Foundations II (Cholley) > Pulmonary Vasculature > Flashcards

Pulmonary Vasculature Flashcards

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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
What imaging is used for pulmonary HTN?
Radiographs & CTs of chest | - PFTs are useful in determining cause of htn for pts in Group 3
26
On PFTs, what combo suggests increased pulmonary arterial pressure?
- Decreased single-breath - Normal FVC - Normal TLC - Increased wasted ventilation
27
What is considered the definitive dx procedure for defining the distribution & extent of disease in chronic thromboembolic pulmonary htn?
Pulmonary angiography
28
What test differentiates chronic thromboembolic pulmonary htn from idiopathic pulmonary arterial htn?
V/Q scan
29
What is 1st line therapy for group 1?
CCBs (Diltiazem, nifedipine) | *Should only be given to pts w/ + acute vasodilator response
30
How do you tx group 3?
Supplemental O2 for 15 hrs or more per day
31
How do you tx group 2 & 5?
Treat underlying condition
32
How do you tx group 4?
- Anticoag | - Thromboendarterectomy if no response to other therapies
33
What phosphodiesterase 5 inhibitors have been approved for the tx of pulmonary htn?
- Sildenafil | - Tadalafil
34
What is the MOA of phosphodiesterase 5 inhibitors?
cGMP accumulation --> decreased muscular tone
35
What is contraindicated w/ PDE-5 inhibitors?
Any drug serving as a nitric oxide donor
36
How do you tx the sx of pulmonary htn?
- Diuretics: Furosemide - Warfarin (or ASA in children) - O2 - Exercise
37
Pregnant women w/ PAH, should be tx w/ what?
A prostanoid
38
Define: Cor Pulmonale
RV alteration due to pulmonary dz &/or hypoxia that may progress to RV failure
39
What are the etiologies of cor pulmonale?
- COPD - Pulmonary htn - idiopathic pulmonary fibrosis - thromboembolic disease - ARDs - Pneumoconiosis or kyphoscoliosis (less common)
40
Cor pulmonale has ____ pulmonary vasoconstriction & ____ pulmonary vascular bed.
- Increased | - Decreased
41
Define: pneumoconiosis
- Inhaled dust deposited deep in lungs | - An occupational lung dz
42
Pneumoconiosis includes what subcategories?
- Coal workers' pneumoconiosis (black lung dz) - Asbestosis - Silicosis
43
In pts w/ COPD, RV volume & fxn differs depending on what?
The degree of emphysema | - Greater degree = smaller RV volume & lower RVEF
44
What are sx of cor pulmonale?
- CP - Dyspnea, wheezing, cough - Palpitations - Syncope, pre-syncope - Fatigue - Edema * No sx is 100% specific. Depends on entire picture
45
What are signs of cor pulmonale?
- Cyanosis - Clubbing - JVD - Tricuspid regurg - RV heave/gallop - Enlarged/tender liver - Ascites
46
What is a frequent cause of chest pain? What is it usually described as?
- MI | - Pressure, tightness, squeezing, gas
47
Ischemic sx are 1st noted w/...
exercise or cardiac stress
48
What represents unstable angina?
Progressive sx or sx @ rest | - Due to plaque rupture or thrombosis
49
CP may be accompanied by what other sx?
- SOB - Dizziness - Feeling of impeding doom - Vagal sx
50
Who has a higher frequency of atypical angina?
Women! | - Depression can mask sx
51
The HEART score is composed of what?
- History - EKG - Age - RFs - Troponin
52
What is the purpose of the HEART score?
Distinguish CP from non-coronary causes
53
In cor pulmonale, what labs are used for dx?
- CBC: Polycythemia present - ABG: Hypoxemia +/- hypercarbia - BNP
54
What dx test provies an inexpensive noninvasic alternative means for monitoring hemoglobin sat w/ O2?
Oximetry
55
What imaging is used for dx of cor pulmonale?
- CXR: enlarged pulmonary artery, dilated R atrium - CT - Echo
56
What other dx tests are used in cor pulmonale?
- PFT & spirometry - Lung biopsy - EKG - Right heart cath
57
How do you tx cor pulmonale?
- Reverse hypoxia - Improve RV contractility - CPAP for pts w/ sleep apnea - Phlebotomy - Longterm O2 for COPD pts
58
What meds are used to tx cor pulmonale?
- Anticoag pts w/ thromboembolic dz - Diuretics - CCBs, prostacyclin analogues, endothelin-receptor antagonists for PAH - Theophylline
59
What is the avg life expectancy for pts w/ cor pulmonale?
2-5 yrs | - Those w/ COPD, have 30% chance of survival
60
What is the most common EKG finding for PE? What is considered the "classic" EKG?
- Sinus tach = most common | - S1Q3T3 = classic
61
Define: DVT vs PE
* Both types of VTE - DVT: blood clot in deep vein - PE: obstruction of pulmonary artery
62
What causes PE?
Over 90% are due to emboli originating from LE DVTs
63
What makes up virchows triad?
- Vessel wall injury - Venous stasis - Hypercoagulability
64
What are RFs for VTE?
- 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
What are sx of DVT?
- Unilateral swollen UE or LE - Pain - Discoloration
66
What do you see on PE for DVT?
- Tenderness to palpation - Erythema - SF venous dilation - Palpable cord: + Homan's
67
What are complications of a DVT?
- PE | - Post-thrombophlebitic syndrome (abnormal blood pooling)
68
UE DVT is associated w/ what?
Catheter placement
69
What scoring system is used in both DVT & PE?
Wells Criteria
70
What labs are used for dx of DVT?
- CBC, BMP - PT/INR: measures extrinsic pathway of coagulation - aPPT: measures intrinsic pathway of coagulation - D-dimer: sensitive but not specific
71
What can cause an elevated d-dimer?
- VTE - Post-op states - Malignancy - Pregnancy
72
What imaging is used for dx of DVT?
- US *Test of choice | - Contrast venography
73
Besides DVT, what else can cause a PE?
- Fat or air emboli - Amniotic fluid - Talc - Parasite
74
Describe: Massive PE
- SBP < 90, or a drop in > 40 | - Results in acute RV failure, shock, & possible death
75
Describe: Submassive PE
RV dysfxn or myocardial necrosis
76
What are the most common signs & sx of PE?
- SOB or DOE | - Tachypnea
77
What clinical features does the Wells Criteria include?
- 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
If the pt is unstable, how do you tx PE?
- O2 - IV fluids - BP support - ICU - Consider thrombolytics
79
What labs do you use for dx of PE?
Same as DVT! Plus troponin
80
Risk of inherited thrombophilia is greater in those w/...
- Initial thrombosis prior to 50 yo - Family hx of VTE - Recurrent VTE - Hx of warfarin-induced skin necrosis (suggests protein c deficiency)
81
What imaging is used for dx of PE?
- US - CXR: Hampton's hump (pathognomonic for PE), pulmonary wedge sign - CTA - Echo
82
When is a V/Q scan considered + for PE?
If there ≥1 “miss match”
83
What are the advantages of using a CTA for dx of PE?
- Provides direct visualization - May provide alternative dx - Highly sensitive - Accessible - Non-invasive
84
What are the disadvantages of using a CTA for dx of PE?
- Interpreter dependent - IV contrast - May miss subsegmental emboli
85
What is the gold standard dx test used for PE?
Angiogram
86
What are the disadvantages of using an angiogram for dx of PE?
- Invasive - High contrast - Technically demanding - Costly
87
What is the initial tx for VTE? What is the MOA?
IV unfractionated heparin - Inhibits clotting cascade by inactivating thrombin - Used w/ warfarin
88
What do you need to monitor in pts on IV unfractionated heparin?
CBC, aPTT or Anti-Xa
89
What are side effects of heparin?
Bleeding | Thrombocytopenia
90
What is the antidote for heparin?
Protamine
91
What is used for outpatient tx of DVT & stable PE? What is the MOA?
Low molecular weight heparin (Enoxaparin) - Inhibits clotting cascade - used w/ warfarin
92
What med is used for long-term tx of VTE?
Warfarin (coumadin)
93
What do you need to monitor in pts on warfarin?
PT/INR
94
What are side effects of warfarin?
Bleeding | Skin necrosis
95
What is the antidote for warfarin?
Vitamin K | Fresh frozen plasma (FFP)
96
How long should pts remain on heparin?
Min of 5 days or 2 days after INR btwn 2-3.
97
What is the MOA of NOACs?
Factor Xa or direct thrombin inhibitor
98
What are the side effects of NOACs?
- Bleeding | - Irreversibility
99
What is the duration of tx for someone w/ 1st VTE?
3 months
100
What is the duration of tx for someone w/ 1st idiopathic VTE?
3-6 months
101
What is the duration of tx for someone w/ recurrent VTE or inherited coagulopathy?
Indefinite
102
What is the MOA of thrombolytics (used in unstable PE)?
Ex. streptokinase, urokinase, recombinant tissue plasminogen activator - Activate plasminogen --> plasmin --> lysis of thrombi
103
What is the name of a mechanical device that is used to remove clots from veins?
Thrombectomy/embolectomy
104
When are IV filters indicated?
- Recurrent PE despite anticoagulation - Complication of anticoagulation - Hemodynamic or respiratory compromise
105
Where are IV filters placed?
In IVC | - Prevents DVT from propagating to lungs
106
What are prophylactic measures for VTE?
- SCDs | - TED hose
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