Flashcards in Pulmonary Vascular Disorder Deck (55)
What is pulmonary hypertension?
What are the measurements that define pulmonary hypertension?
How would you describe the prognosis?
Increase in pulmonary arterial pressure from increased pulmonary vascular resistance
Pulmonary artery systolic pressure > 30 mmHg or a mean PAP of > 20 mmHg
Poor prognosis especially in the setting of cor pulmonale
The etiology is extensive for pulmonary hypertension and grouped 1-5. What are the groupings?
1. Pulmonary arterial hypertension
2. Pulmonary hypertension secondary to left heart disease
3. Pulmonary hypertension secondary to lung disease/chronic hypoxia
4. Chronic pulmonary thromboembolic disease
5. Pulmonary hypertension with unclear multifactorial mechanisms
Pulmonary hypertension can be caused by a number of factors but they all lead to what happening?
1. Force the right side of the heart to work harder to pump blood to the lungs.
2. The right chambers may enlarge because of this and struggle to function.
3. Blood is then forced backward towards the tricuspid valve
Symptoms of Pulmonary Hypertension?
1. Dyspnea on exertion
--May be at rest in severe cases
3. Chest pain
4. Syncope with exertion
5. Nonproductive cough
Signs of pulmonary hypertension?
1. Narrow splitting of S2 with loud pulmonary component
2. Right ventricular hypertrophy
3. Right atrial enlargement
4. Enlarged central pulmonary arteries on CXR
6. Right sided heart failure symptoms such as Hepatomegaly, LE edema
The workup for pulmonary hypertension may include what?
2. CT of the chest
4. Echocardiography with Doppler flow
5. Right sided cardiac catheterization with vasodilator challenge
6. V/Q scanning if suspect disease is from chronic thromboembolic disease
7. Exclude HIV and collagen vascular disease
What will you see on the chest xray of someone with pulmonary hypertension?
1. interstitial pulmonary markings
2. enlargement of the right and left ventricles and also the right atrium
3. Large attenuated peripheral pulmonary arteries
Treatment approach for pulmonary hypertension depends on what?
Treating the underlying cause first
Treating the underlying cause first for pulmonary hypertension usually with what?
2. Supplemental oxygen if hypoxemia present
3. May require chronic anticoagulation
What kind of vasodilators would we prescribe for pulmonary hypertension?
1. Oral calcium channel blockers (first line therapy)
2. Oral phosphodiasterase inhibitors (sildenafil, tadalafil)
3. Oral endothelin receptor antagonists (ambrisentan, bosentan)
4. Continuous infusion of prostacyclin agents (epoprostenol, treprostinil)
What is cor pulmonale?
What is the prognosis?
What is it most commonly caused by?
RV systolic and diastolic failure secondary to pulmonary disease or from pulmonary vascular disease
Most commonly caused by
1. Pulmonary hypertension,
2. COPD or
3. idiopathic pulmonary fibrosis
Symtpoms of cor pulmonale?
1. Chronic productive cough
2. Exertional dyspnea
4. Easy fatigability
6. RUQ pain
7. Dependent edema
Signs of cor pulmonale?
3. Distended neck veins
4. RV heave or gallop
5. Prominent lower sternal or epigastric pulsations
7. Dependent edema
9. Severe lung disease
What would we see in the diagnostic studies for cor pulmonale?
1. Polycythemia secondary to chronic hypoxemia
2. SaO2 of less than 85%
May show RAD, peaked P waves, Deep S waves in V6, may see Q waves in inferior leads b/c of vertically placed heart
Confirm underlying lung disease
What will the EKG show on cor pulmonale?
What will the echo show on a cor pumonale pt?
1. May show RAD,
2. peaked P waves,
3. Deep S waves in V6,
4. may see Q waves in inferior leads b/c of vertically placed heart
1. Should show normal LV size and function
2. RV and RA dilation and RV systolic dysfunction
How should we treat cor pulmonale?
1. Treat chronic respiratory failure
2. Supplemental O2
Manage right heart failure symptoms with
3. Fluid and salt restriction
What does supplemental oxygen help to do in cor pulmonale patients?2
1. May improve survival
2. Helps to decrease RV afterload by reducing the pulmonary vascular resistance
What is the key to treating pulmonary embolism?
Key is prevention and always considering this in the differential diagnosis when applicable
PE may be caused by the following:
(what is the most common cause?)
2. Amniotic fluid (during active labor)
3. Fat (long bone fractures)
4. Foreign bodies (talc in IV drug users)
5. Parasite eggs
6. Septic emboli
7. Tumor cells
8. Most common cause is a venous thrombus
Where do the clots come from in a pulmonary embolism? 2
What place has the highest risk of developing a PE?
have lower extremity DVT (deep vein thrombosis) when evaluated
1. Calf veins
If localized to the calf veins, rarely travel to lungs
20% of thrombi here migrate proximally to popliteal and femoral veins
2. Popliteal and ileofemoral veins
50-60% of patients with thrombi here will develop PE
Risk factors for PE and DVT are the same. What is this called and what is part of it?
1. Venous stasis
2. Injury to the vessel wall
Factors that promote venous stasis that could cause PE
2. Postoperative state
5. Increased central venous pressure such as
6. Low cardiac output
Vessel damage may occur from what three things that could cause PE?
1. Prior episodes of thrombosis
2. Orthopedic surgery
Factors associated with hypercoagulability that could cause PE
2. Meds such as hormones
3. Disease such as malignancy
What are the genetic factors that could increase the risk of PE?
1. Factor V Leiden (most common inherited)
2. Dysfunction of Protein C, Protein S, Antithrombin III, prothrombin gene mutation, hyper-homocysteinemia, antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibody)
Physiologic changes with PE
1. Reflex bronchoconstriction and vasoconstriction from neurohormonal responses
2. Right ventricular failure
If massive thrombus
3. Pulmonary vasculature obstruction
Pulmonary vasculature obstruction during a PE causes what?2
1. Increased pulmonary vascular resistance
2. Causes physiologic deadspace (ventilation of the lung without perfusion)
What does the presence of dead space (vent without perfusion) lead to?
1. Hypoxemia due to R to Left “shunting” of blood
2. Decreased cardiac output
3. Surfactant depletion causing atelectasis
Pulmonary Embolus symptoms?
(What are the two most common?)
2. Pleuritic chest pain**
4. Leg pain
8. Anginal pain