Pulmonary Emboli; Pulmonary Hypertension

Pulmonary Hypertension when PAP > 25 mm Hg at rest

symptoms

early = none

after right heart starts to fail

lower body edema

RUQ pain or fullness (liver swollen)

sob on exertion

weakness, fatigue

direct signs

• increased or palpable P2
• systolic ejection murmur

indirect signs

• signs of RV hypertrophy
• para-sternal heave (lift)
• right sided S4
• increased atrial "a" wave
•  
• signs of RV failure
• tricuspid regurgitation (due to hypertrophy)
• "v" wave from tricuspid regurgitation 
• right sided S3
• peripheral edema

Diagnosis of pulmonary hypertension

direct measure of PAP

Swan Ganz

indirect measure of PAP

echo Doppler

Etiologies of Pulmonary Hypertension

Pathophysiologic

• chronic increase in flow = remodeling
• increase in pulmonary vascular resistance (e.g., hypoxia)
• increase in pulmonary venous pressure (Left heart failure)

Classifications of Pulmonary Hypertension (Dana Point 2008)

• Pulmonary Arterial Hypertension

• idiopathic (young women)
• weight loss drugs

• PH due to left heart failure
• PH with lung disease/hypoxia
• Chronic pulmonary thromboemboli

Workup

liver function tests, echo, CXR, V/Q scan

Treatment

drugs - NO pathway, endothelin pathway, prostacyclin pathway

NO works but patients get tachyphylactic in 1-2 days

PDE5 inhibitor

prostacyclins = vasodilator (gold standard for patients with severe pulmonary HTN)

anticoagulation

atrial septostomy - create a shunt

transplant - heart and lung

Pulmonary Embolism

risk factors

classic = Virchow's triad = stasis, hypercoagulability, endothelial damage

new = acquired or congenital

clinical signs

pleural friction rub (infarcted tissue)

ECG changes: tachy, right axis, RBBB, S1Q3T3

ABG: low PO2, low PCO2

Well's Criteria to determine whether or not DVT and/or PE

Tests for PE

• D-dimer = crosslinked fibrin   (clotting always includes fibrinolysis).  sensitive but lots of false positives = not specific since d-dimers occur in inflammation, malignancy, pregnancy, recent surgery.
• Ultrasound of legs.  clot in legs often means clot in lungs.  negative test does not rule out PE.
• V/Q scan - radioactive xenon for ventilation scan.  microspheres for perfusion.  looks for areas that are ventilated but not perfused.  no risk for renal damage.
• CT scan
• timed bolus of IV contrast to light up  pulmonary arteries.  more senstive and specific than V/Q.  lifetime increase in lung cancer risk with 1 CT scan = 1 in 1000.
• Pulmonary angiography (not used currently)

Treatment for  PE

• anticoagulant meds - heparin or low MW heparin
• remove aggravating cause
• thrombolysis (TPA) clot busters  (mostly for severe cases, hypotension, heart strain = risk of cerebral hemorrhage)
• IVC filters for pts. with LE DVT.