Pulmonary Hypertension and Right Heart Failure - PowerPoint PPT Presentation

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Pulmonary Hypertension and Right Heart Failure

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Pulmonary Hypertension and Right Heart Failure Pulmonary venous hypertension (Cardiac) LVF-ischaemic Mitral Regurgitation / Stenosis Cardiomyopathy-eg alchohol ,viral – PowerPoint PPT presentation

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Title: Pulmonary Hypertension and Right Heart Failure


1
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)

2
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 )

3
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

4
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

5
THROMBOEMBOLIC LUNG DISEASE
  • Pulmonary infarction -in situ -venous
    emboli
  • Virchows Triad -Stasis -Vessel wall
    damage -Hypercoagulablity

6
  • 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

7
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

8
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

9
Clinical presentation of DVT
  • Whole leg or calf involved depending on site
  • Swollen,hot,red,tender
  • DifferentialPopliteal synovial ruptureBakers
    cyst,Superficial thrombophlebitis,Calf
    cellulitis

10
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(irri
    tant,allergy) -Rarely indicated

11
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

12
Diagnosis of PE 1
  • Clinical Signs-Tachycardia,Tachypnoea,Cyanosis,Fev
    er Low BP,Crackles, Rub, Pleural effusion
  • Arterial blood gases-?PaO2,?Sao2 (Type 1 resp
    failurePaCO2 normal or low)
  • CXR-Normal early on before infarction -Basal
    atelectesis,Consolidation ,
    Pleural effusion after infarction

13
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
  • PerfusionVentilation matched defect after
    infarction

14
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
?
?
?
?
?
15
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

16
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
?
17
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

18
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

19
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)

20
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

21
Treatment of DVT/PE 3
  • Start concurrent oral warfarin-takes 3
    days-antagonises vit K1 dependent prothrombin
  • After 3-5 days stop heparin-when INRgt2
  • Need to monitor APTT with unfractionated -but not
    with low mol wt heparin

22
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

23
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 PEs
  • Thrombo-embolectomy rarely indicated
  • Aspirin no role anti-platelet

24
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
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