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Pulmonary Hypertension Case Discussion - Dr. Shashi Prabha.pptx

  1. 1. Case Discussion By Dr. Shashi Prabha Pandey First Year MD- Clinical Yoga
  2. 2. Content Case History Disease Description Management
  4. 4. Preliminary data •Name : Divya •Age: 43 years •Sex: Female •Occupation : Home Maker •Marital Status : Married •Religion : Hindu •Address : Bangalore •D.O.A: 26-01-2023 History Taking
  5. 5. Chief complaints • C/O increased body weight since 2yrs. • K/C/O pulmonary hypertension since 2 yrs. • C/O lower back pain since 6 months. • K/C/O sinusitis since 3 months.
  6. 6. History of Chief Complaint • H/C/O Increased body weight . The weight gain is gradual in onset, due to sedentary lifestyle. • PH on treatment from last 2 years. • Low back pain since 6 months. • Sinusitis since 3 months.
  7. 7. • Not relevant. Past History Medical History • Zoamet Nasal Drops - SOS • Tab. Lasilactone 50 mg ½ - ½ - 0
  8. 8. Surgical History • No surgical history Obstetric History • G - 6 • P - 1 • L - 1 • A - 5 • C - 0
  9. 9. Gynaec History • Last menstrual period (LMP) - 15/01/2023 • Cycle length and frequency - 3/28 • Clots- Ab • Dysmenorrhea - Ab • Intermenstrual bleeding (IMB) - Ab • Postcoital bleeding (PCB) - Ab • Age of menarche- 14 yrs. of age • Breast Tenderness- Present
  10. 10. Family History • Maternal – Hypertension , CVD • Paternal - Tuberculosis
  11. 11. • Diet - Mixed • Appetite - Good • Thirst - Normal • Micturition - Normal in frequency • Bowel - Regular • Sleep - Disturbed • Habit - Coffee, once daily • Addiction - Nil • Food allergy - Nil Personal History Vital Parameters • Blood pressure - 130/82 mm Hg • Pulse rate - 84 bpm • Respiratory rate - 16 cpm • Temperature - Afebrile • Height - 155 cm • Weight - 94.1 kg • BMI - 39.1 kg per meter square
  12. 12. General Physical Examination • Built- Obese • Nutrition- Vit. B12 and D deficiency • Nails- Normal • Conjunctiva- Clear • Pallor- Absent • Clubbing- Absent • Tongue- Not coated • Cyanosis- Absent • Lymph nodes- Not enlarged • Varicosity- Absent • Icterus- Absent • Edema- Absent • Shape of spine - Normal
  13. 13. Cardinal Symptoms • Dyspnea – Present ( on exertion ) • Sweating - Present ( on exertion ) • Palpitations – Present ( on exertion ) • Cough - Absent • Chest Pain - Absent • Hemoptysis - Absent • Syncope - Absent • Chest tightness - Absent • Blurred Vision - Absent
  14. 14. Systemic Examination
  15. 15.  Respiratory system: Vesicular breathing sounds heard.  Abdominal Examination: p/a soft, non-tender, no organomegaly, bowel sounds are heard.  Central Nervous System: Conscious, Well oriented, Higher mental functions are normal  Locomotor system: Heel Strike gait with an alignment.
  16. 16. Cardio Vascular Examination : 1) General Examination(CVS) 2) Inspection 3) Palpation 4) Percussion 5) Auscultation
  17. 17. General Examination Pallor • The pallor of anemia is seen in the mucous membranes of the conjunctivae, lips, tongue and in the nail beds. • Anemia can cause sinus tachycardia, heart failure (Hyperdynamic)
  18. 18. General Examination • Cyanosis • Bluish discoloration of the skin and mucous membranes caused by increased concentration of reduced hemoglobin (5g/dl). • Central cyanosis may result from the reduced arterial oxygen saturation caused by cardiac or pulmonary disease. • Peripheral cyanosis may result when cutaneous vasoconstriction slows the blood flow and increases oxygen extraction in the skin and the lips.
  19. 19. General Examination  Clubbing • It is painless soft-tissue swelling of the terminal phalanges. • Congenital cyanotic heart disease, Infective endocarditis.
  20. 20. General Examination  Edema • Edema is tissue swelling due to an increase in interstitial fluid. • Pressure should be applied over a bony prominence (tibia, lateral malleoli, sacrum). • Cardinal feature of congestive heart failure. • Prominent around the ankles in the ambulant patient and over the sacrum in the bedridden patient.
  21. 21. • In advanced heart failure, edema may involve the legs, genitalia and trunk.  Edema
  22. 22. • Rate – 60-100bpm • Rhythm  Pulse General Examination
  23. 23.  Blood Pressure General Examination
  24. 24. 1. Precordium • It is the anterior aspect of the chest, which overlies the heart. • The subject should be examined in the recumbent and sitting position, and in good light. • Bulging - 1. Enlarged heart 2. Pericardial effusion 3. Mediastinal tumor 4. Pleural effusion 5. Scoliosis • Flattening - 1. Fibrosis of lung 2. Congenital deformity Inspection
  25. 25. 2. Apex Impulse • Normally it is in the fifth left intercostal space just inside the mid clavicular line. • Left lateral position. • Not seen in case of obesity emphysema and pericardial effusion. Inspection
  26. 26. 3. Pulsations • Check for abnormal pulsations in other parts of the chest. • Ex. Left Parasternal- Left atrial enlargement, Aneurysm of aorta etc. • Epigastric : Right ventricular hypertrophy etc. • On the right side of the chest - Dextrocardia, Right atrial enlargement etc. Inspection
  27. 27. • Palpation for Apex Beat (Position and Character) • Palpation for Position of trachea • Palpation for Parasternal Heave, thrills Palpation
  28. 28. Apex Beat • Position - Normally in the fifth left intercostal space, the mid- clavicular line. • Enlargement of the heart due to hypertrophy or dilatation may shift the apex beat. • Pulling or pushing of the mediastinum due to lung disease may shift the position of the apex beat. • May not be palpable in some cases- located behind a rib, obesity, plural effusion, pericardial effusion, dextrocardia etc. Palpation
  29. 29. Parasternal Heave • Position - Systolic impulse in the left parasternal region. • Left ventricular enlargement. • It is assessed by placing the ulnar border of the hand on the left parasternal area, with the patient in supine position. Palpation
  30. 30. Percussion for Borders of the Heart • Left Border - fourth and fifth space in the mid- axillary region. • Upper Border - in the second and third left intercostal spaces in the parasternal line. Normally there is resonant note in the second space and dull note in the third space. • Right Border of Heart - Right border of the heart, which is formed by the right atrium, lies behind the sternum.
  31. 31. Auscultation • Heart Sounds • Murmurs
  32. 32. Auscultatory Areas • Aortic valve: second intercostal space at the right sternal border. • Pulmonary valve: second intercostal space at the left sternal border. • Tricuspid valve: fourth intercostal space at the left sternal border. • Mitral valve: fifth intercostal space at the left midclavicular line.
  33. 33. First Heart Sound (S1), ‘lub’ • It is best heard at the apex, tricuspid and mitral valve area. • Prolonged – low pitched
  34. 34. Second Heart Sound (S2), ‘dup’ • It is caused by closure of the pulmonary and aortic valves. • At the end of ventricular systole and is best heard at the left sternal edge. • Shorter- High pitched.
  35. 35. • Murmurs are abnormal heart sounds caused by vibration of the valves or the wall of the heart or great vessels. • Develop due to alterations in blood flow. • Systolic: occurs at or after S1, finishing before S2 • Diastolic: occurs at or after S2, finishing before S1 • Continuous Murmurs Murmurs Thomas SL, Heaton J, Makaryus AN. Physiology, Cardiovascular Murmurs. [Updated 2022 Jul 18].
  36. 36. Investigations
  37. 37. Imaging – To look for PH • Chest X-ray: to assess for signs of underlying lung disease or left ventricular dysfunction (pulmonary venous congestion). It may show enlarged pulmonary arteries. • Echocardiography: May show increase pulmonary arterial pressure, enlarged right ventricle.
  38. 38. • Spirometry: to look for chronic lung disease. • Ventilation/ Perfusion Scan: to look for thromboembolic disease. • Autoantibodies : To exclude autoimmune diseases. Tests- for underlying causes
  39. 39. • Right heart Catheterization : to measure the pressure of blood vessels in the lungs. To confirm PH
  40. 40. Diagnosed only when other causes have been rule out • Aortic Stenosis • Atrial Septal Defect • Chronic Obstructive Pulmonary Disease (COPD) • Chronic Pulmonary Embolism • Cardiomyopathies • Emphysema Differential Diagnoses • Interstitial Lung Disease • Mitral Regurgitation • Mitral Stenosis • Obesity-Hypoventilation Syndrome • Obstructive Sleep Apnea (OSA) • Restrictive Lung Disease
  41. 41. Provisional Diagnosis • Grade II Obesity • Pulmonary Hypertension • Sinusitis • Mechanical low back pain
  42. 42. Pulmonary Hypertension
  43. 43. Definition Classification Pathology & Pathophysiology Approach to diagnosis Treatment Table of Content
  44. 44. Pulmonary Arteries • The pulmonary arteries are the two major arteries coming from right ventricle of our heart. • They carry low-oxygen blood from the heart to the lungs. • There oxygenation takes place and excess carbon dioxide is removed. • The blood is then pumped back into the left atrium via the pulmonary veins.
  45. 45. Definition • By WHO - Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (PAP) measured by right heart catheterization ≥ 25 mm Hg at rest. Leads to right sided heart failure. • It is an umbrella term for many different diseases which lead to increased pressure in the pulmonary arteries. • Normal pressure is 14-18mmHg at rest • 20-25mmHg on exercise. Hoeper MM, Bogaard HJ, Condliffe R, et al. Definitions and diagnosis of pulmonary hypertension. J Am Coll Cardiol. 2013
  46. 46. Signs and Symptoms Initial - • Difficulty breathing • Fatigue • Weakness • Chest Pain • Dizziness • Syncope Later - • Hemoptysis • Hoarseness- due to nerve compression in the chest
  47. 47. Signs and Symptoms of Untreated PH • Right heart failure • Ascites • Liver enlargement • Increase Jugular Venous Pressure • Cyanosis
  48. 48. • Prevalence of about 1% of the global population, which increases up to 10% in individuals aged more than 65 years. • Left-sided heart and lung diseases have become the most frequent causes of pulmonary hypertension. • About 80% of the disease is associated with congenital heart disease and various infectious disorders, including schistosomiasis, HIV, and rheumatic heart disease. • It is associated with clinical deterioration and a substantially increased mortality risk. Epidemiology and Risk factors
  49. 49. Clinical Classification of Pulmonary Hypertension • Group 1: pulmonary arterial hypertension (PAH) • Group 2: PH due to left heart disease • Group 3: PH due to lung diseases or hypoxia, or both • Group 4: chronic thromboembolic PH (CTEPH) • Group 5: PH with unclear multifactorial mechanisms.
  50. 50. A global view of PA global view of pulmonary hypertension- The Lancet hypertension
  51. 51. • In this group of PH, the arteries and lungs are not as thick or stiff as WHO Group 1, but there are problems with how the heart squeezes or relaxes, or problems with the valves on the left side of the heart. Because of this, the left heart is unable to keep up with the blood returning from the lungs — causing a “backup” of blood which raises pressure in the lungs. 2.Pulmonary Hypertension Due to Left Heart Disease
  52. 52. • Includes PH due to chronic lung disease and/or hypoxia. • Due restrictive lung diseases, lung cannot expand fully which leads to high blood pressure throughout the lungs. 3. Pulmonary Hypertension Due to Lung Disease
  53. 53. • WHO Group 4 is called chronic thromboembolic pulmonary hypertension (CTEPH). • This can lead to scar tissue in the blood vessels of the lungs, which blocks normal blood flow and makes the right side of the heart work harder. 4.Pulmonary Hypertension Due to Chronic Blood Clots in the Lungs
  54. 54. • PH is secondary to other diseases in ways that are not well understood. These associated conditions include sarcoidosis, sickle cell anemia, chronic hemolytic anemia, splenectomy (spleen removal) and certain metabolic disorders. 5.Pulmonary Hypertension Due to Unknown Causes
  55. 55. Conventional Management 1. Supportive Therapy • Diuretics • Supplemental Oxygen • Anticoagulants 2. Specific Treatments – Vasodilators which work on following pathways. • Prostacyclin Pathway- Epoprostenol, treprostenol etc. • Endothelin Pathway – Ambrisentan, Bosenten etc. • Nitric Oxide Pathway – Sildenafil, tadalafil etc 3. Advanced – Double lung transplantation
  56. 56. Naturopathy and Yogic Management
  57. 57. Yogic Diagnosis
  58. 58. General Measures • Prohibit the physical strain that causes shortness of breath, chest pain, dizziness, and syncope. • Patients with “cor pulmonale” it is not recommended to stay in the mountain areas above an altitude of 1200m. • Airplane travel is also not recommended if there is no availability of oxygen inhalation in emergency during flight.
  60. 60. Components of a healthy Yogic lifestyle Achar – healthy physical activities and exercise  Vichar- right thought and right attitude  Ahar – healthy and nourishing diet  Vihar – proper recreational activities
  61. 61. Achar Achara - Interventions Rationale Loosening practices. Ankle stretch breathing Hand in and out breathing Tiger breathing Ardhakati chakrasana,, Katichakrasana, Vrikshasana, vakrasana. Slow paced pranayama, Bhramari Cyclic Meditation, Yoga Nidra Reduces peripheral resistance hence reduces BP. Slow, deep breathing activates parasympathetic nervous system which decreases the heart rate and dilates blood vessels, reducing overall blood pressure. Chest expansion to improve cardiac and lung health Stress management, relaxation.
  62. 62. Title Author Intervention Outcome Development of a modified yoga program for pulmonary hypertension: a case series Rana Awdish Three discreet yoga programs were designed with modifications specific to PH patients: • Chair yoga, • Intermediate yoga with a chair assist • experienced yoga. • Subjective and objective effects on clinical, physical function, and psychological outcomes were measured. • Patients described decreases in anxiety and joint pain, with improvements in health-promoting behaviors.
  63. 63. Title Author Intervention Outcome Effect of Yoga Lifestyle in Patients with Heart Failure: A Randomized Control Trial Ashish Asana, Pranayama, Meditation • QOL as assessed by Minnesota living with heart failure questionnaire score improved significantly in YG as compared to CG • There was a significant improvement within YG in terms of LVEF. • CRP decreased by 49.3% in YG and 35.8% in CG.
  64. 64. Vichar- Interventions • Avoid smoking, alcohol as it is associated with an increased risk of heart and lung diseases. • Develop positive attitude, practice gratitude. • Develop healthy sleep and relaxation habits.
  65. 65. The review shows that early studies have investigated the presence of mental disorders such as anxiety, depression, panic, and cognitive impairment. The prevalence of mental disorders in PAH patients lies between 7.5% and 53% for depression and 19% and 51% for anxiety and panic disorders.
  66. 66. EFFECT OF SLOW BREATHING • The changes of heart rate during the different phases of breathing may have a positive influence on lung gas exchange via a more efficient ventilation/perfusion matching. • Controlled breathing has been shown to be beneficial in COPD, heart failure, and high altitude hypoxia that are characterized by a gas exchange impairment. • These studies demonstrated that slow and controlled breathing can improve vagal activity and concomitantly reduce sympatho-excitation, with a favorable effect on symptoms and prognostic variables. Furthermore, controlled breathing can have a favorable psychological effect.
  67. 67. Achar Ahara - Interventions Rationale Leafy green vegetables, Beetroot Whole grains. Berries Omega 3 FA Barley water They are a great source of nitrates which reduce blood pressure, decrease arterial stiffness. Reduces cholesterol levels. Anthocyanins, which protect against the oxidative stress and inflammation, which might contribute to heart diseases. Helps decrease triglycerides. Diuretic Nitrate-Rich Fruit and Vegetable Supplement Reduces Blood Pressure in Normotensive Healthy Young Males without Significantly Altering Flow-Mediated Vasodilation: A Randomized, Double-Blinded, Controlled Trial
  68. 68. Title Author Intervention Outcome Effects of Oral Supplementation With Nitrate-Rich Beetroot Juice in Patients With Pulmonary Arterial Hypertension- Results From BEET-PAH, an Exploratory Randomized, Double-Blind, Placebo- Controlled, Crossover Study Henrohn Beet root Juice which contained (∼16 mmol nitrate ) for 7 days. • BRJ administered for 1 week increases pulmonary NO production and the relative arginine bioavailability in patients with PAH, compared with placebo.
  69. 69. DASH Diet To Stop Hypertension • Originated in the 1990s. • Subjects included in the study were advised to follow just the dietary interventions and not include any other lifestyle modifications to avoid confounding factors. It included- • Vegetables: about five servings per day • Fruits: about five meals per day • Carbohydrates: about seven servings per day • Low-fat dairy products: about two servings per day • Lean meat products: about two or fewer servings per day • Nuts and seeds: 2 to 3 times per week • Results - They found that only the dietary intervention alone could decrease systolic blood pressure by about 6 to 11 mm Hg. Challa HJ, Ameer MA, Uppaluri KR. DASH Diet To Stop Hypertension. [Updated 2022 May 15].
  70. 70. Vihar- Interventions • Meditation and Relaxation techniques. • Self-study. • Nature walk • Bhajans • Educational lectures
  71. 71. Title Author Intervention Outcome Effects of Meditation versus Music Listening on Perceived Stress, Mood, Sleep, and Quality of Life in Adults with Early Memory Loss: A Pilot Randomized Controlled Trial Innes Kirtan Kriya Meditation (KK) and music listening (ML) • Participants in both groups showed significant improvement at 12 weeks in psychological well-being and in multiple domains of mood and sleep quality. • KK group showed greater gains in perceived stress, mood, psychological well-being, and QOL-Mental Health.
  72. 72. Nature Cure
  73. 73. Title Author Intervention Outcome Exercise and respiratory training improve exercise capacity and quality of life in patients with severe chronic pulmonary hypertension Mereles Nutrition, Physical therapy such as massages, Counseling, and muscular relaxation without exercise. • At week 15, patients in the training groups had an improved 6-minute walking distance • Exercise training was well tolerated and improved scores of quality of life • Systolic pulmonary artery pressure values at rest did not change significantly after 15 weeks of exercise and respiratory training.
  74. 74. Title Author Intervention Outcome Repeated Waon therapy improves pulmonary hypertension during exercise in patients with severe chronic obstructive pulmonary disease Megumi Waon therapy at 60 °C in sauna for 15 min following 30 min warmth with blankets outside of the sauna room. This therapy was performed once a day, for 4 weeks. • Repeated Waon therapy improved right ventricular positive dP/dt, PH during exercise, exercise tolerance and the QOL in patients with severe COPD.
  75. 75. Title Intervention Outcome Magnetic stimulation of carotid sinus as a treatment for hypertension. Rongrong • The Optimum Magnetic stimulator (MagPro X 100; Tonica, DK, Farum, Denmark) with a C‐100 circular coil was used for magnetic stimulation. • The subjects were instructed to bend their necks backward slightly with face turn left for better exposing the right carotid sinus. The center of the coil disk was pointed to the right carotid sinus. • It was found that 1 Hz MSCS with the intensity of 20% can lower SBP (6.6 ± 0.4 vs −2.5 ± 0.4 mm Hg, P < 0.0001) and HR (0.5 ± 0.5 vs −1.9 ± 0.3 beats/min, P = 0.002) than sham stimulation. • The nerve fibers with low resistant inside carotid sinus are conductors which can be stimulated by the stimulation. Therefore, the BP‐lowering effects of MSCS observed in this study were supposed to be the activation of carotid baroreflex.
  76. 76. Magnetic stimulation uses Faraday's law of induction to convert a time‐varying magnetic field into induced electrical currents in tissues.The nerve fibers with low resistant inside carotid sinus are conductors which can be stimulated by the stimulation. Therefore, the BP‐lowering effects of MSCS observed in this study were supposed to be the activation of carotid baroreflex.
  77. 77. Acupuncture
  78. 78. Title Author Intervention Outcome Long-Lasting Reduction of Blood Pressure by Electroacupunc ture in Patients with Hypertension: Randomized Controlled Trial Pengli Patients were assessed with 24- hour ambulatory blood pressure monitoring. They were treated with 30- minutes of EA at PC 5-6+ST 36-37 or LI 6-7+GB 37-39 once weekly for 8 weeks. Four acupuncturists provided single- blinded treatment.. • After 8 weeks, 33 patients treated with EA at PC 5-6+ST 36-37 had decreased peak and average SBP and DBP, compared with 32 patients treated with EA at LI 6- 7+GB 37-39 control acupoints.
  79. 79. • Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. McGraw Hill; 2018 • P. J. Mehta’s practical medicine | nihar p. Mehta, s. P. Mehta, sr joshi REFERENCES