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Flashcards in pHTN and pulmonary lung disease Deck (72):
1

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

Deep veins in the leg
Less commonly in the pelvic, renal, or UE veins

2

What percent of patients with a PE will be symptomatic?

less than 50%

3

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

25%

4

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

20%

5

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

PICC or other lines in place

6

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

75%

Other 25% will develop into a proximal DVT

7

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

Rare

8

What is a chronic PE?

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

9

What happens to the BP with a massive PE?

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

10

Where do PEs lodge, generally?

Bifurcation of the main pulmonary artery (saddle)
lobar and peripheral arteries

11

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

large ones that occlude the main Pulmonary artery

12

What are the ssx of smaller PEs?

Usually affect the distal arteries and cause pleuritic chest pain.

13

What percent of emboli are associated with a document pulmonary infection

10%

14

When does RV failure occur with a PE?

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

15

What is the most common presentation of a PE?

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

16

Pleuritic chest pain from a PE indicates what about it?

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

17

What causes hemoptysis with a PE?

Death of lung tissue

18

What causes wheezing with a PE?

Showering of clots throughout the pulmonary vasculature

19

What causes the crackles with a PE?

Atelectasis

20

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

Tachypnea
Tachycardia

21

What causes an accentuated P2?

pHTN

22

What are the components of the Well's criteria?

-CA
-Immobilization/hypercoagubility
-Local TTP
-Leg swelling
-Calf greater than 3 cm
-Pitting edema
-Collateral superficial veins

23

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

Greater than 2

If alternative more likely, than subtract 2

24

What is the pattern of ABG findings with a PE?

Respiratory alkalosis and hypoxemia

25

Will the BNP be elevated with a PE?

can be

26

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

30-50%

27

What is a D-dimer?

FIbrin degradation product

28

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

S1
Q3
T3

29

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

RV strain
Incomplete RBBB

30

What is the most common EKG finding with a PE?

Sinus tach

31

What are the "classic" CXR findings with a PE?

Hampton's hump and Westermark's sign

32

What is Hampton's hump?

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

33

What is the Westermark's sign?

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

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

Gold = pulmonary angiography

CT pulmonary angio

35

Who gets a VQ scan for a PE?

Pts who cannot tolerate contrast (CKD)

36

What is the treatment for a PE?

Anticoagulation ASAP:
-Unfractionated heparin
-LMWH

37

When are thrombolytics indicated for a PE?

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

38

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

Surgical thrombectomy
Catheter based therapies

39

When is a surgical thrombectomy appropriate?

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

40

What are the two main sequelae of massive PEs?

Hypotension/shock
RV failure

41

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

Inotropes (NE, dobutamine)
NO
RVAD
ECMO

42

What is the use of an IVC filter?

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

43

What are the indications for an IVC filter?

failure of anticoagulants
Acute PE when additional thrombi could be lethal

44

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

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

45

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

3-6 month echo to look for pHTN

46

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

8-20

pHTN = greater than 25 mmHg at rest

47

What is group 1 of the WHO classification for pHTN?

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

48

What is group 2 of the WHO classification for pHTN?

Pulmonary venous HTN from left sided heart disease

49

What is group 3 of the WHO classification for pHTN?

PH from lung disease and/or hypoxia

50

What is group 4 of the WHO classification for pHTN?

Chronic thromboembolic PH

51

What is group 5 of the WHO classification for pHTN?

PH with unclear, multifactorial mechanisms

52

What is the most common cause of pHTN worldwide?

Schistosomiasis

53

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

Slow onset of DOE

Late ssx:
-chest pain
-syncope
-right heart failure

54

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

2 years

55

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

echo

IV cath of the right heart is definitive

56

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

Look for secondary causes

Determine need for right heart cath

57

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

V/Q scan (PE)
PFTs (pulmonary causes)

58

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

VQ scan

59

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

PAWP is greater than 15 in group 2

60

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

Give 100% O2 and see if sat improves

Positive indicates Left heart failure

61

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

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

62

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

Rare
Women

63

What is known about the etiology of isolated pHTN?

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

64

What is the treatment for group I pHTN pts?

DHP CCBs if responsive

65

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

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

66

What are the components of the adjunctive therapy for pHTN?

Diuretics for overload
Na restriction

67

What is the treatment for Groups II pHTN pts?

Treat the right heart failure

68

What is the treatment for Group III pHTN pts?

Treat underlying lung disease

69

What is the treatment for Group IV pHTN pts?

Pulmonary thromboendarterectomy

70

What is the treatment for Group V pHTN pts?

No specific therapy

71

What is the goal of therapy with treatment for PAH?

Get them to functional class I or II

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

72

What are the high risk groups for group I PAD?

Scleroderma
Family h/o it