Pulmonary Vascular Disease

Question 1

What is a pulmonary embolism?

Answer 1

A thrombus which forms in the venous system, usually in deep veins of the legs and embolises to the pulmonary arteries

Question 2

What is the prognosis of pulmonary embolism?

Answer 2

• Massive PE can be fatal
• Minor PE treated with anticoagulation has a very good prognosis
• Mortality at 30 days varies from 0 to 25%

Question 3

Describe the diagnosis of PE?

Answer 3

• Over diagnosed as it is often suspected when it isn’t there
• Underdiagnosed as true diagnosis of PE is often missed

Question 4

What are the major risk factors for a venous thromboembolism?

Answer 4

• Recent major trauma
• Recent surgery
• Cancer
• Significant cardiopulmonary disease
• Pregnancy
• Inherited thrombophilia

Question 5

Why are you at increased risk of developing a venous thromboembolism id you have recently had surgery or a major trauma?

Answer 5

Your clotting system will be active and therefore you are more likely to develop clots. You are also less likely to be active and so the blood supply to the legs slows.

Question 6

What 3 sets of symptoms may you have with a a pulmonary embolism?

Answer 6

1. Pleuritic chest pain, cough and haemoptysis
2. Isolated acute dyspnoea
3. Syncope or cardiac arrest

Question 7

When would symptoms of pulmonary embolism include pleuritic chest pain, cough and haemoptysis?

Answer 7

• A small clot lodging in a small peripheral artery
• The part of the lung becomes infarcted and as a result haemoptysis
• The surface of the lung becomes inflamed and rubs across the chest wall

Question 8

When would symptoms of pulmonary embolism include syncope or cardiac arrest?

Answer 8

• Large blood clot blocks the main pulmonary artery

- Reduction in cardiac output from heart reduces blood flow to the brain

Question 9

What are the 3 sets of signs you may have with pulmonary embolism?

Answer 9

1. Pyrexia, pleural rub, stony dullness to percussion at base (pleural perfusion)
2. Tachycardia. tachpnoea, hypoxia
3. Tachycardia, hypotension, tachpnoea, hypoxia

Question 10

What investigations are carried out in diagnosing pulmonary embolism?

Answer 10

• Full blood count, biochemistry, blood gases
• Chest X-ray
• ECG
• D-dimer
• CT pulmonary angiogram
• V/Q scan
• Echocardiography
• Consider CT abdomen and mammography
• Consider thrombophilia testing

Question 11

What pre-test probability tests are there?

Answer 11

• Wells score

- Revised Geneva score

Question 12

What is included in the Wells score?

Answer 12

Symptoms and signs of VTE, previous VTE and risk factors

Question 13

What is included in the Revised Geneva score?

Answer 13

Based on risk factors, symptoms and signs

Question 14

What do you need to pay particular attention to in an echocardiogram?

Answer 14

Right ventricle

Question 15

What is the D-dimer test?

Answer 15

Blood test of the product of clotting cascade of the blood

Question 16

What test is used in the prognosis of PE?

Answer 16

PESI score

Question 17

What is the PESI score based on?

Answer 17

Age, sex, comorbidity and physiological parameters

Question 18

What are the treatments for pulmonary embolism?

Answer 18

-Oxygen
-Low molecular weight heparin
-Warfarin
-Direct oral anticoagulants
-Thrombolysis
Pulmonary embolectomy

Question 19

How long is a patient usually treated for PE?

Answer 19

• Usually for 3 months

- If patient is at risk of reoccurrence then they might be put on lifelong anticoagulants

Question 20

What is pulmonary hypertension?

Answer 20

Elevated blood pressure in the pulmonary artery or tree

Question 21

How is pulmonary hypertension defined?

Answer 21

A mean pulmonary artery pressure of >25 mmHg

Question 22

How can pulmonary hypertension occur?

Answer 22

Either primary or secondary to other conditions

Question 23

What is the epidemiology of primary pulmonary hypertension?

Answer 23

• Rare

- Incidence of 1-2 million population

Question 24

What happens if pulmonary hypertension is left untreated?

Answer 24

It is a rapidly progressive condition that leads to premature death

Question 25

What is the epidemiology of secondary pulmonary hypertension?

Answer 25

- It is more common than primary | - Tends to occur in an older age group

Question 26

What are the causes of pulmonary hypertension?

Answer 26

-Idiopathic -Secondary to chronic respiratory disease -Secondary to left heart disease Chronic Thromboembolic PH -Miscellaneous (Collagen vascular disease, Portal hypertension, Congenital heart disease with L to R shunt, HIV infection)

Question 27

What are the symptoms of pulmonary hypertension?

Answer 27

- Exertional dyspnoea - Chest tightness - Exertional presyncope or syncope

Question 28

What are the signs of pulmonary hypertension?

Answer 28

-Elevated JVP -Right ventricular heave -Loud pulmonary second heart sound Hepatomegaly -Ankle oedema

Question 29

What investigations are carried out to diagnose pulmonary hypertension?

Answer 29

- ECG - Lung function tests - Chest X-ray - Echocardiography - V/Q scan - CTPA - Right heart catheterisation

Question 30

What does right heart catheterisation allow the measurement of?

Answer 30

- Direct measurement of pulmonary artery pressure - Measurement of wedge pressure - Measurement of cardiac output

Question 31

What is the general treatment for pulmonary hypertension?

Answer 31

- Treat underlying condition - Oxygen - Anticoagulation - Diuretics

Question 32

What are the specific treatments for pulmonary hypertension?

Answer 32

- Calcium channel antagonist - Prostacyclin - Endothelin receptor antagonists - Phosphodiester inhibitors

Question 33

What surgical treatments are there for pulmonary hypertension?

Answer 33

- Thromboendarterectomy | - Lung or heart lung transplant