Pulmonary vasc disease by benbenzhou


									  Pulmonary Hypertension and Right Heart Failure

Pulmonary venous hypertension (Cardiac)
• LVF-ischaemic
• Mitral Regurgitation / Stenosis
• Cardiomyopathy-eg alchohol ,viral
Pulmonary arterial hypertension
• Hypoxic – COPD , OSA , Fibr Alveolitis
• Multiple Po Emboli
• Po vasculitis –eg SLE , PAN ,Systemic Sclerosis
• Drugs –eg appetite suppressants
• Cardiac Left to right shunt – ASD , VSD
• Primary pulmonary hypertension (only after excluding all of above)
  Clinical Signs of Pulmonary Hypertension
            and Right Heart Failure
• Central cyanosis if hypoxic
• Dependent oedema
• Raised JVP with V waves (due to secondary
  tricuspid regurg)
• Right ventricular heave at left parasternal edge
• Murmur of tricuspid regurgitation
• Load P2
• Enlarged liver (pulsatile )
        Investigation of Pulmonary
•   ECG
•   CXR
•   SaO2 and arterial blood gases
•   Pulmonary function
•   Echocardiogram / Cardiac Catheterisation
•   D dimers and VQ scan if PE suspected
•   CT Pulmonary Angiogram
•   Auto-antibodies if vasculitis suspected
Primary pulmonary hypertension
• Diagnosis by exclusion of other secondary causes
• Progressive SOBOE and signs of right heart
• Pharmacologic Treatment
  -prophylactic anticoagulation [warfarin]
  -O2 if hypoxic
  -Po Vasodilators :Endothelin antagonist (Oral
  Bosentan) , PDE5-inhibitor (Oral Sildenafil), iv

• Pulmonary infarction
     -in situ
     -venous emboli
• Virchow’s Triad
     -Vessel wall damage

•Thrombophilia- FH,freq,site,age

•Contraceptive pill ,HRT


•Pelvic obstruction-eg uterus,ovary,lymph nodes

•Trauma-eg RTA

• Surgery- eg pelvic,hip,knee

• Immobility-eg bed rest,long haul flights

• Malignancy

• Myocardial infarction

• Po hypertension/vasculitis
• Proximal (Ileofemoral)
     -most likely to embolise
     -most likely to lead to chronic venous
     insufficiency and venous leg ulcers
• Distal (Polpiteal)
     -least likely to embolise
 Clinical presentation of DVT
• Whole leg or calf involved depending on
• Swollen,hot,red,tender
• Differential:Popliteal synovial
  rupture[Bakers cyst],Superficial
  thrombophlebitis,Calf cellulitis
       Investigation of DVT
• Ultrasound Doppler leg scan(1st line)
          -Non invasive
          -Exclude popliteal cyst, pelvic mass
• CT scan of ileofemoral veins,IVC and pelvis
• Constrast venography
          -Rarely indicated
           Pulmonary Emboli
• Predisposing DVT may be silent

• Clinical presentation depends on size:

• Large-cardiovascular shock,low BP,central
  cyanosis,sudden death

• Medium-pleuritic pain,haemoptysis,breathless

• Small recurrent-progressive dyspnoea,
  pulmonary hypertension and right heart failure
            Diagnosis of PE #1
• Clinical Signs-
  Low BP,Crackles, Rub, Pleural effusion

• Arterial blood gases-PaO2,Sao2
     (Type 1 resp failure:PaCO2 normal or low)

• CXR-Normal early on before infarction
     -Basal atelectesis,Consolidation ,
      Pleural effusion after infarction
         Diagnosis of PE #2
• ECG :Acute Rt heart strain pattern
  (S1,Q3,T3 , T inv in V1-3)
• D-dimers usually raised
• Isotope lung scan (Ventilation/Perfusion)
• Perfusion defect before infarction
• Perfusion+Ventilation matched defect after
V/Q isotope scan in Recurrent Po emboli
Multiple filling defects (arrows) on perfusion (Q) scan
Mismatched to ventilation (V) scan
Dyspnoea ,Hypoxia,Cardiomegaly ,Po Hypertension and Large RV on
Echo , Restrictive Lung Vols with Low DLCO ,Hypoxia


                    

                     
         Diagnosis of PE #3
• CT pulmonary angiogram to image
  pulmonary artery filling defect
• Leg and pelvic ultrasound to detect silent
• Echocardiogram to measure pulmonary
  artery pressure and RV size
• Gas transfer factor (TLCO) to measure
  perfusion defect
CT Po Angiogram in Acute Massive PE
Occluded Rt main Po Artery (arrow ) and filling defect Lt Po artery
Acute Dyspnoea ,Hypoxia ,Low BP , Acute Rt Heart Strain on ECG
Raised D dimers .No clot seen in IVC or ileofemoral veins
Treated with Thrombolysis and Low MW Heparin

   Investigation of underlying cause of PE

• If no obvious underlying cause –eg surgery
  /pregnancy /malignancy /immobility
• Look for underlying Ca – Clin exam
  ,CXR,PSA,CA125,CEA,Pelvic USS
• Autoantibodies (SLE) – Antinuclear ,Anti-
• Coagulation factor screen – Antithrombin-
  3,Protein C/S, Factor 5/8
         Prevention of DVT
• Early post-op mobilisation
• TED compression stockings
• Calf muscle exercises
• Subcutaneous low dose low mol wt heparin
• Dabigatran - direct thrombin inhibitor
  Rivaroxaban - direct inhibitor of activated
  factor X- both given orally for prophylaxis of
  venous thromboembolism in adults after hip or
  knee replacement surgery
    Treatment of DVT/PE #1
• Anticoagulation prevents clot
  propagation-tips balance to thrombolysis-
  body dissolves clot
• Initiate with parenteral heparin-fast
  acting-via antithrombin-3
• Usually therapeutic dose of s/c low mol wt
  heparin ( Dalteparin “Fragmin”)
    Treatment of DVT/PE #2
• Low mol wt heparin –once daily injection
  ,no monitoring –no hassle
• IV infusion unfractionated heparin -more
  hassle-need to monitor clotting, increased
  bleeding risk- rarely used nowadays
    Treatment of DVT/PE #3

• Start concurrent oral warfarin-takes 3
  days-antagonises vit K1 dependent
• After 3-5 days stop heparin-when INR>2
• Need to monitor APTT with unfractionated
  -but not with low mol wt heparin
     Treatment of DVT/PE #4
• Continue Warfarin for 3-6 months

• Monitor Warfarin with INR-Target range 2.5-

• Interactions which increase anticoagulation
  -Alcohol,Antibiotics ,Aspirin,NSAIDs,
  Amiodarone, Cimetidine,Omeprazole ,etc etc

• Look in BNF for possible interactions
    Treatment of DVT/PE #5
• Thrombolysis-Streptokinase or TPA
• Only for large life threatening PE-ie low BP
  and severe hypoxaemia due to main pulmonary
  artery occlusion
• IVC filter to prevent embolisation from large
  ileofemoral/IVC clot - for recurrent PE’s
• Thrombo-embolectomy –rarely indicated
• Aspirin –no role – anti-platelet
• Address underlying cause-eg drug
  interaction,chronic liver disease,CHF
• If bleeding then stop anticoagulant and reverse
• Low MW Heparin has a long half life
• Warfarin has a long half life
• May need cover with prothrombin complex
  concentrate or fresh frozen plasma
• Reverse warfarin with vitamin K1(especially if
  chronic liver disease)
• Reverse heparin with protamine

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