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
Virchow’s 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(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

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 PE’s
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