3) This program is intended for #healthcare providers and is supported by educational grants from Actelion, Bayer, Chiesi, & AstraZeneca. Faculty disclosures are listed at cardiometabolic-ce.com/disclosures/. Prior programs, still available for credit, are at cardiometabolic-ce.com
4) #PulmonaryEmbolism is common and the 3rd leading cause of cardiovascular death. But there are important long-term complications in those who survive acute PE, including #CTEPH. CTEPH can cause significant morbidity and mortality after #PE. Let’s start with a case!
5) A 67♀️ presents to #emergencymedicine with dyspnea x 3 months that acutely worsens for 3 days. PMHx significant only for #Hypertension. She has taken hydrochlorothiazide for years. She has no prior history of #PulmonaryEmbolism or #DVT.
6) On exam: Sats 91% on room air. HR 91, BP 110/75 . Her JVP is elevated at 6cm, there is mild edema. Lungs are clear and there is a parasternal heave. S2 is loud over the right upper sternal border🩺
7) Labs: D-dimer ⬆️, NT-proBNP⬆️at 2000 ng/L, T-wave inversion in V1-V6. A #CT pulmonary angio is done. See images below:
8) What do you see? There are bilateral filling defects in the proximal pulmonary arteries consistent with pulmonary embolism, but they have a “chronic” appearance to them. Geez, if only these scans always came with the red arrows!
9) Clot from acute PE tends to more central, similar to a “bulls-eye":
10) CTEPH occurs from incomplete resolution and fibrotic organization of thrombus leading to vascular obstruction. See 🔓pubs.rsna.org/doi/10.1148/rg…
11) Other CT features of #CTEPH include webs, bands, complete occlusions & focal stenoses. Calcification of thrombus ➡️ chronicity. Dilation of the pulmonary artery & RV & heterogenous attenuation of the lung (mosaic attenuation) are also often present 🔓doi.org/10.1016/j.heal…
And, for adding consideration of #moyamoya disease to your day . . . YOU ARE WELCOME
13) Time for a brief #Inception thread: A 🧵 within a 🧵! Why is it important to know about & recognize CTEPH? Here are3⃣ good reasons:
1⃣ CTEPH is not that rare! #PE is common. CTEPH occurs in ~ 1/30 or 3% of survivors of acute PE! (fig from 🔓erj.ersjournals.com/content/49/2/1…)
14) 2⃣ Untreated, #CTEPH carries a 70% mortality by 5 years! #CTEPH leads to progressive [Up arrow] in pulmonary pressure, dilation & failure of the #RightVentricle. Higher pressure = worse outcomes.
See doi.org/10.1378/chest.…
15) 3⃣ The most important reason to think about (and find) CTEPH is that effective treatments (and often a cure) exists…more on that later.
17) Back to our patient in the ED. She has signs of chronic PE and pulmonary hypertension on imaging & is hemodynamically stable. What is the most appropriate initial management?
A. Anticoagulation x 3 months
B. Thrombolysis
C. Catheter-directed thrombolysis
D. Thrombectomy
20) Yesterday's quiz? Scroll back⤴️to 17 if you didn't answer!
A. Anticoagulation for 3mos is best initial management. Diagnosing #CTEPH requires 1⃣ at least 3mos of effective anticoagulation 2⃣Pulmonary hypertension 3⃣Persistent obstruction on imaging. 🔓pubmed.ncbi.nlm.nih.gov/26320113/
21) Our patient in the ED likely has #CTEPH, given CT feature & symptom chronicity. In some cases, adequate course of anticoag can improve burden of thromboembolic disease. Close follow-up is required & patients who worsen or have right heart failure need urgent, definitive Rx.
22) Side note: it is always important to consider #CTEPH in a patient with #pulmonaryhypertension. Importantly, NOT all patients with CTEPH have prior history of #VTE. In a patient with #PH on #Echocardiogram, what is the best screening test to rule out #CTEPH? VOTE before ⤵️!
24) In the #PulmonaryHypertension diagnosis algorithm, VQ comes first, as the sensitivity is higher than CT. A normal VQ effectively rules out CTEPH.
25) Defects on VQ (top) suggests CTEPH but can’t differentiate acute from chronic clot. VQ-SPECT CT (bottom) improves Specificity by visualizing areas of parenchymal lung disease doi.org/10.1016/j.heal…
26) If the VQ is abnormal, the next step should be a CT pulmonary angiogram to confirm the presence of #CTEPH and to determine whether it is surgically operable.
28) PTE involves a sternotomy and cardiopulmonary bypass. Patients undergo deep hypothermia to protect neurologic function as the removal of thromboembolic material is done under full circulatory arrest. See 🔓consultqd.clevelandclinic.org/pulmonary-thro…
29) Once the thromboembolic material is removed, the pulmonary vascular resistance and pulmonary artery pressure are usually markedly lower and recovery can begin. An example of surgical specimen from PTE is below.
30) For patients able to successfully undergo PTE surgery, long-term survival is markedly better with >90% survival at 5-years. 🔓pubmed.ncbi.nlm.nih.gov/26826181/
31) Exercise capacity, quality of life and symptoms are also markedly improved after PTE. This figure shows rapid improvements in the #CAMPHOR questionnaire for a) activity b) quality of life and c) symptoms pubmed.ncbi.nlm.nih.gov/32513780/
32) PTE is major surgery that carries risks, but it's also potentially curative. Determining whether a patient is a good candidate for PTE req's multidisciplinary discussion in an expert #CTEPH surgical centre. Factors related to surgical suitability:🔓pubmed.ncbi.nlm.nih.gov/30545969/
33) So for patients unable or unwilling to undergo PTE surgery, which other treatment options can be considered?
A. Balloon pulmonary angioplasty (BPA)
B. Riociguat
C. Lung transplantation
D. All of the above
35) Welcome back! You are just a few 🖱️clicks away from 0.75h CE/#CME! And what a ride! @AlbertaPHdoc is teaching us ALL about #CTEPH--a big problem! Per 🔓pubmed.ncbi.nlm.nih.gov/28356407/, incidence of CTEPH in 🇫🇷🇩🇪🇮🇹🇪🇸🇬🇧🇺🇸🇯🇵 is dramatically ⤴️ing, as is severity at the time of dx.
36) Yesterday's quiz (tweet 33) answer is D. Some pts have distal disease in subsegmental vessels or in the pulmonary microcirculation that is inaccessible to surgery. Some are medically unable to undergo PTE due to comorbidities.
37) #Riociguat and/or #BPA are both options in such patients. Lung Tx can be considered in those with refractory #PH after medical Rx or BPA.
38) The choice of medical therapy with riociguat or BPA depends on the location of the #CTEPH lesions. Some patients receive a combination of PTE (a.k.a. PEA), BPA and medical therapy. 🔓erj.ersjournals.com/content/53/1/1…
39) Currently #riociguat is the only medical therapy approved by the @US_FDA for #CTEPH. Other studies tested #bosentan and #macitentan, but they are not approved (both are endothelin receptor antagonists used in pulmonary arterial hypertension). 🔓doi.org/10.1183/139930…
40) Riociguat is a soluble guanylate cyclase stimulator that increases #cGMP in pulmonary arteries leading to vasodilation and lower pulmonary vascular resistance. It acts independently of nitric oxide availability 🔓err.ersjournals.com/content/19/115…
41) In the CHEST-1 trial, riociguat improved 6-minute walking distance by 36 meters (36 m; 95% CI, 20 to 52 m) at 12 weeks vs placebo, which led to its approval for #CTEPH. See 🔓pubmed.ncbi.nlm.nih.gov/23883378/
43) #BPA is a catheter-based approach like coronary angioplasty where a wire crosses a #CTEPH lesion in a small segmental or subsegmental artery. A balloon is inflated to dilate and disrupt the obstructing lesion and improve blood flow.
🔓err.ersjournals.com/content/26/143…
44) Here is a video of a lower lobe BPA procedure with sluggish, minimal blood flow before ballooning and markedly improved blood flow afterwards.
45) Exercise intolerance in #CTEPH is multifactorial & other defects in the oxygen delivery and uptake pathway may contribute to impairment. Even after restoring or improving cardiac function, many patients have residual peripheral muscle dysfunction 🔓pubmed.ncbi.nlm.nih.gov/33853383/
46) These residual peripheral factors in #CTEPH highlight the role of #exercise training & #rehabilitation. Indeed, a recent RCT of exercise training showed improvements in exercise capacity as is seen with adding medical therapy! pubmed.ncbi.nlm.nih.gov/33232470/
47) There you go! In summary, #CTEPH is an important complication of #VTE but many patients have no prior history of #PE or #DVT. Always consider #CTEPH in a patient with #pulmonaryhypertension
1) Welcome to our #accredited#tweetorial on optimal mgt of #hyperkalemia in the patient with #CKD. Earn 0.5h #CME/CE credit by following this thread. I am Sourabh Sharma MD DNB FASN 🇮🇳 @iamnephrologist & u have found the ONLY source for CE credit delivered entirely on Twitter!
9) Many risk factors modulate the propensity of LDL-C to traverse the endothelium and enter the arterial intima. See 🔓academic.oup.com/eurheartj/arti….
10) It now appears that the passage of #LDL into the #intima is not a merely passive process whereby the concentration in blood & the permeability of the endothelium determine LDL accumulation.
11) It’s #Transcytosis (an active process), through a vesicular pathway involving #caveolae, scavenger receptors (#SRB1) and activin like receptor kinase 1 (#ALK1). Hence for a given blood level of LDL-C the amount of atherosclerosis is variable.
1) Welcome to an #accredited#tweetorial on the role of ⬆️ #LDL-C levels in the pathogenesis & pathophysiology of #ASCVD. I am Kausik Ray MD FRCP @profkausikray, Professor of Public Health & Cardiologist @imperialcollege London AND President of European Atherosclerosis Society
3) #Atherosclerosis starts in childhood, progresses in fits and spurts and presents in middle to late life in the form of major adverse cardiovascular events #MACE.
3) @PaulDThompsonMD took on education re mechanisms & use of ezetimibe & bempedoic acid. He proposes a case: 45 ♂️ w/history of inferior wall #MI treated with primary angioplasty.
3) It is an unfortunate fact of life that one cannot prescribe #anticoagulant or #antiplatelet (together, #antithrombotic) therapy without increasing a patient's #bleedingrisk. That is why it should be an individualized risk:benefit decision, ideally . . .