Pulmonary Hypertension and Right Heart Failure
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Transcript of Pulmonary Hypertension and Right Heart Failure
Pulmonary Hypertension and Right Heart Failure
Pulmonary venous hypertension (Cardiac)• LVF-ischaemic • Mitral Regurgitation / Stenosis• Cardiomyopathy-eg alchohol ,viralPulmonary 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 Hypertension
• 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 failure • Pharmacologic Treatment
-prophylactic anticoagulation [warfarin] -O2 if hypoxic -Po Vasodilators :Endothelin antagonist (Oral Bosentan) , PDE5-inhibitor (Oral Sildenafil), iv Epoprostenol
THROMBOEMBOLIC LUNG DISEASE
• Pulmonary infarction-in situ
-venous emboli
• Virchow’s Triad-Stasis
-Vessel wall damage-Hypercoagulablity
RISK FACTORS FOR DVT AND PE #1
•Thrombophilia- FH,freq,site,age
•Contraceptive pill ,HRT
•Pregnancy
•Pelvic obstruction-eg uterus,ovary,lymph nodes
•Trauma-eg RTA
RISK FACTORS FOR DVT AND PE #2
• Surgery- eg pelvic,hip,knee
• Immobility-eg bed rest,long haul flights
• Malignancy
• Myocardial infarction
• Po hypertension/vasculitis
DVT
• 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 site
• 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 -Invasive,contrast(irritant,allergy)-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-Tachycardia,Tachypnoea,Cyanosis,Fever 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
Investigations• 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
infarction
V/Q isotope scan in Recurrent Po emboli Multiple filling defects (arrows) on perfusion (Q) scanMismatched to ventilation (V) scanDyspnoea ,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 DVT
• Echocardiogram to measure pulmonary artery pressure and RV size
• Gas transfer factor (TLCO) to measure perfusion defect
CT Po Angiogram in Acute Massive PEOccluded 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-Cardiolipin
• 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
perioperatively• 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 prothrombin
• 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 2.5-3.5
• 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
Overanticoagulation
• Address underlying cause-eg drug interaction,chronic liver disease,CHF
• If bleeding then stop anticoagulant and reverse effect• 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