Difference between revisions of "COVID-19-associated pulmonary hypertension"

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(Differentiating COVID-19-associated pulmonary hypertension from other Diseases)
(Screening)
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==Treatment==
 
==Treatment==
 
===Medical Therapy===
 
===Medical Therapy===
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
 
  
OR
+
* The mainstay of therapy for pulmonary hypertension in covid19  is(10)(13)
  
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
+
# Pulmonary vasodilator
 +
# Supplement oxygen for correction of  hypoxia to maintain oxygen saturation above %90 ,
 +
# Correction of hypotension  with  fluild and inotropic agents to avoid decreased RV coronary perfusion and RV ejection.
 +
# Correction of  acidosis, hypercarbia,hypothermia, hypervolemia
 +
# Intubation is not recommended due to  effect of positive pressure ventilation on increased RV  preload and vasodilatory effect of sedation agents  impending systemic hypotension and                                  hemodynamic collapse.
 +
# If intubation is indicated , vasoactive agent should be given before anesthesia. Etomidate  is recommended for general anesthesia due to  little effect on cardiac contractiliy and vascular tone.
 +
# Ventilator should be set with low tidal volumes and moderate positive end expiratory pressure for minimum air way pressure and sufficient oxygenation and ventilation.
  
OR
+
<br />
 
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
 
 
OR
 
 
 
[Disease name] is a medical emergency and requires prompt treatment.
 
 
 
OR
 
 
 
The mainstay of treatment for [disease name] is [therapy].
 
 
 
OR
 
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
 
 
OR
 
 
 
[Therapy] is recommended among all patients who develop [disease name].
 
 
 
OR
 
 
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
 
 
OR
 
 
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
 
 
OR
 
 
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
 
 
OR
 
 
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
 
  
 
===Surgery===
 
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
+
Surgical intervention is not recommended for the management of pulmonary hypertension in covid 19
 
 
OR
 
 
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
 
 
OR
 
 
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
 
 
OR
 
 
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
 
 
OR
 
  
Surgery is the mainstay of treatment for [disease or malignancy].
+
<br />
  
 
===Primary Prevention===
 
===Primary Prevention===

Revision as of 11:26, 1 July 2020

WikiDoc Resources for COVID-19-associated pulmonary hypertension

Articles

Most recent articles on COVID-19-associated pulmonary hypertension

Most cited articles on COVID-19-associated pulmonary hypertension

Review articles on COVID-19-associated pulmonary hypertension

Articles on COVID-19-associated pulmonary hypertension in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on COVID-19-associated pulmonary hypertension

Images of COVID-19-associated pulmonary hypertension

Photos of COVID-19-associated pulmonary hypertension

Podcasts & MP3s on COVID-19-associated pulmonary hypertension

Videos on COVID-19-associated pulmonary hypertension

Evidence Based Medicine

Cochrane Collaboration on COVID-19-associated pulmonary hypertension

Bandolier on COVID-19-associated pulmonary hypertension

TRIP on COVID-19-associated pulmonary hypertension

Clinical Trials

Ongoing Trials on COVID-19-associated pulmonary hypertension at Clinical Trials.gov

Trial results on COVID-19-associated pulmonary hypertension

Clinical Trials on COVID-19-associated pulmonary hypertension at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on COVID-19-associated pulmonary hypertension

NICE Guidance on COVID-19-associated pulmonary hypertension

NHS PRODIGY Guidance

FDA on COVID-19-associated pulmonary hypertension

CDC on COVID-19-associated pulmonary hypertension

Books

Books on COVID-19-associated pulmonary hypertension

News

COVID-19-associated pulmonary hypertension in the news

Be alerted to news on COVID-19-associated pulmonary hypertension

News trends on COVID-19-associated pulmonary hypertension

Commentary

Blogs on COVID-19-associated pulmonary hypertension

Definitions

Definitions of COVID-19-associated pulmonary hypertension

Patient Resources / Community

Patient resources on COVID-19-associated pulmonary hypertension

Discussion groups on COVID-19-associated pulmonary hypertension

Patient Handouts on COVID-19-associated pulmonary hypertension

Directions to Hospitals Treating COVID-19-associated pulmonary hypertension

Risk calculators and risk factors for COVID-19-associated pulmonary hypertension

Healthcare Provider Resources

Symptoms of COVID-19-associated pulmonary hypertension

Causes & Risk Factors for COVID-19-associated pulmonary hypertension

Diagnostic studies for COVID-19-associated pulmonary hypertension

Treatment of COVID-19-associated pulmonary hypertension

Continuing Medical Education (CME)

CME Programs on COVID-19-associated pulmonary hypertension

International

COVID-19-associated pulmonary hypertension en Espanol

COVID-19-associated pulmonary hypertension en Francais

Business

COVID-19-associated pulmonary hypertension in the Marketplace

Patents on COVID-19-associated pulmonary hypertension

Experimental / Informatics

List of terms related to COVID-19-associated pulmonary hypertension

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: sara zand,MD

Synonyms and Keywords:

Overview

Pulmonary hypertention (PH) is determined as an increase in mean pulmonary arterial pressure(mPAP) of 25 mm Hg or greater at rest.Pulmonary arterial remodeling and vasoconstriction prompting to increase pulmonary artery pressure and finally right heart failure..Few cases of covid 19 with PH were found and it seems due to keeping social distance and quarantine the number of cases are understimated. PH is a rare disease and Studies about PH in SARS -COV implied the role of inflammation in this process.

Historical Perspective

[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].

The association between [important risk factor/cause] and [disease name] was made in/during [year/event].

In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].

In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].

There have been several outbreaks of [disease name], including -----.

In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].

Classification

There is no established system for the classification of [disease name].

OR

[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].

OR

[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3]. [Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].

OR

Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.

OR

If the staging system involves specific and characteristic findings and features: According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].

OR

The staging of [malignancy name] is based on the [staging system].

OR

There is no established system for the staging of [malignancy name].

Pathophysiology

  • .The SARS-CoV-2 and SARS-CoV virus genomes are highly similar, and patients infected with these viruses have common pathological features.(8)
  • The pathogenesis of PH in covid19 is characterized by pulmonary vasoconstriction due to lack of ACE2 and pulmonary microthromboembolism due to local endothelial cell dysfunction .(lancet rheumatology ,dennis mc ganagle)
  • Renin angiotensin system (RAS) is responsible for hemeostasis of blood pressure and electrolyte balance and inflammatory response. Renin is a protease which is produced in kidney and cleaves angiotensinogen to angiotensin 1.Then angiotensin convertase enzyme(ACE) cleaves angiotensin 1 to angiotensin 2. Angiotensin2 is a key factor of RAS and has two receptors including type1 and type2 [1].
  • angiotensin-converting enzyme 2 (ACE2), and neprilysin hydrolyze angiotensin 2 to anti inflammatory agents including Ang1–7, Ang III, Ang IV, and Ang A .[2]
  • Angiotensin-converting enzyme 2 (ACE2) was a receptor of spike protein on SARS corona virus in epithelial cell and after attaching virus the activity of enzyme(ACE2) was decreased and then virus spread quickly[3](12)
  • Lack of ACE2 causes elevation in angiotensin2 level causing vascular permeability and lung edema and neutrophil infiltration and further lung deterioration.
  • ACE2 has anti inflammation effect and protected the lung from acute lung injury.(4)
  • Phosphorilized ACE2 is much more stable form in which converts angiotensin 2 to angiotensin 1-7 and increases endothelial nitric oxide synthase-derived NO bioavailability ,
  • then lack of phosphorilized ACE2 caused vasoconstriction and pulmonary hypertension (5)
  • Nitric oxide inhalation for SARS-corona patients was correlated with vasodilation and relaxation of pulmonary artery, reduction in pulmonary artery pressure and improvement in arterial oxygenation. (6)
  • Endothelin-1 caused downregulated ACE2 expression in lung epithelial cells and pulmonary vasoconstriction.(7)
  • On microscopic histopathological analysis, pulmonary wall edema,hyalin thrombosis , inflammatory cell infiltration of pulmonary microvasculature , vessle thrombosis due to diffuse alveolar damage and septal inflammation are characteristic findings of PH in covid19.(9)


Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating COVID-19-associated pulmonary hypertension from other Diseases

  • Pulmonary intravascular coagulopathy causing pulmonary hypertention in covid19 must be differentiated from disseminated intravascular coagulation(DIC) based on clinical features including and lab data including:(lancet rheumatology)


Disseminated intravascular coagulopathy Pulmonary intravascular coagulopathy
Onset Acute Subacute
Pulmonary involvement (%) 50% 100%
Thrombosis Multi-organ clotting Mainly lung (occasional CNS and peripheral thrombosis reported; related to DIC evolution?)
Bleeding Generalised Intrapulmonary microhaemorrhage
Liver function Decreased synthetic function including fibrinogen and other clotting factors; raised transaminase +++ Preservation of liver synthetic function; +/−
Anaemia +++
Thrombocytopenia +++ Normal or low
Immune cell cytopenia ++ No but lymphopenia is a feature of COVID-19 in general
Creatine kinase + (skeletal and cardiac origin) + (worse prognosis)
Troponin T + ++ with high levels associated with worse outcome
Elevated prothrombin time or activated partial thromboplastin time +++/+++ + or normal
Fibrinogen levels Decreased Normal or slight increase
Fibrin degradation products or D-dimer Increased Increased
C-reactive protein Elevated Elevated
Ferritin elevation +++ Elevated
Hypercytokinaemia +++ ++








Epidemiology and Demographics

The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.

OR

In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

OR

In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.


Patients of all age groups may develop [disease name].

OR

The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.

OR

[Disease name] commonly affects individuals younger than/older than [number of years] years of age.

OR

[Chronic disease name] is usually first diagnosed among [age group].

OR

[Acute disease name] commonly affects [age group].


There is no racial predilection to [disease name].

OR

[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].


[Disease name] affects men and women equally.

OR

[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.


The majority of [disease name] cases are reported in [geographical region].

OR

[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Risk Factors

Common risk factors in the development of pulmonary hypertention in covid 19 are male sex, hypertension, obesity, and diabetes (lancet rheumato)

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

OR

According to the [guideline name], screening for [disease name] is not recommended.

OR

According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Study of Choice

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

History and Symptoms

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

  • Physical examination in PH may be remarkable for:
  • Rale,dulness or decreased breath sound due to pulmonary congestion or effusion
  • central cyanosis due to hypoxia
  • Holosystolic murmur increased with inspiration due to tricuspid regurgitation (TR)
  • Diastolic murmur due to pulmonary regurgitation
  • Hepatojugular reflux
  • Right ventricular S3 due to RV dysfunction
  • Distention of jugular veinsdue to RV dysfunction and TR
  • Peripheral edema and ascites
  • Low blood Pressure , diminished pulse pressure , cool extremities due to reduced cardiac out put ,prepheral vasoconstriction


Laboratory Findings

  • laboratory findings consistent with the diagnosis of pulmonary hypertension in covid19 include:(lancet rheumato)

Increased D-dimer(due to pulmonary vascular bed thrombosis with fibrinolysis)

Elevated cardiac enzyme concentration due to right ventriclular strain induced by pulmonary hypertention

Normal fibrinigen and platelet level

Electrocardiogram

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of pulmonary hypertension include right atrial enlargement, right axis deviation,right ventricular enlargement with strain pattern

X-ray

An x-ray may be helpful in the diagnosis of pulmonary hypertension in covid 19. Findings on an x-ray suggestive of pulmonary hypertension include enlarged main pulmonary artery, prunning ot attenuation of peripheral vascultureand right ventricular enlargement specially in lateral view with other evidence of lung involvement in covid19

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

  • The mainstay of therapy for pulmonary hypertension in covid19 is(10)(13)
  1. Pulmonary vasodilator
  2. Supplement oxygen for correction of hypoxia to maintain oxygen saturation above %90 ,
  3. Correction of hypotension with fluild and inotropic agents to avoid decreased RV coronary perfusion and RV ejection.
  4. Correction of acidosis, hypercarbia,hypothermia, hypervolemia
  5. Intubation is not recommended due to effect of positive pressure ventilation on increased RV preload and vasodilatory effect of sedation agents impending systemic hypotension and hemodynamic collapse.
  6. If intubation is indicated , vasoactive agent should be given before anesthesia. Etomidate is recommended for general anesthesia due to little effect on cardiac contractiliy and vascular tone.
  7. Ventilator should be set with low tidal volumes and moderate positive end expiratory pressure for minimum air way pressure and sufficient oxygenation and ventilation.


Surgery

Surgical intervention is not recommended for the management of pulmonary hypertension in covid 19


Primary Prevention

There are no established measures for the primary prevention of [disease name].

OR

There are no available vaccines against [disease name].

OR

Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

OR

[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

Secondary Prevention

There are no established measures for the secondary prevention of [disease name].

OR

Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].

References



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