Flashcards in pHTN and pulmonary lung disease Deck (72):
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
What percent of patients with a PE will be symptomatic?
less than 50%
What percent of isolated calf vein thrombi will propagate above the popliteal fossa?
What percent of LE venous emboli being in the proximal veins without prior calf involvement?
When emboli originate from the upper extremities, what is this usually due to?
PICC or other lines in place
What percent of calf DVTs will resolve spontaneously? What happens if they do not?
Other 25% will develop into a proximal DVT
What is the risk of developing a PE with a clot that does not grow proximally from the popliteal vein?
What is a chronic PE?
Embolus that lodges in the pulmonary vasculature, and causes occlusion of a vessel
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
Where do PEs lodge, generally?
Bifurcation of the main pulmonary artery (saddle)
lobar and peripheral arteries
What type of PEs are most likely to cause hemodynamic compromise?
large ones that occlude the main Pulmonary artery
What are the ssx of smaller PEs?
Usually affect the distal arteries and cause pleuritic chest pain.
What percent of emboli are associated with a document pulmonary infection
When does RV failure occur with a PE?
If the embolus causes a 75% compromise in pulmonary blood flow
What is the most common presentation of a PE?
Dyspnea at rest or DOE
Pleuritic chest pain
Pleuritic chest pain from a PE indicates what about it?
That it has been there long enough (a day) to cause local inflammation/irritation
What causes hemoptysis with a PE?
Death of lung tissue
What causes wheezing with a PE?
Showering of clots throughout the pulmonary vasculature
What causes the crackles with a PE?
What are the two most common exam findings with a PE?
What causes an accentuated P2?
What are the components of the Well's criteria?
-Calf greater than 3 cm
-Collateral superficial veins
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
What is the pattern of ABG findings with a PE?
Respiratory alkalosis and hypoxemia
Will the BNP be elevated with a PE?
What percent of patients with a PE will have an elevated troponin?
What is a D-dimer?
FIbrin degradation product
What is the EKG pattern that can be seen with a PE?
What, besides the SQT133 pattern can be found on an EKG with a PE?
What is the most common EKG finding with a PE?
What are the "classic" CXR findings with a PE?
Hampton's hump and Westermark's sign
What is Hampton's hump?
very insensitive but specific wedge shaped opacity on CXR that indicates a PE causing a wedged area of infarction
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
What is the gold standard for PE detection? What is usually used?
Gold = pulmonary angiography
CT pulmonary angio
Who gets a VQ scan for a PE?
Pts who cannot tolerate contrast (CKD)
What is the treatment for a PE?
When are thrombolytics indicated for a PE?
For massive PE with hemodynamic compromise (less than 90 mmHg DBP)
What, besides thrombolytics, can be used to treat a large PE? (2)
Catheter based therapies
When is a surgical thrombectomy appropriate?
For patients that cannot tolerate thrombolytics or who have recently undergone surgery
What are the two main sequelae of massive PEs?
What are the treatments for cardiogenic shock or RV failure, secondary to a PE?
Inotropes (NE, dobutamine)
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
What are the indications for an IVC filter?
failure of anticoagulants
Acute PE when additional thrombi could be lethal
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
When should f/u be done with a massive PE, and what should be done? Why?
3-6 month echo to look for pHTN
What is the normal pulmonary artery pressure? What is the definition of pHTN?
pHTN = greater than 25 mmHg at rest
What is group 1 of the WHO classification for pHTN?
pHTN (precapillary PAH)--pHTN from the right side of the heart
What is group 2 of the WHO classification for pHTN?
Pulmonary venous HTN from left sided heart disease
What is group 3 of the WHO classification for pHTN?
PH from lung disease and/or hypoxia
What is group 4 of the WHO classification for pHTN?
Chronic thromboembolic PH
What is group 5 of the WHO classification for pHTN?
PH with unclear, multifactorial mechanisms
What is the most common cause of pHTN worldwide?
What are the usual ssx of pHTN (early and late)? How do these progress?
Slow onset of DOE
-right heart failure
How long is the delay between onset of pHTN and diagnosis?
What is the best methodology of diagnosing pHTN? What is the definitive way to diagnose pHTN?
IV cath of the right heart is definitive
If pHTN is suspected on echo, what should you do for the workup?
Look for secondary causes
Determine need for right heart cath
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)
What is the test of choice for a chronic pulmonary embolism?
What is the difference between group 1 and 2 pHTN according to the WHO classification?
PAWP is greater than 15 in group 2
What is a vasodilator challenge and what is it used for?
Give 100% O2 and see if sat improves
Positive indicates Left heart failure
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
What is the incidence (relatively) of isolated pHTN? Which gender is more often affected?
What is known about the etiology of isolated pHTN?
Genetic and environmental factors cause proliferation, thrombosis, and vasoconstriction of the pulmonary vasculature
What is the treatment for group I pHTN pts?
DHP CCBs if responsive
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)
What are the components of the adjunctive therapy for pHTN?
Diuretics for overload
What is the treatment for Groups II pHTN pts?
Treat the right heart failure
What is the treatment for Group III pHTN pts?
Treat underlying lung disease
What is the treatment for Group IV pHTN pts?
What is the treatment for Group V pHTN pts?
No specific therapy
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