pulmonary heart disease andrew ying-siu lee, md,phd.

心臟病及保健 heart disease and health
Pulmonary heart disease
Andrew Ying-Siu Lee, MD,PhD.
(I) Pulmonary Hypertension
= mean pulmonary arterial pressure > 25mmHg at rest or = abnormal cellular proliferation (eg. smooth muscle hypertrophy, fibrosis, neovascularization), thrombosis and imbalance between vasoconstriction (angiotensin II, leukotrienes, serotonin, thromboxane etc) and vasodilation (bradykinin, endothelin, nitric oxide, prostaglandins etc) increased pulmonary vascular resistance  right heart failure  decreased cardiac output 心臟病及保健 heart disease and health
Causes and classification of pulmonary hypertension
1.
Pulmonary arterial hypertension:-
idiopathicfamilial associated with : collagen vascular ds, liver ds, portal hypertension, drug and toxin, thyroid ds, hemoglobinopathies associated with : pulmonary venous or capillary ds 2.
Pulmonary hypertension with left-sided heart disease:-
left-sided atrial or ventricular heart ds 3.
Pulmonary hypertension associated with lung disease or
hypoxemia:-
COPD, interstitial lung ds, sleep apnea, high altitude, 4.
Pulmonary hypertension due to chronic thrombotic and/or
embolic disease:-
thromboembolic obstruction of pulmonary arteriesnonthrombotic pulmonary embolism (tumor, parasites, foreign materials) 5. Miscellaneous (eg. sarcoidosis, compression of pulmonary vessels)
心臟病及保健 heart disease and health
Symptoms = dyspnea (most common),
fatigue, chest pain, syncope, pedal
edema, palpitation, cough,
hemoptysis, hoarseness, Raynaud
phenomenon, cyanosis, sudden death
Diagnosis = increased brain natriuretic peptide
chest CT or MRI = enlargement
of main pulmonary artery,
right ventricular hypertrophy,
decreased caliber of
peripheral pulmonary vessels
echocardiography
cardiac catheterization
心臟病及保健 heart disease and health
 Severity of pulmonary hypertension:-
NYHA classificationhemodynamic values in cardiac catheterization  Treatment of pulmonary hypertension:-
oxygendiuretic, calcium blockers, inhaled or parental prostanoids, anticoagulation, digoxin, endothelin antagonist, phosphodiesterase inhibitor (eg viagra) surgery (heart-lung and lung transplantation, pulmonary thromboendarterectomy, atrial septostomy) 心臟病及保健 heart disease and health
 Liver disease may develop pleural
effusions (hepatic hydrothorax), pulmonary vascular dilation with hypoxemia (hepatopulmonarysyndrome), pulmonary hypertension (from high cardiac output, or from increased pulmonary vascular resistance = portopulmonary hypetension) 心臟病及保健 heart disease and health
(II) Pulmonary embolism
 Most pulmonary embolism result from thrombi
originated in pelvic or deep veins of leg (=deep
venous thrombosis DVT) embolize to pulmonary
arteries.
 Risk factors of deep venous thrombosis and
pulmonary embolism :-
elderly, obesity, smoking, cancer,
surgery/immobilization/trauma/bed ridden, heart
disease (eg. heart failure), stroke, COPD, pregnancy,
oral contraceptives, hypercoagulable syndrome eg.
Sickle cell ds, protein C, S deficiency,
hyperhomocystenemia, polycythemia, thrombophilia,
thrombophlebitis, prior pulmonary embolism, central
venous instrumentation, postpartum, sepsis etc.
心臟病及保健 heart disease and health
 massive pulmonary embolism  increase right
ventricular wall tension  decrease right coronary
flow and increase right ventricular myocardial
oxygen demand  myocardial ischemia, cardiogenic
shock, death.
 massive pulmonary embolismrisk of cardiogenic
moderate to large pulmonary embolism  right
ventricular hypokinesis but
normal blood pressure
small to moderate pulmonary embolismnormal blood
pressure and right
ventricular function
 pulmonary infarctionunremitting chest pain, hemoptysis
paradoxical embolism  stroke
心臟病及保健 heart disease and health
Diagnosis of deep venous thrombosis
tenderness, palpable cords, calf asymmetry, Homan’s sign = pain associated with active and/or passive dorsiflexion of foot.
 plasma markers eg. D-dimer, P-selectin ,  compression ultrasound of lower limbs 心臟病及保健 heart disease and health
Diagnosis of pulmonary embolism
 Usually nonspecific. So suspicious particularly in
patients with risk factors
 Symptoms eg. dyspnea, tachypnea (most common),
pleuritic pain or hemoptysis, circulatory collapse,
cyanosis, diaphoresis, cough, palpitation, DVT
symptoms (calf or thigh pain and swelling), low
grade fever
 Electrocardiogram = S1Q3T3, S1S2S3, right axis
deviation, RBBB, right atrial enlargement, right
ventricular hypertrophy
 Chest X-ray = oligemia, pleonemia of the obstructed
lung, dilated hilar arteries, elevated hemidiaphragm,
dilated pulmonary artery trunk, pleural effusion,
atelectasis, infiltrate
心臟病及保健 heart disease and health
 Arterial blood gas = low PO2
low alveolar-arterial oxygen difference (< 20 mmHg)
= 150 – 1.25 (PCO2) – PO2
 Echocardiogram = 1. visualization of emboli in right
atrium or ventricle, or pulmonary artery;
2. right ventricular enlargement or dysfunction
 Ventilation-perfusion lung scan=large, wedge-shaped,
pleural-based perfusion defects in areas that
ventilate normally and are radiographically
 SPECT perfusion lung scan
 Spiral chest CT or MRI angiography
 Pulmonary angiography = definitive diagnosis for
pulmonary embolism
心臟病及保健 heart disease and health
Prevention and treatment of deep venous thrombosis and
pulmonary embolism
 Thrombolytic agents (tPA 100 mg intravenously for 2 hours) after spiral CT (confirmation of pulmonary embolism) in hemodynamically unstable patients (if no contraindication)  In massive ileofemoral deep venous thrombosis at risk of limb gangrene, catheter-directed thrombolytic agent administered directly into the thrombus 心臟病及保健 heart disease and health
 Inferior vena cava filter indication:-
1. anticoagulants contraindicated
2. pulmonary embolism (not DVT) recurrence in
of adequate anticoagulants
3. severe pulmonary embolism that any recurrence
may be fatal
 Catheter-tip embolectomy for acute massive
pulmonary embolism
 Surgical pulmonary embolectomy for massive
pulmonary embolism, hemodynamically unstable
patients despite heparin and resuscitative efforts,
failure or contraindication of thrombolytic therapy
 Pulmonary thromboendarterectomy for patients with
chronic thromboembolic pulmonary hypertension
(due to incomplete resolution of pulmonary
embolism  pulmonary hypertension  right heart
failure  death)
心臟病及保健 heart disease and health
(III) Cor pulmonale
= right ventricular hypertrophy and dilatation secondary to pulmonary hypertension caused by lung parenchymal disease pulmonary fibrosis, high altitude, sleep apnea, chest wall deformity etc.) and/or pulmonary vasculature (eg. pulmonary thromboembolism, pulmonary veno-occlusive disease, pulmonary vascular tumors and malformations, pulmonary vasculitis etc) , unrelated to left heart.

Source: http://home.educities.edu.tw/leeyingsiu/engslide-cor-heartdisease.pdf