils HT so risk osa
PH
G1 G4 G5
Mx as G1 as well as hydration and transfusion
Acute chest crisis
Infection
Fat embolism
Thrombosis
Pulmonary oedema
Hypoxia so sickle and voc
Infarction so consolidation
MOF
Fever sob cough
Risk factor
Younger
Raised wcc
High HiB
Smoke
Com
Ix wcc hbss% ABG cxr septic screen echo
O2
Incentive spiro
Cause mx
Hydration
Analgesia
Tx
Exchange to reduce hbss less than 20%
Risk factor PH at Dx
3 strata model
Low
No clinical signs RHF
No progressive symptoms
No syncope
Fc 1-2
6WT more than 440
Cpet vo2 more than 15
Low bnp less than 50
RA area less than 18 and no pericardial effusion
RAP less than 8, CI more than 2.5 and svo2 more than 65
Intermediate
Slow progression
Fc 3
6wt 165-440
Vo2 11-15
BNP 50-300
Ra 18-26 area with minimal pericardial effusion.
RP 8-14/ CI 2-2.4/svo2 60-65%
High
RHF
Rapid progression
Iv functional
Vo2 <11
BNP over 300
Rap over 26 area
Rap over 14/ CI <2 and svo2 less than 60%
PH pregnancy
Ecv increased
Fixed sv
Fixed pvr
Increased pv remodel
Risk VTE
25% mortality
Deliver at centre
Caesarean
Hospital 10d before then 2d after
Screen ph
Systemic sclerosis 10%
Mctd 2.5%
Sle 1%
Familial ph first degree relative
BMPR2 gene carrier
Portal hypertension pre liver tx
PE on CT auxiliary
50% effusion
10% westerman sign
Prominent pa is fleischners sign
Hampton hump pulmonary infarction
Fat embolism
12-72 hours after injury
Resp failure
Dic
fever
Dx Gurds criteria
Mx supportive
ICU
Fluid resus
Correct hypoxia
Subsegmental PE
Indication anticoagulation
Cancer
DVT
Multiple or proximal clots
Symptoms
Follow up ph
Who fc
6wt
ECG
ABG
Bloods inc bnp
Echo probabilities
Based on TRV
Low less than 2.8
Int 2.8-3.4
High more than 3.4
Vasoreactive agents
Inhaled NO
Iv epo
Inhaled ileoprost
Chemicals PAH
Aminorex
Benfluorex
Desatinib
Dexfenfluramine
Metanelhrines
Toxic rapeseed
PH bloods
Routine
Immunology
HIV
TFT
CTD
Mortality PH
Low risk less than 5%
Intermediate 5-20%
High 20%
Teratogenic PH meds
ERA
Riociguat
CTEPD no PH
Long term anticoagulation
Wells score PE
Above 4 likely
DVT (3)
Alternative less likely than PE (3)
Hr over 100 (1.5)
Immobilisation more than 3 days or surgery in the last month (1.5)
Previous DVT or PE (1.5)
Haemoptysis (1)
Malignancy with treatment in 6m (1)
PE tx weight cutoff
Less than 50
More than 120
Antenatal VTE risk
4x
6 weeks pp 20x
Adult life highest risk VTE
60s
8x higher
Echo findings poor outcome acute PE
RV over LV over 1
TAPSE less than 16
Bloods increased risk
Trop and bnp
Lactate above 2
Elevated cr
Anca
CANCA
Anti PR3
PANCA
Anti mpo
GPA best prognosis
Lung No renal
CANCA negative
Colander lesions
Associated with CTEPH
Recanalisation in organised thrombus
GBS indication I+V
FVC falls below 15ml/kg
Hypercapnia
Hypoxia
Heralded facial weakness or bulbar dysfunction
Poor prognosis
Poor cough
Bulbar or facial or weakness
Peripheral neuropathy or ans
Rapid onset
Infection
Fvc drops 30%
40% develop Resp and 30% of these tx itu
COPD with mPAP above 40 5y mortality
15%
