Pulm HTN/ Cor. Pulm Flashcards by Morgan Evans

Define pulmonary HTN

Heterogeneous group of disorders characterized by elevated mean pulmonary arterial pressure:
PH = mean pulmonary arterial pressure > 20 mmHg @ rest during RH catheterization
OR
Mean pulmonary arterial pressure > 35 mmHg via non-invasive estimate (Transthoracic ECHO)

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Pulmonary HTN
1) Normal pulmonary artery pressure
2) Chronic elevated pulmonary artery pressure leads to what?
3) Most common cause of pulmonary HTN is a downstream consequence of what?

1) 8 mmHg
2) Vessel remodeling, vasoconstriction, and increase vascular resistance
3) Cardiopulmonary disease; HF, COPD

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List the WHO Classifications for pulmonary hypertension by group and give examples

Group 1: Pulmonary Arterial Hypertension (PAH)
Idiopathic – primary pulmonary HTN
Group 2: PH 2nd to left heart disease
Systolic, diastolic heart failure, valvular heart disease (mitral stenosis)
Group 3: PH 2nd to lung disease and hypoxia
COPD, OSA, ILD
Group 4: PH 2nd to chronic PE
Group 5: PH 2nd to multifactorial
Metabolic, systemic, and hematologic d/o (SSD) and others

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Describe the pathophys Primary pulmonary HTN (PAH)

Group 1: PAH - progressive narrowing of distal pulmonary arteries via various pathologic insults such as vasoconstriction, medial hypertrophy, intimal proliferation and fibrosis

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Describe Secondary PH

Group 2: PH (HF) primarily a venous process from passive congestion with vasoconstriction and venous remodeling
Group 3: PH (lung disease) destruction of the alveolar capillary beds or chronic hypoxic vasoconstriction
Group 4: (PE) subsequent vasoconstriction and remodeling of the pulmonary arterial bed
Group 5: secondary affects of systemic/autoimmune disease

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Selected annual screening for PAH in what 2 groups? Give examples

Asymptomatic patients at increased risk
Carrier for bone morphogenic protein receptor type II gene mutation
1st degree relative with PAH
Systemic scleroderma
Pre-liver transplant w/u
Symptomatic patients at increased risk
Congenital heart disease
HIV
Methamphetamine use
Portal HTN
SSD

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What is scleroderma, also known as systemic sclerosis?

Group of rare diseases that involve the hardening and tightening of the skin
Scleroderma also may cause problems in the blood vessels, internal organs and digestive tract

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Pulmonary hypertensionPresentation

Non-specific
Similar to HF or valvular disease
Symptoms are chronic, progressive dyspnea with minor exertion, fatigue, and pre-syncope or syncope

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Give the OLDCARTS for pulmonary HTN

Onset, Duration, Timing – chronic, progressive symptoms, may develop parallel to other chronic disease progression such as HF or COPD
Location – pulmonary circulation, depends on secondary cause/group
Characterization – progressive dyspnea , fatigue, symptoms associated with right heart failure (ascites, HJR, JVD, hepatomegaly, LE edema, prolonged cap refill)
Aggravating/Alleviating – underlying disease not well controlled/optimal management of secondary cause
Radiation – associated with CV, Pulmonary, PE, and systemic disease
Associated Symptoms – depends on cause – chest pain, palpitations, weight gain due to fluid retention

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PH Examination

Exam findings generally related to affects of the underlying disease
Signs of RHF
JVD/HJR/hepatomegaly
Peripheral LE edema
Abdominal distention/ascites

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Diagnostic evaluation in patient with dyspnea & suspect Pulmonary HTN: What are your 4 office based options, and what would each show?

1) CXR: RV enlargement, lung disease, prominent pulmonary arteries and congestion
2) ECG: findings suggestive of right ventricular hypertrophy - Cor Pulmonale, and P-Pulmonale.
3) Labs: elevated BNP (HF), troponins, D-dimer for DVT/PE,
4) PFT – normal spirometry, low DLCO

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Specialty referral for suspected pulmonary HTN in a pt with dyspnea

If any combination of work up suggests PH, referral to specialist is indicated
Trans Thoracic Echocardiogram (TEE): best first look at pulmonary arteries, RH (> 35 mm Hg)
Right heart catheterization: gold standard (> 20 mm Hg)

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Pulmonary HTNtreatment: PAH

Referral to pulmonology
Supplemental O2, anticoagulation?
Calcium channel blocker in appropriate patients, endothelin receptor antagonist, PDE-5 inhibitors (Viagra), etc.

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You should ID and treat underlying causes of PH; give 4 examples

1) HF – will cover in Cardio
2) COPD – optimize treatment, smoking cessation
3) PE – anti-coagulate, treat cause if reversible (smoking, OCP, hypercoag state)
4) Treat underlying systemic disease

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Pulmonary hypertension: What vaccines should pts get?

Annual flu vaccination
Pneumonia vax – PCV 20 or 21
COVID vaccination
RSV vaccination in select patients (60+)
Tdap
Contraception - pregnancy is currently discouraged (estrogen hypercoagulable)

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Cor Pulmonale: Describe

Persistent PH …
Strains the thin-walled right ventricle … RVH, then dilation …
Ultimately right ventricle failure
Most common cause of death in patients with pulmonary HTN

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Cor Pulmonale:
1) What are the 3 non-specific Sx?
2) What are the 3 signs of right heart failure?

1) DOE, Fatigue, Exercise intolerance
2) Lung: wheezing and crackles
Cardiovascular: cyanosis, parasternal lift, JVD/HJR, peripheral edema, digital clubbing
GI: hepatomegaly, HJR

Cor pulmonale: What should primary care do?

EKG – changes c/w right ventricular and atrial enlargement
CXR – enlarged heart
Right atria and ventricle
Enlarged pulmonary arteries

Cor pulmonale do: What should a specialist do?

Echocardiogram
Estimates pulmonary arterial pressure
Evaluates heart
Right heart catheterization

Describe Cor Pulmonale management

Optimal management of underlying pulmonary condition:
1) COPD – smoking cessation, home oxygen, Rx, non-invasive ventilatory support
2) Vasodilators – CCB
3) Consider anticoagulation due to increased risk of DVT/PE
4) Cautious diuretic therapy – right heart failure is pre-load dependent

PE (pulmonary embolism): most result from what that sends emboli to heart and on to lung?

Lower extremity DVT

What are symptoms of PE (pulmonary embolism)?

Acute onset
1) Dyspnea
2) Pleuritic CP
3) Cough
4) Hemoptysis
5) Syncope
(not specific)

What are Sx of a lower extremity DVT?

Acute onset of unilateral leg (calf) swelling and pain

Describe the presenting S/Sx of a PE (embolism)

Tachypnea, tachycardia, may be hypotensive/unstable
Chest exam - pleural friction rub, crackles/rales
Signs of DVT: unilateral leg swelling/pitting edema, tenderness, visible collateral vein
Signs of RV failure: JVD, systolic murmur left sternal edge, hepatomegaly

Differentiate between hemodynamically stable and unstable pts

1) Hemodynamically stable patients -May be treated as outpatient Vs. 2) Hemodynamically unstable patients -SBP < 90mmHg or a drop of 40 mmHg from baseline for greater than 15 minutes -Acute morbidity from obstructive shock -Need mor aggressive intervention

Differential diagnosis chest pain & dyspnea: 1) List pulmonary DDx

P.E. Pneumonia Bronchitis Pneumothorax COPD/Asthma exacerbation Pulmonary edema/effusion

Differential diagnosis chest pain & dyspnea: 1) List cardiovasc DDx 2) List MSK DDxs

Cardiovascular: ACS Pericarditis HF Aortic dissection MSK: Rib fracture, chest wall pain

Pulmonary emboli: 1) Briefly sum up the clinical presentation 2) What are the clinical prediction rules? 3) What are ancillary tests for this?

1) Clinical presentation: Classic S/S of DVT/PE often not found – “high index of suspicion” Clinical prediction rules Wells criteria for PE/DVT Perc Test 3) ECG, Labs, Radiology/nuclear medicine

1) Define Angiography 2) What is generated by the angiography?

1) The procedure to evaluate blood vessels 2) Angiograms are the images generated by the angiography

Standard pulmonary angiography involves inserting a catheter into the pulmonary artery CT angiography does not use a catheter in the vessel but utilizes IV contrast injected into vein

Diagnostic testing for a PE: 1) What can be used for Validated prediction scores? 2) What are other diagnostic tests)

Validated prediction scores PERC test Wells Criteria for PE (there is a separate Wells criteria for DVT) EKG Labs CBC, D-dimer, troponins, BNP Radiology CXR Compression doppler US lower extremity for DVT CT angiography Nuclear medicine Ventilation:perfusion scan

What is a PERC test validated for? 2) When can it rule it out?

1) Validated in emergency room environment for suspected PE 2) R/O PE if NO criteria present and pre-test probability is less than 15%

Describe PE labs

No specific test 1) CBC 2) Coagulation studies 3) D-dimer as clinically indicated 4) BNP, Troponins as clinically indicated

Describe PE EKG findings (don't need to know yet)

Most are normal, but: Sinus tachycardia Non-specific ST/T wave changes RBBB & S1 Q3 T3 pattern RSR’ Deep S wave in lead I Q wave in III Inverted T wave in III “Classic” finding is neither sensitive nor specific for PE, found in only ~ 20% of patients with PE.

Describe PE radiology findings

CXR – most are normal …but classic findings sHampton’s hump – peripheral lung infact Westermark ign – hypovolemic PA beyond clot Ultrasound – r/o DVT LE compression doppler US Nuclear medicine – V/Q scan CT Pulmonary angiography - Gold Standard

Describe PE tx if hemodynamically stable (3 things). What is not indicated?

1) Anti-coagulate if low risk of bleeding 2) If contraindicated, consider inferior venocava filter between DVT and heart 3) Subsegmental PE may be considered for observation (serial LE doppler US) vs. anticoagulation Thrombolytics nor embolectomy indicated

Describe PE tx if hemodynamically unstable (2 things)

1) Resuscitate; cardiopulmonary support 2) May need thrombolytic therapy or surgical embolectomy

PE treatment summary from 2019 guideline ECS 1) Long-term Rx for PE includes what? 2) In patients with PE due to a transient risk factor, discontinuation of _______________ at 3 months is recommended.

1) Anticoagulant therapy for at least 3-6 months, longer if elevated risk of recurrence. 2) anticoagulation

PE treatment summary from 2019 guideline ECS" 1) What are the treatment of choice in patients with PE, *except* during pregnancy, patients with severe renal impairment, antiphospholipid syndrome, or cancer? 2) What should you give for antiphospholipid syndrome? 3) What should you give for Pregnancy, severe renal impairment or cancer? (don't think we need to know)

1) Direct-acting oral anticoagulants 2) Vit K antagonist 3) LMWH (low molecular weight) * some recent trials indicate direct oral anticoagulants can be used for cancer patients

1) What is an adj. therapy for PE? 2) How do you prevent a VTE? (4 things)

1) Ambulation for fully anticoagulated patients rather than bed rest 2) Exercise/movement Elevate legs Compression stockings/pneumatic compression device post op/bed ridden patients LMWH for patients undergoing surgery and post op

P.E. is the most common serious cause Patients presenting ER w/ pleuritic CP - 5% to 21% MI, pericarditis, aortic dissection, pneumonia, and pneumothorax - serious causes “CP” that should be ruled out

What are common causative agents of pleuritic chest pain? Give examples

Viruses Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus