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pHTN and pulmonary lung disease Flashcards

1
Q

Where do most emboli that cause PEs originate from? Where else?

A

Deep veins in the leg

Less commonly in the pelvic, renal, or UE veins

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2
Q

What percent of patients with a PE will be symptomatic?

A

less than 50%

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3
Q

What percent of isolated calf vein thrombi will propagate above the popliteal fossa?

A

25%

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4
Q

What percent of LE venous emboli being in the proximal veins without prior calf involvement?

A

20%

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5
Q

When emboli originate from the upper extremities, what is this usually due to?

A

PICC or other lines in place

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6
Q

What percent of calf DVTs will resolve spontaneously? What happens if they do not?

A

75%

Other 25% will develop into a proximal DVT

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7
Q

What is the risk of developing a PE with a clot that does not grow proximally from the popliteal vein?

A

Rare

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8
Q

What is a chronic PE?

A

Embolus that lodges in the pulmonary vasculature, and causes occlusion of a vessel

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9
Q

What happens to the BP with a massive PE?

A

SBP less than 90 or drop of greater than 40 mmHg in less than 15 minutes

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10
Q

Where do PEs lodge, generally?

A

Bifurcation of the main pulmonary artery (saddle)

lobar and peripheral arteries

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11
Q

What type of PEs are most likely to cause hemodynamic compromise?

A

large ones that occlude the main Pulmonary artery

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12
Q

What are the ssx of smaller PEs?

A

Usually affect the distal arteries and cause pleuritic chest pain.

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13
Q

What percent of emboli are associated with a document pulmonary infection

A

10%

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14
Q

When does RV failure occur with a PE?

A

If the embolus causes a 75% compromise in pulmonary blood flow

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15
Q

What is the most common presentation of a PE?

A

Dyspnea at rest or DOE
Pleuritic chest pain
Calf/thigh pain

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16
Q

Pleuritic chest pain from a PE indicates what about it?

A

That it has been there long enough (a day) to cause local inflammation/irritation

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17
Q

What causes hemoptysis with a PE?

A

Death of lung tissue

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18
Q

What causes wheezing with a PE?

A

Showering of clots throughout the pulmonary vasculature

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19
Q

What causes the crackles with a PE?

A

Atelectasis

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20
Q

What are the two most common exam findings with a PE?

A

Tachypnea

Tachycardia

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21
Q

What causes an accentuated P2?

A

pHTN

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22
Q

What are the components of the Well’s criteria?

A
  • CA
  • Immobilization/hypercoagubility
  • Local TTP
  • Leg swelling
  • Calf greater than 3 cm
  • Pitting edema
  • Collateral superficial veins
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23
Q

What is the value of Well’s criteria that warrants further workup? What is an alternative diagnosis is more likely?

A

Greater than 2

If alternative more likely, than subtract 2

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24
Q

What is the pattern of ABG findings with a PE?

A

Respiratory alkalosis and hypoxemia

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25
Q

Will the BNP be elevated with a PE?

A

can be

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26
Q

What percent of patients with a PE will have an elevated troponin?

A

30-50%

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27
Q

What is a D-dimer?

A

FIbrin degradation product

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28
Q

What is the EKG pattern that can be seen with a PE?

A

S1
Q3
T3

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29
Q

What, besides the SQT133 pattern can be found on an EKG with a PE?

A

RV strain

Incomplete RBBB

30
Q

What is the most common EKG finding with a PE?

A

Sinus tach

31
Q

What are the “classic” CXR findings with a PE?

A

Hampton’s hump and Westermark’s sign

32
Q

What is Hampton’s hump?

A

very insensitive but specific wedge shaped opacity on CXR that indicates a PE causing a wedged area of infarction

33
Q

What is the Westermark’s sign?

A

Very insensitive but specific sign for a PE that consists of a loss of the vascular markings in a lung d/t clot showering

34
Q

What is the gold standard for PE detection? What is usually used?

A

Gold = pulmonary angiography

CT pulmonary angio

35
Q

Who gets a VQ scan for a PE?

A

Pts who cannot tolerate contrast (CKD)

36
Q

What is the treatment for a PE?

A

Anticoagulation ASAP:

  • Unfractionated heparin
  • LMWH
37
Q

When are thrombolytics indicated for a PE?

A

For massive PE with hemodynamic compromise (less than 90 mmHg DBP)

38
Q

What, besides thrombolytics, can be used to treat a large PE? (2)

A

Surgical thrombectomy

Catheter based therapies

39
Q

When is a surgical thrombectomy appropriate?

A

For patients that cannot tolerate thrombolytics or who have recently undergone surgery

40
Q

What are the two main sequelae of massive PEs?

A

Hypotension/shock

RV failure

41
Q

What are the treatments for cardiogenic shock or RV failure, secondary to a PE?

A

Inotropes (NE, dobutamine)
NO
RVAD
ECMO

42
Q

What is the use of an IVC filter?

A

Filter that will break down clots and prevent them from passing as a whole to the heart

43
Q

What are the indications for an IVC filter?

A

failure of anticoagulants

Acute PE when additional thrombi could be lethal

44
Q

What are the outpatient meds to give to pts post PE? How long should these be used for?

A

Anticoagulants likes warfarin
3 months if reversible cause
Extended if there are recurrent events

45
Q

When should f/u be done with a massive PE, and what should be done? Why?

A

3-6 month echo to look for pHTN

46
Q

What is the normal pulmonary artery pressure? What is the definition of pHTN?

A

8-20

pHTN = greater than 25 mmHg at rest

47
Q

What is group 1 of the WHO classification for pHTN?

A

pHTN (precapillary PAH)–pHTN from the right side of the heart

48
Q

What is group 2 of the WHO classification for pHTN?

A

Pulmonary venous HTN from left sided heart disease

49
Q

What is group 3 of the WHO classification for pHTN?

A

PH from lung disease and/or hypoxia

50
Q

What is group 4 of the WHO classification for pHTN?

A

Chronic thromboembolic PH

51
Q

What is group 5 of the WHO classification for pHTN?

A

PH with unclear, multifactorial mechanisms

52
Q

What is the most common cause of pHTN worldwide?

A

Schistosomiasis

53
Q

What are the usual ssx of pHTN (early and late)? How do these progress?

A

Slow onset of DOE

Late ssx:

  • chest pain
  • syncope
  • right heart failure
54
Q

How long is the delay between onset of pHTN and diagnosis?

A

2 years

55
Q

What is the best methodology of diagnosing pHTN? What is the definitive way to diagnose pHTN?

A

echo

IV cath of the right heart is definitive

56
Q

If pHTN is suspected on echo, what should you do for the workup?

A

Look for secondary causes

Determine need for right heart cath

57
Q

What are the two tests that are beneficial to r/o other causes of pHTN or RV failure?

A

V/Q scan (PE)

PFTs (pulmonary causes)

58
Q

What is the test of choice for a chronic pulmonary embolism?

A

VQ scan

59
Q

What is the difference between group 1 and 2 pHTN according to the WHO classification?

A

PAWP is greater than 15 in group 2

60
Q

What is a vasodilator challenge and what is it used for?

A

Give 100% O2 and see if sat improves

Positive indicates Left heart failure

61
Q

What are the criteria for a good response to the vasodilator challenge?

A

Mean PAP less than 40 mmHg
Mean PAP decreases by 10 mmHg
CO increases or stays constant

62
Q

What is the incidence (relatively) of isolated pHTN? Which gender is more often affected?

A

Rare

Women

63
Q

What is known about the etiology of isolated pHTN?

A

Genetic and environmental factors cause proliferation, thrombosis, and vasoconstriction of the pulmonary vasculature

64
Q

What is the treatment for group I pHTN pts?

A

DHP CCBs if responsive

65
Q

What is the treatment for group I pHTN pts that do not respond to CCBs? What is the role of each?

A

PDE-5 inhibitors (increases NO)
Prostacyclins (increases PGI2)
ERAs (Binds to ET-1 to prevent remodeling)

66
Q

What are the components of the adjunctive therapy for pHTN?

A

Diuretics for overload

Na restriction

67
Q

What is the treatment for Groups II pHTN pts?

A

Treat the right heart failure

68
Q

What is the treatment for Group III pHTN pts?

A

Treat underlying lung disease

69
Q

What is the treatment for Group IV pHTN pts?

A

Pulmonary thromboendarterectomy

70
Q

What is the treatment for Group V pHTN pts?

A

No specific therapy

71
Q

What is the goal of therapy with treatment for PAH?

A

Get them to functional class I or II

NOT treat the numbers, since RV failure can also show decreased numbers

72
Q

What are the high risk groups for group I PAD?

A

Scleroderma

Family h/o it

Respiratory (34 decks)

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