Pulmonary Hypertension Explained Clearly by MedCram.com

Aug 24, 2023

Pulmonary Hypertension Explained Clearly by MedCram.com

Dr. Roger Seheult of https://www.medcram.com/?utm_source=Y…
explains the key aspects of pulmonary hypertension:

0:14 - Definition of pulmonary hypertension
0:20 - Mean pulmonary artery pressure
1:00 - Using systolic to estimate pulmonary hypertension with echocardiogram
1:18 - 5 different WHO pulmonary hypertension groups
1:30 - Pulmonary arteriolar hypertension (PAH), Idiopathic pulmonary hypertension, collagen vascular diseases, portal HTN
3:35 - BMPR2
4:00 - Left heart failure
4:10 - Lung disease, COPD, OSA, idiopathic pulmonary fibrosis
4:35 - Pulmonary embolism, chronic VTE
4:50 - Hematologic disorders, sarcoidosis, glycogen storage diseases, renal failure
5:40 - Amphetamines
5:50 - Diagnosis of pulmonary hypertension and physical exam findings
6:07 - Heart sounds, loud P2, tricuspid regurgitation, RV heave
6:35 - JVP, c,v waves liver pulsatile, edematous legs
6:58 - Chest Xray findings with pulmonary hypertension
7:36 - ECG/EKG findings with pulmonary hypertension, RVH, RBBB
8:17 - Echocardiogram findings with pulmonary hypertension
9:03 - Tricuspid regurgitation, regurgitant jet, Modified Bernoulli Equation
10:40 - Advantages of echocardiogram: PASP,
11:10 - Echo bubble study
11:25 - Right heart catheter, wedge pressure, Left atrial pressure (LAP), mean artery pressure (MAP)

Speaker: Roger Seheult, MD
Clinical and Exam Preparation Instructor
Board Certified in Internal Medicine, Pulmonary Disease, Critical Care, and Sleep Medicine.

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Produced by Kyle Allred PA-C

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Content

0.56 -> well welcome to another MedCram lecture we're going to talk about

4.77 -> pulmonary hypertension this is an interesting topic there's been a lot of

9.059 -> developments recently so let's get talking about pulmonary hypertension so

14.07 -> you have to know the definition first of pulmonary hypertension and there's a

17.55 -> couple of ways of measuring it the first one is looking at the mean pulmonary

23.73 -> artery pressure and the other one is looking at the systolic this is how you

32.88 -> measure it and but by definition it's by the mean pulmonary artery pressure and

39.059 -> generally speaking if it is greater than or equal to 25 millimeters of mercury at

46.17 -> rest or greater than or equal to 30 millimeters of mercury at an exercise

54.26 -> that will meet the criteria for you having pulmonary hypertension systolic

60.899 -> is used when we are trying to estimate using echocardiogram we'll talk about

67.92 -> that echocardiogram okay so there are major different categories for pulmonary

75.06 -> hypertension let's talk about those so these are the five different whu-oh

81.689 -> groups this is the World Health Organization they've divided pulmonary

86.58 -> hypertension into five different groups so what are the different groups the

91.439 -> first one is actually termed as pulmonary arteriolar hypertension and

98.28 -> the key there is this word arteriolar because all the other ones are really

103.77 -> just PAH or pH I should say pulmonary hypertension and we'll talk about those

111.72 -> but PAH has to do with the artery so why is the artery enlarged so this includes

118.829 -> the term what it used to be known as this primary pulmonary hypertension so

122.82 -> I'll just put primary pulmonary hypertension but specifically it's

126.39 -> idiopathic pulmonary hypertension so this was typically in young women

133.94 -> and really couldn't find a reason for why the pulmonary artery pressures were

140.34 -> enlarged but then it also included some secondary forms of pulmonary

145.89 -> hypertension that having to do with collagen vascular diseases HIV portal

155.97 -> hypertension even schistosomiasis chronic hemolytic anemia persistent

164.43 -> pulmonary hypertension of the newborn even pulmonary vino occlusive disease or

171.92 -> even pulmonary capillary Humanzee o mitosis so those are some of the more

176.4 -> uncommon ones I think the one that you really need to focus in on is this

180.57 -> idiopathic pulmonary hypertension okay but the reason why I include all of

186.03 -> these in here is because the medicines that we're going to talk about really

188.73 -> are for Group one there is another one that fits into Group four which will

193.2 -> talk about the new one but generally speaking the new medications and even

197.61 -> the old medications that we have for Palmeri hypertension really are for this

202.65 -> type so if you've got a patient that's got pulmonary hypertension in one of

206.22 -> these other categories with maybe the exception of number four these medicines

210.48 -> really haven't been shown to be very beneficial so things like idiopathic

215.58 -> pulmonary hypertension there's even one now that we're thinking about it here

220.769 -> that has a gene called the bone morphogenetic protein receptor type -

228.959 -> okay so type 1 is a huge massive group of different types of idiopathic

235.35 -> pulmonary hypertension so let's talk about number two because these are all

239.58 -> different - is pretty simple it has to do with left heart failure okay number

248.67 -> three has to do with lung disease okay so that would include COPD that would

257.1 -> include idiopathic pulmonary fibrosis we can think of a whole bunch of other

261.87 -> things even sleep diseases like obstructive sleep apnea

266.76 -> okay so things that causes hypoxemia alveolar hypoventilation disorders like

271.89 -> obesity hypoventilation things of that nature group four has to do with

277.68 -> pulmonary embolism and chronic VTE now there's a medication that we'll talk

284.07 -> about that actually is approved for whu-oh four and then finally five was

290.73 -> kind of left there for those that are unclear

292.95 -> so hematological disorders myeloproliferative disorder splenectomy

297.29 -> sarcoidosis is one glycogen storage diseases fibrosis in medius tinnitus

308.49 -> about chronic renal failure okay so what I want you to take home from this is

315.42 -> number one is PAH it has to do with the artery it's pulmonary arterial or

320.4 -> hypertension and the biggest one that fits into that category is the

324.48 -> idiopathic pulmonary hypertension but there's also collagen vascular diseases

327.84 -> etc number two left heart disease number three lung disease number four pulmonary

333.69 -> embolism number five sort of the grab bag like sarcoidosis

338.25 -> there's also amphetamines which can also fall into type one and so and feta means

347.57 -> okay so we've divided these up into the different categories let's actually talk

353.07 -> about now some of the physical diagnosis findings how do you actually diagnose pH

358.86 -> and then the treatment for pulmonary hypertension in this and the next videos

364.26 -> so let's move on to some of the physical findings okay let's talk about the heart

370.2 -> sounds the first thing that you're going to notice here is that there's going to

374.22 -> be a loud p2 and that's because of the pulmonary hypertension that is closing

380.67 -> very hard the pulmonic valve the other thing that you're going to notice is a

385.05 -> murmur of tricuspid regurgitation which remember is hollow systolic you're also

391.95 -> going to have right ventricular heave that you might feel on JDP because of

398.67 -> the pulmonary hypertension you're going to notice larger c/v waves

404.78 -> okay otherwise known as regurgitant waves and

408.45 -> it's this regurgitation that allows you to estimate the PA pressure the liver is

412.98 -> going to be pulsatile the legs are going to have edema and on chest x-ray what

419.58 -> you'll notice is something we call pruning of the blood vessels so in the

426.42 -> middle of the chest whereas normally you would see these blood vessels go out

430.2 -> what happens is because the pulmonary hypertension is these blood vessels

434.37 -> don't go very far they stay in the middle they're enlarged and they stay in

438.99 -> the middle and then for the most part the periphery is generally free of blood

445.5 -> vessels so it's almost this all a gimme ax or darker lung fields on the

451.02 -> peripheral chest x-ray okay so what would you think you might see on a EKG

458.39 -> so on EKG what you would expect to see is right ventricular deviation so an r v

466.919 -> h maybe a right axis the other thing that you would see is an enlarged right

472.65 -> atrium so if you remember and lead to you would have a peaked or a tenting P

478.83 -> wave okay that would be what you would expect also if you have right

483.84 -> ventricular hypertrophy remember in lead v1 you're probably going to see a large

488.9 -> V wave you might even see a right bundle branch block depending on how much

496.1 -> enlargement there is however the biggest thing that you're going to see is an

500.16 -> echocardiogram and what what's going on here is if we were to look at the heart

506.39 -> here's the right side and here's the tricuspid valve if we get an echo

512.7 -> machine an echo probe which is looking exactly on that tricuspid valve

521.52 -> every time that right ventricle contracts it's got to pump blood into

527.52 -> the pulmonary outflow tract and to do that it has to overcome the pressure to

533.13 -> get the blood into the pulmonary artery well when that

536.73 -> happens the pressure here in the right ventricle is going to be equal to the

541.889 -> pressure in the pulmonary artery well this tricuspid valve may not close

546.66 -> completely and so what's going to happen is you're going to get a tricuspid

549.42 -> regurge attend jet going away from the probe now if it's going away at a zero

554.73 -> degree angle then we can directly measure the velocity of that regurgitant

559.38 -> jet and that velocity is related secondary to the modified Bernoulli's

564.089 -> equation to the pressure that's in the right atrium the fact that the right

568.32 -> atrial pressure is lower means that there's going to be a regurge than jet

571.11 -> the difference between them is going to affect the velocity of that wave and the

575.699 -> way it's affected is that the change in pressure is equal to four times the

581.1 -> velocity squared so if we know what the velocity is let's say it's three meters

586.079 -> per second we can square that which will give us nine and multiply it by four and

591.99 -> in that case nine times four would be thirty six millimeters of mercury so

600.209 -> this becomes very helpful in estimating this is an estimate of what the PA

605.25 -> pressure is to this this is the difference between the right atrium and

609.32 -> the right ventricle so what you need to do is add the pressure the absolute

614.88 -> pressure that is in the right atrium so you'll know what the actual pressure is

618.149 -> and the right ventricle so for this we add the RA pressure now we estimate that

623.37 -> by looking at the IVC if the IVC is very distended then we give it a fifteen if

629.16 -> it's moderately distended we give it a ten if it's collapsible we give it a

632.67 -> five and we simply add it to the four v squared number so echocardiogram is very

639.48 -> helpful so what is Ecco good at doing number one it's good at estimating the

645.779 -> pulmonary artery systolic pressure not the mean but the systolic pressure we

650.55 -> talked about that before number two it can also measure things like the right

656.01 -> atrial size and the right ventricular size to show how long this has been

660.54 -> going on for because the pressures on the right side are higher than that on

664.35 -> the left the question then then becomes is there a patent

668.1 -> for amen Ovalle and to do that you're going to have to inject bubbles so you

673.11 -> can do a bubble study and that's very helpful to see if there is a shunt

677.16 -> process going on the other thing that has to be done is when you want to

682.649 -> confirm this is you want to do something called a right heart catheter now right

688.23 -> heart catheter is when you stick the catheter down into the right atrium into

693.12 -> the right ventricle and then out through the pulmonary artery and you actually

697.709 -> measure now what the pulmonary artery pressure is so here you get an actual

703.37 -> measurement of the PA pressure this is not the systolic pressure we're going to

709.56 -> get the systolic we're going to get the diastolic and we're going to get the

714.12 -> mean and that's where we can find out if the patient actually has pulmonary

718.199 -> hypertension so before we actually treat anybody we really want to make sure we

722.339 -> have a right heart cath the other thing that a right heart cath allows us to do

726.269 -> is to wedge the balloon catheter into a pulmonary artery so we can figure out

732.139 -> what the left atrial pressure is and if the left atrial pressure is less than 18

738.06 -> that means it's not due to left ventricular failure and so that would

743.009 -> rule out a group too and would rule in a group one and the pressure that we're

748.47 -> looking for there is approximately around 18 the mean artery pressure again

753.72 -> what we kind of want that is to be above 25 millimeters at rest and 30

759 -> millimeters with exercise okay well join us for our next video where we talk

763.139 -> about the treatment of pulmonary hypertension

774.339 -> you

Source: https://www.youtube.com/watch?v=V7LyWmFXuaY