PULMONARY HYPERTENSI

LEARNING OBJECTIVES
shouldbe able to:
After completing this case study, the reader hypertension.
"Determine risk factors for developing pulmonary arterial
pulmonary hypertension.
"Discuss common signs and symptoms associated with hypertension.
"List the pharmacologic agents used to treat pulmonary hypertension.
"List the nonpharmacologic agents used to treat pulmonary
education for apatient
"Recommend appropriate pharmacologic and nonpharmacologic
with pulmonary arterial hypertension.
PATIENTPRESENTATION

Chief Complaint passed out on

"A few hours ago, Ifelt really dizzy and short of breath, and I suddenly
the bathroom fleor."
HPI
of episodes of
Cindy Price is a 32-year-old woman who presents to the ED complaining
dyspnea and dizziness. Whilestepping out of the shower this morning, she became very
falling to the floor and hiting
weak and experienced a syncopal episode. She remembers to the ED this morning by
her head but remembers nothing after that. She was brought
her sister.
PMH
Hypertension x 4 years
GERD x 6 years
Possible asthma
FH Mother is 57 and was diagnosedwith pulmonary
Father died of heart failure at ageef6 with her sister (her only sibling).
hypertension 4 years ago. She ysingleAnd lives
SH
use. Admits td heavy cocaineuse in her late 20's. Has tried
Denies tobacco or alcohol prescription amphetamines) since she was in college.
various fad diets (including
Meds
Hydrochlorothiazide 12.5 mg po Q AM
Q46 h PRNSOB
Albulrol MDI 1-2 puffs
once daily PRN
10
wosining mg po m i
Conde

pregnans
AlI
NKDA
ROS
Today, Cindy says she is
increased dyspnea, fatigue, çomfortable
ahd
at rest but
complains of having experienced
months. Shesays that these dizziness with her everyday
experiencingandthese symptoms symptoms only mildlylimit her activities for the past 6
at resty/Over the past 2-3 physical activity and denies
nalpitations noticeable swelling ini her ankles. She months, she has developed
this acute incident. denies episodes of syncope before
Approximately
for jncreasing shortness of breath. Her9 months ago, Cindy was seen by her family doctor
as attributed to asthma, so he physician believed that her increasing dyspnea
prescribed
saýs that the atbuterol inhaler did not aD albuterol inbaler for her to use. The patient
inprove her shortness of breath.
Physical Examination
Gen
Class|l
Patient is lying in ED bed and appears to be in moderate distress
VS
BP 130/84, P 120/RR 26, T 37°C; Wt 128 kg, Ht 5'6"(02 sat 88% on
room ajr
795
Skin
Çoolto touch;)no diaphoresis
HBENpoor CnCalcio Biooe Jovital orqan
membranes; TMs intact
PERRLA; EOMI; dry mucous
NeckLymph Nodes Dupler ae equale Bgh
thyromegaly:no bruits
()JVD} no lymphadenopathy; no(Right Side
Lungs/Thorax HE rales
’ rhonchi,
Clear without wheezes, or
Breasts
Deferred
CV
plit S2,loud P2,S3 gallopl
Abd sounds; no guarding
enlarged; normal bowel
Soft; (+) HJR; liver slightly
Genit/Rect
Deferred

25
 MS/Ext extremities; no clubbing or cyanoci.
2-+ cdema o both lower
Fullrarnge of moticn:
pulses palpable.
Neuro
A &O x 3: normal DTRs.
Labs WBC 8.8 x
103/mm3 Mg 2.1 mg'dL.
Na 138 mEq/L Hgb 14 g/dL Ca 8.4 mg/dL
Neutros 62%
Hct 40%
K3.8 mEq/L BNP 60pg/mL
RBC 5.lx 106/mm3
Cl98 mEq/L Eos 1%
Plt 311 x 103/mm3
CO2 28 mEq/L Lymphs 32%
MCV 84 um3
BUN 12 mg/dL Monos 3%
MCHC 34 g/dL
SCr 0.9 mg/dL
Glu88 mg/dL
depression in right precordialleads.
ECG) 120 bpm), ST-segment
Sinus tachycardia(rate pulmonary edema
Chest X-Ray artery; no apparent
Cardiomegaly:|prominent main pulmonary
Echocardiography tricuspid regurgitation,estimated
ventricular andatrial hypertrophy;
Right
mmn Hg.4
ontera
mPAP55
Ventilation/Perfusion
Negative
pulmonary
Scan
embolism
forFunction Tests
Pulmonary
of predicted)
(61%
FEVI1.87L ofpredicted)
(57%
F&O2.10=L0.89
EVIE
Problem Identificaion
1a. What potential(risk
l.a. factors
QUESTIONS
hypertension? locs this patient have for
devcloping pulmonary
)Foily Hoong
2) 4IN, Ait a
3) cai Apheawi
4) Sywptocj (Dypnee
Diiguiss /Syulo
epissd

evidence is suggestive of pulmonary

1.6.What subjective and objective clinical
hypertension?
Suhjechudyspuea,Fatigues dureneSwels

galtop

+
+2edena
 case?-
Desired Outcome
thetreatmentin this
2. What are the desired goalsfor

XComplicatioM Syapo,
pograssios_orSfouw

Therapeutic Alternatives
for the treatment f puBmonary
3.a. What pharmacologic alternatives are available management, mechanism
hypertension? Include each medication's role in disease state
contraindications.
of action, potential adverse effects, and KCHF
Dprstaglhaloges ebprastrnolhHpe

2) Ganelylcgloseanalayuc
tecyptor Anbgoný
3)L ndotne one reeptor
A) DE-51 lee nbrisent a
Heoclah Hypofensi 4LTAST
XMHte
5

SAaulatgrs block bXher

t.6. What
What
bypertension?
nonpharmacologic alternatives are
availablc for thetrcatment of
pulmonary

pulm
VAvoic
oner
escersiceg hanng ecuctio n.
Optimal Plan win woYse- Conolitio
4.a. Design atreatment plan for the initial
management of this patient's pulmonary
bunertension. Include patient-specific infonation,
schedule. inçluding dosage form, dose, and
baastSATi ASThora ’ Juticte
Preghancgst
Class n
’ momitorn
rag ECI6.ai -uslt
L Acverseeech if the initialtherapy
ASSISmen
fails or cannot be
4.b. What alternatives would be appropriate
used?

29
 30

dopujhmonary edenCaurgn
bit re
Level wa
okeStyseMol*icadin
cfeA Side

eoduati: ationt p

effects? adverse minimize andtherapy, Successtul

lianee enhance patient
to the provided
to information
should
be What 6.
Education Patient