Pulmonary Vascular Disease

Question 1

Explain pulmonary embolism

Answer 1

Thrombus forms n venous system, usually in deep veins of the leg. It embolises to pulmonary arteries

Question 2

What is the treatment for minor PE?

Answer 2

Anticoagulation which has very good prognosis

Question 3

What are major risk factors for venous thromboembolism?

Answer 3

Recent major trauma, recent surgery, cancer, significant cardiopulmonary disease, pregnancy and inherited thrombophilia

Question 4

What are the symptoms for small peripheral thrombus?

Answer 4

Pleuritic chest pain, cough and haemoptysis

Question 5

What are the symptoms for multiple small peripheral emboli?

Answer 5

Isolated acute dyspnoea

Question 6

What are the symptoms for massive embolism in pulmonary arteries?

Answer 6

Syncope or cardiac arrest

Question 7

What are clinical signs of a small peripheral thrombus?

Answer 7

Pyrexia, pleural rub, stony dullness to percussion at base (pleural effusion)

Question 8

What are the clinical signs of multiple small thrombi?

Answer 8

Tachycardia, tachypnoea and hypoxia

Question 9

What are the clinical signs of massive thrombus?

Answer 9

Tachycardia, hypotension, tachypnoea and hypoxia

Question 10

How can you calculate pre-test probability?

Answer 10

Wells score and revised Geneva score

Question 11

Explain Wells score

Answer 11

Includes symptoms and signs of VTE, previous VTE and risk factors

Question 12

Explain revised Geneva score

Answer 12

Based on risk factors, symptoms and signs (heart rate)

Question 13

What are some investigations for PE?

Answer 13

FBC, biochemistry, Tn1 and blood gases
CXR, ECG, D-diner, CT pulmonary angiogram, V/Q scan, Echocardiography, CT abdomen and thrombophilia testing

Question 14

How can a V/Q scan show perfusion and ventilation?

Answer 14

Ventilation looks normal
Perfusion has absence of tracer as embolism has prevented perfusion

Question 15

What is given for treatment if patient is hypoxic?

Answer 15

Oxygen

Question 16

What is the treatment for PE?

Answer 16

Low molecular weight heparin ex. dalteparin
Warfarin is less common
Direct oral anticoagulants
Thrombolysis
Pulmonary embolectomy

Question 17

What is thrombolysis?

Answer 17

Breakdown of thrombus by medication so breaks down blood clot
Pulmonary embolectomy if cant give thrombolysis

Question 18

Explain prognosis in PE

Answer 18

Mortality at 30 days varies from 0 -25%
PESI score - age , sex, comorbidity, physiological parameters

Question 19

What is pulmonary hypertension?

Answer 19

Chronic illness
Elevated blood pressure in pulmonary arterial tree
Mean pulmonary artery pressure of > 25mm Hg
Primary or secondary to other conditions

Question 20

Explain epidemiology of pulmonary hypertension

Answer 20

Idiopathic pulmonary arterial hypertension is rare
Untreated can lead to premature death
Usually second to other medical conditions and usually older

Question 21

What happens to arteries and heart during pulmonary hypertension?

Answer 21

Arteries constrict which increases pressure
This causes pressure on right side of heart causing hypertrophy

Question 22

What are the causes of pulmonary hypertension?

Answer 22

Idiopathic
Secondary to left heart disease
Secondary to chronic resp. disease
Chronic thromboembolic PH (CTBPH)
Miscellaneous

Question 23

What is a miscellaneous cause for pulmonary hypertension?

Answer 23

Sarcoidosis

Question 24

What are some idiopathic causes for pulmonary hypertension?

Answer 24

Collagen vascular disease
Portal hypertension
Congenital heart disease
HIV infection

Question 25

What are the symptoms of pulmonary hypertension?

Answer 25

Exertional dyspnoea, chest tightness, exertional presyncope or syncope and haemoptysis

Question 26

What does the terms presyncope and syncope mean?

Answer 26

Presyncope - feeling of going to faint, light headedness Syncope - fainting

Question 27

What are the clinical signs of pulmonary hypertension?

Answer 27

Elevated JVP, right ventricular heave, loud pulmonary second heart sound, hepatomegaly and ankle oedema

Question 28

What is hepatomegaly?

Answer 28

Enlarged liver due to congestion

Question 29

What investigations are needed for pulmonary hypertension?

Answer 29

ECG, lung function tests, CXR, Echocardiography, V/Q scan, CTPA and right heart catheterisation

Question 30

Explain right heart catheterisation

Answer 30

Allows direct measure of pulmonary artery pressure Measurement of wedge pressure and cardiac output Vasodilator trial

Question 31

What is shown on ECG of patient with pulmonary hypertension?

Answer 31

More serious case V1 is increased and P waves are tall and peaked Both showing right atrium enlargement

Question 32

What does pulmonary hypertension look like on CXR?

Answer 32

Enlarged right atrium Enlarged right main artery

Question 33

What is the general treatment for pulmonary hypertension?

Answer 33

Treat underlying condition Oxygen Anticoagulation Diuretics

Question 34

What is the general treatment for pulmonary hypertension?

Answer 34

Treat underlying condition Oxygen Anticoagulation Diuretics

Question 35

What is specific treatment used for pulmonary hypertension?

Answer 35

Calcium channel antagonists Prostaglandins Prostacyclin agonist Riociguat Endothelin receptor agonist Phosphodiesterase inhibitors

Question 36

What treatment would you give if vasodilator trial was positive?

Answer 36

Calcium channel antagonists

Question 37

What are some other treatment for pulmonary hypertension?

Answer 37

Thromboendarterectomy (CTEPH) Lung or heart lung transplant as can get fibrosis of pulmonary vessels