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Pulmonary Hypertension and Right Heart Failure Pulmonary venous hypertension (Cardiac) LVF-ischaemic Mitral Regurgitation / Stenosis Cardiomyopathy-eg.

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Presentation on theme: "Pulmonary Hypertension and Right Heart Failure Pulmonary venous hypertension (Cardiac) LVF-ischaemic Mitral Regurgitation / Stenosis Cardiomyopathy-eg."— Presentation transcript:

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 Differential:Popliteal synovial rupture[Bakers cyst],Superficial thrombophlebitis,Calf cellulitis

10 Investigation of DVT Ultrasound Doppler leg scan(1 st line) -Non invasive -Exclude popliteal cyst, pelvic mass CT scan of ileofemoral veins,IVC and pelvis Constrast venography -Invasive,contrast(irritant,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,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

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 Perfusion+Ventilation 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 INR>2 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 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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