Pulmonary embolism

Cor pulmonale is right ventricular structural and functional impairment caused by group 3 pulmonary hypertension from chronic lung disease or hypoxemia. Diagnosis rests on echocardiographic screening confirmed by right heart catheterization, and management centers on treating the underlying lung disease, correcting hypoxemia, and cautious diuresis.

Pulmonary hypertension is a resting mean pulmonary artery pressure of 20 mmHg or greater on right heart catheterization, classified into five WHO groups by mechanism. Diagnosis requires screening echocardiography followed by confirmatory right heart catheterization, and management is group-specific, with PAH-targeted vasodilator therapy reserved for group 1 disease.

Right heart failure is inability of the right ventricle to maintain output at acceptable filling pressures, most often from left heart failure or pulmonary hypertension, and acutely from pulmonary embolism or right ventricular infarction. It causes systemic venous congestion, and management centers on the underlying cause, careful volume and afterload optimization, and preload-dependent support in acute disease.

Cardiogenic shock is primary cardiac pump failure that produces sustained hypotension and end-organ hypoperfusion despite adequate filling, most often from a large acute myocardial infarction. Survival depends on emergently reversing the cause, usually by revascularization, while supporting perfusion with vasopressors, inotropes, and, when refractory, mechanical circulatory support.

Antiphospholipid syndrome is an acquired autoimmune thrombophilia in which antiphospholipid antibodies cause recurrent venous and arterial thrombosis and pregnancy morbidity, paradoxically prolonging the aPTT in vitro while promoting clotting in vivo. Diagnosis requires a qualifying clinical event plus a laboratory antibody confirmed positive on two occasions at least 12 weeks apart, and thrombotic disease is treated with indefinite warfarin rather than a DOAC.

Thrombophilias are inherited or acquired hypercoagulable states that predispose to venous, and in some acquired conditions arterial, thrombosis. Testing is selective and deferred until the patient is off anticoagulation and remote from acute clot, because acute thrombosis, heparin, warfarin, and estrogen all distort results, and most results do not change acute management except in antiphospholipid syndrome.

Syncope is a transient loss of consciousness from global cerebral hypoperfusion with spontaneous complete recovery. The central task is separating benign reflex and orthostatic causes from dangerous cardiac syncope, using history, examination, and ECG, since cardiac syncope carries a risk of sudden death; treatment is directed by mechanism, from reassurance and hydration for reflex syncope to a pacemaker, ICD, or structural intervention for cardiac syncope.

Deep vein thrombosis or pulmonary embolism occurring in a patient with active malignancy, driven by tumor-derived procoagulant activity plus stasis and vascular injury. Diagnosis is confirmed by compression ultrasonography or CT pulmonary angiography, and first-line treatment is apixaban, rivaroxaban, or low molecular weight heparin continued while cancer is active.