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

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THROMBOEMBOLIC LUNG DISEASE

• Pulmonary infarction -in situ -venous
  emboli
• Virchows Triad -Stasis -Vessel wall
  damage -Hypercoagulablity

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• 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

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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

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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

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Clinical presentation of DVT

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

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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

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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

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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

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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

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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
?
?
?
?
?
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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

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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
?
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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

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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

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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)

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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

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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

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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

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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

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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