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Pulm > Pulmonary Circulation Disorders - Exam 2 > Flashcards

Pulmonary Circulation Disorders - Exam 2 Flashcards

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1
Q

What is the MC source of PEs? What do fat PEs arise from? What do septic emboli arise from?

A

thrombus arising from the deep veins of the lower extremities

long bone fractures

acute infective endocarditis

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2
Q

_______ occurs most often when small emboli lodge distally where there is a little collateral blood flow

A

infarction

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3
Q

What are the 3 pathophysiological response from pulmonary vascular obstruction?

A

infarction

impaired gas exchange leading to hypoxia

cardiovascular compromise

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4
Q

What does impaired gas exchange leading to hypoxia lead to?

A

altered ventilation to perfusion ratio

Inflammation → Surfactant dysfunction → Atelectasis → Functional intrapulmonary shunting

Stimulation of the respiratory drive → hypocapnia and respiratory alkalosis

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5
Q

What is the pathophys behind cardiovascular compromise?

A

Obstruction of the vascular bed → Increased pulmonary vascular resistance → Right heart and intraventricular septal strain

Less blood returning to the left ventricle → Reduced cardiac output → Hypotension

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6
Q

**What is Virchow’s triangle? What does it increase your risk for?

A

venous stasis

injury to the vessel wall

hypercoagulability

increased risk for PE

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7
Q

What are the risk factors for venous stasis?

A

immobility

hyperviscosity

increased central venous pressures (low cardiac output states and pregnancy)

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8
Q

What are the risk factors for hypercoagulability?

A

medications

disease: malignancy or surgery

inherited gene defects: factor V leiden, protein C, S and antithrombin deficiency, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies

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9
Q

What is the MC inherited gene defect that leads to hypercoagulability?

A

Factor V leiden

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10
Q

What are the MC s/s of PE? What does significant pain indicate? _____ is the most reliable physical exam finding

A

dyspnea, pleuritic chest pain, cough

small PEs that result in infarction

tachypnea

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11
Q

What are s/s of DVT?

A

Lower leg pain or “charley horse” in the calf
Associated symptoms DVT: swelling, warmth and/or erythema

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12
Q

What is the scale of Wells criteria for PE tell you? **What are the ranges of the scale?

A

determines the pre-test probability of the s/s being a PE

Determine “pre-test” probability
>6 points = high risk (78.4%)
2–6 points = moderate risk (27.8%)
<2 points = low risk (3.4%)

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13
Q

When are the PERC rules used? What are the PERC rules? **What does it stand for?

A

PERC rules are only used if Well’s risk is low risk

PERC Rules (Pulmonary Embolism Rule-Out Criteria)

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14
Q

What do you do if the pt is low risk and no PERC rules criteria are met?

A

no testing is needed

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15
Q

What do you do if the pt is low risk and there is at least 1 positive PERC rule?

A

move on to plasma D-dimer

Normal → no imaging
Elevated d-dimer → imaging

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16
Q

What do you do if the pt is intermediate risk?

A

D- dimer

Normal → no imaging
Elevated d-dimer → imaging

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17
Q

What do you do if the pt is high risk?

A

Imaging (no D-dimer)

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18
Q

What does a positive D-dimer indicate? What is normal?

A

A protein fragment from a broken down blood clot

normal is less than 500 ng/ml

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19
Q

**What is the equation for age adjusted d-dimer? What age do you need to adjust?

A

Adults over age 50 use an age-adjusted threshold (age × 10 ng/mL)

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20
Q

T/F: All elevated d-dimer are diagnostic for a PE/DVT

A

False!!! there are lots of false positive aka non-PE reasons why the d-dimer would be elevated

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21
Q

What are some reasons why the d-dimer would be elevated?

A

age >50 years, recent surgery or trauma, acute illness, PREGNANCY or postpartum state, rheumatologic disease, renal dysfunction and sickle cell disease

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22
Q

What is the first line imaging modality in PE? Does it require contrast? What will the radiologist report find?

A

CTA

YES! requires IV contrast (need to order BUN/Cr before)

**positive filling defect

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23
Q

What are the cautions for a CTA?

A

pregnancy, metformin and allergy to contrast dye

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24
Q

What is the preferred imaging of choice for PE when a pt is pregnant? Name some additional indications.

A

V/Q scan

pregnancy, renal insufficiency or adverse reaction to contrast

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25
When a PE is present, what will the V/Q results say?
PE is likely when there is reduced perfusion with normal ventilation
26
** _____ is the gold standard for diagnosing PE. When is it indicate?
pulmonary angiography Indicated when there is high pre-test probability and inconclusive CTA results
27
____ and ____ are elevated in up to 25-50% of patients. What are they related to?
troponin and BNP related to size of PE causing acute right ventricular myocardial stretch
28
**What are the MC EKG findings associated with PE?
sinus tachycardia non-specific ST segment and T-wave changes affecting R precordial leads V1-3 +/- V4 S1Q3T3 pattern +/- new incomplete RBBB
29
**What are 2 rare CXR findings that are associated with PEs?
westermark's sign and hampton's hump
30
**______ is an area of lung oligemia, usually from complete lobar artery obstruction
Westermark's sign
31
**______ is a dome-shaped dense opacification in the periphery of the lung - indicative of pulmonary infarction
Hampton's hump
32
Why is a lower extremity venous doppler ordered?
to look for evidence of DVT and helps to determine the etiology of the PE
33
What qualifies as a high risk PE?
hypotension (SBP < 90 mmHg for > 15 minutes) drop in SBP > 40 mmHg below baseline hypotension requiring vasopressors causing a cardiac arrest
34
What qualifies as an intermediate risk PE?
Hemodynamic stability with signs of R sided heart strain/dysfunction via CTA, echo, elevated troponin or BNP. aka right heart strain
35
What qualifies as a low-risk PE?
Normotension without signs of right ventricular dysfunction aka no signs of right heart strain
36
What is the initial management of PE in ALL patients? What do you need to avoid?
supplemental oxygen ventilatory support hemodynamic support avoid excessive IV fluids → increased risk of right sided heart failure
37
What are the 3 primary forms of therapy in a PE?
Anticoagulation - mainstay Fibrinolysis Thrombectomy
38
What is the MOA of unfractionated heparin?
Binds to and accelerates the activity of antithrombin, preventing additional thrombus formation
39
**What is the UFH dosing?
80 units/kg/dose IV bolus x 1 (or 5000 U) followed by 18 units/kg/hour (max 2000 u/hr)
40
What is the monitoring requirements for UFH?
Monitoring required: obtain aPTT at baseline and every 6 hours during tx with a goal of 60-80 seconds, signs of bleeding, H/H, plt
41
**When is UFH used? Who is it reserved for?
in high risk patients! anticoag may be given before imaging confirms dx Reserved for unstable patients, severe renal insufficiency
42
**What is the reversal agent for UFH? What is a normal aPTT?
Protamine sulfate normal aPTT 25-30 seconds
43
**What is the dosing for LMWH? When is LMWH preferred?
enoxaparin (Lovenox) 1 mg/kg SC q12h Preferred over other injectable agents in those who can not take oral anticoagulants
44
When do you need to monitor LMWH?
Monitoring only in obese, underweight (<45 kg) or renal impairment
45
**What is the reversal agent for LMWH?
Protamine sulfate - reverses effects of heparin Indicated for life-threatening or intracranial hemorrhage
46
What are the 3 factor Xa inhibitors? What are the dosing for each? Which requires bridging with heparin?
rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa) xarelto starts at BID dosing then decreases to QD apixaban and edoxaban are BID dosing savaysa requires bridging therapy with LMWH or UFH
47
What is the reversal agent for factor Xa inhibitors?
andexxa
48
_____ is the direct thrombin inhibitor. Does it require UFH/LMWH bridging? What is the reversal agent?
dabigaran (pradaxa)- BID dosing Requires 5-10 days of bridging with UFH/LMWH Praxbind
49
_____ is the only injectable factor Xa inhibitor. What is the dosing?
fondaparinux (Arixtra) once daily, subq dosing
50
____ is a Vitamin K antagonist prevents activation of coagulation factors II, VII, IX, and X. How long does it take to reach its full effect? What is the ideal INR?
Warfarin 5 days to reach full effect requires bridging with LMWH until INR is 2-3
51
_____ is used in high risk PE patients. How is it given to pts?
Tissue Plasminogen Activator (tPA) - Alteplase 100 mg IV infused over 2 hours
52
**What are the CI to tPA?
intracranial disease (active tumor or hx of bleed) uncontrolled HTN (>220/110) at presentation recent major surgery or trauma (past 3 weeks) ischemic CVA in last 3 months metastatic cancer
53
When is embolectomy used in PE management? What is commonly injected during the procedure?
Hemodynamically unstable patients with a contraindication or failure to respond to tPA Catheter-directed procedure offers the benefit of locally injecting tPA at a lower dose decreasing bleeding risk
54
_____ is used to prevent PE recurrence and is indicated in active bleeding that prevents anticoag and/or recurrent VTE despite intensive anticoag
IVC filter
55
Where is an IVC filter placed?
below the renal arteries in the inferior VC
56
What are the indications for inpt PE treatment?
Severe illness or presence risk factors Associated DVT Educational needs (eg, lack of knowledge about PE and its management) Problematic social situations (eg, prior noncompliance with follow-up care)
57
What are the risk factors that indicate admission for PE?
58
What is the longterm management for PE? What is the minimum?
anticoag therapy for a minimum for 3-6 months but can be indefinite
59
What do you need to do if there is no obvious cause of VTE is identified?
consult hematology
60
What is the normal mean pulmonary arterial pressure?
10-18mmHg systolic pressure around 25mmHg diastolic pressure around 10mmHg
61
What is the pathophys behind pulmonary hypertension? What is the mPap?
Increase in pulmonary vascular resistance, typically due to vasoconstriction, remodeling, and thrombosis of the small pulmonary arteries and arterioles leading to hyperplasia and hypertrophy of the vessels. Pulmonary hypertension is defined by (mPAP) >20 mmHg
62
according to WHO, what are the 5 classifications of pulmonary hypertension?
group 1: idiopathic, hereditary, drug induced, connective tissue disease, congenital heart, HIV group 2: LEFT sided heart disease group 3: chronic hypoxia group 4: chronic PE group 5: catch all
63
What are the 3 MC symptoms of pulmonary hypertension?
malaise, fatigue and dyspnea
64
What does hemoptysis indicate in pulmonary hypertension?
rare - life threatening - results from rupture of pulmonary artery
65
What will late disease pulmonary hypertension present like? What additional heart sounds may be heard?
right sided heart failure Accentuated P2¹ (pulmonic valve closure) 3rd heart sound (“Kentucky”) tricuspid regurg murmur
66
What does cyanosis in pulmonary hypertension indicate?
consider open patent foramen ovale
67
What will the EKG of a pt with pulmonary hypertension show? What will TTE with doppler show?
signs of RVH Elevated estimated pulmonary artery systolic pressure (ePASP) Tricuspid regurgitation, RV enlargement, wall thickness or dysfunction may be seen
68
**What is the gold standard dx test for pulmonary hypertension? What will it show?
Right-sided heart catheterization (aka Swan-Ganz catheter) mPAP ≥ 20 mmHg diagnostic for PH
69
What does a pulmonary capillary wedge pressure assess? What happens if it is increased?
LEFT sided heart disease ≤15 mm Hg = no left sided heart disease Elevated PCWP usually indicates left sided heart disease and should be confirmed with a left heart cath
70
What is the vasodilator response?
After injection of a vasodilator, pressures are remeasured Drop of mPAP of 10-40 mmHg indicative of positive acute vasodilator response
71
What is the diagnostic approach to pulmonary hypertension?
72
What are some general management measures for pulmonary hypertension?
73
What are the New York Heart Association system for classifying pulmonary hypertension?
74
What are the NYHA symptoms for pulmonary hypertension?
NYHA Symptoms: dyspnea, fatigue, chest pain, or near syncope with exertion.
75
What is the step wise treatment for pulmonary hypertension?
76
When are CCB used in pulmonary hypertension? Which ones specifically?
NYHA class I-III High dose diltiazem and nifedipine most commonly used
77
What is the MOA for endothelin receptor antagonist?
reduces endothelin release leading to vasodilation aka decrease in endothelin leads to decrease in vasorestriction so more dilation
78
ambrisentan (Volibris) bosentan (Tracleer) macitentan(Opsumit) What drug class?
Endothelin receptor antagonists
79
What is the MOA for PDE5 inhibitors? What are the 2 medications in this class?
inhibition of PDE5 leads to vasodilation sildenafil (Viagra, Revatio) tadalafil (Cialis, Adcirca)
80
What is the MOA of Soluble guanylate cyclase stimulators? What is the drug in this class?
stimulates the activity of guanylate cyclase which increases CAMP in the lungs as a response to nitric oxide, which causes the arteries to vasodilate riociguat (Adempas) -> only available PO
81
What is the MOA of prostanoid agents?
potent pulmonary vasodilation by acting on prostaglandin receptors with an additional benefit of inhibiting platelet aggregation
82
epoprostenol (Flolan) treprostinil iloprost What drug class?
prostanoid agents
83
What is the MOA of prostacyclin receptor agonists? what form?
attaches to and activates prostacyclin receptors in the lung resulting in vasodilation available IV and PO: IV only for short term if unable to take PO
84
Prostacyclin receptor agonists are more selective for the _____ than the ______
prostacyclin receptor prostanoid agents
85
What is the tx of pulmonary hypertension based on the NYHA categories?
86
What is the additional management for pulmonary hypertension?
87
**What are the 2 MC EKG abnormalities on the MAJORITIES of PE's?
sinus tachycardia non-specific ST segment and T wave changes affecting R precordial leads V1-3 +/- V4
88

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