2) I am Jason Weatherald @AlbertaPHdoc of @UAlberta and you may recall my previous tweetorial in this feed. It's still available for credit at https://t.co/CWef5ewHmp. @pulmmed_ce is your ONLY home for earning 🫁-focused CE/#CME entirely on Twitter! pic.twitter.com/KmCawAeFux
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
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!
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
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🩺 pic.twitter.com/YBK93X8IZM
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
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!
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
10) CTEPH occurs from incomplete resolution and fibrotic organization of thrombus leading to vascular obstruction. See 🔓https://t.co/Kw6JXgez59 pic.twitter.com/1aJjrqHtXW
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
12) For the #radiology buffs and those who like long lists of #ddx, there are several conditions that can mimic #CTEPH on imaging. 🔓https://t.co/8EVoASU9J2
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
And, for adding consideration of #moyamoya disease to your day . . . YOU ARE WELCOME pic.twitter.com/6Gjat9mwXt
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.
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
See https://t.co/nPccmTikj1 pic.twitter.com/AanQCUdPHm
16) There are several well recognized risk factors for developing #CTEPH including ⬆️Factor VIII, #antiphospholipid antibodies, #splenectomy, #IBD and infected shunts. See 🔓 https://t.co/plvpA5MDTB pic.twitter.com/Yh3CUfVI8D
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
18) Mark your best answer and return tomorrow for MORE education & MORE on this case. Don't miss it!@kurt_prins @PGeorgeMD @anjalivaidyaMD @rjbernardoMD @SashaPrisco @mdlizs @LucillaPiccari @3CPRCouncil @MakLab_ @vic_tapson
— pulmmed_ce (@Pulmmed_CE) November 15, 2022
20) Yesterday's quiz? Scroll back⤴️to 17 if you didn't answer!
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
A. Anticoagulation for 3mos is best initial management. Diagnosing #CTEPH requires 1⃣ at least 3mos of effective anticoagulation 2⃣Pulmonary hypertension 3⃣Persistent obstruction on imaging. 🔓https://t.co/xN26RxflKv
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?
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
24) In the #PulmonaryHypertension diagnosis algorithm, VQ comes first, as the sensitivity is higher than CT. A normal VQ effectively rules out CTEPH.
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
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. pic.twitter.com/brISB6fbku
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
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 🔓https://t.co/nBfWHefCn5 pic.twitter.com/8MI7beLtGF
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
30) For patients able to successfully undergo PTE surgery, long-term survival is markedly better with >90% survival at 5-years. 🔓https://t.co/DDa9wKjeHW pic.twitter.com/1bI4g7xiYE
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
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:🔓https://t.co/nLpxDB3DA4 pic.twitter.com/PJZHjZDoOE
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
34) Mark your best answer and RETURN TOMORROW for a wrap-up of this program & your certificate for 0.75h 🆓CE/#CME 🇺🇸🇬🇧🇪🇺🇨🇦! @CTEPHAdvisor @PVRI @heresi_gustavo @RogerAlvarezDO @LaurentBertole1 @SaraHegabMD @PForfiaPHDOC @ebrosenzweig @DocAsger @DocHirsch @ICA_CTEPH @madelcroix
— pulmmed_ce (@Pulmmed_CE) November 16, 2022
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.
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
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. 🔓https://t.co/v2GrGPNxLB pic.twitter.com/wNNno4VfK4
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
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 🔓https://t.co/aFzrTfCDxH pic.twitter.com/ufhNby5i9j
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
42) The phase 2 MERIT-1 trial compared #macitentan to placebo for inoperable #CTEPH and demonstrated a ⬇️ in pulmonary vascular resistance #PVR of 26% and ⬆️ #6MWD by 34m at 24 weeks 🔓https://t.co/pT9IpnX1Z1 pic.twitter.com/DKIxjFTa39
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
44) Here is a video of a lower lobe BPA procedure with sluggish, minimal blood flow before ballooning and markedly improved blood flow afterwards. pic.twitter.com/1N2TOBberM
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
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!https://t.co/Rs22tPEmj2 pic.twitter.com/r2ZP9h0fLh
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
48) Management of #CTEPH includes careful evaluation for #PulmonaryEndarterectomy, lifelong anticoagulation, #BalloonPulmonaryAngioplasty, #riociguat and #exercise training. pic.twitter.com/kWQNg7HeUa
— pulmmed_ce (@Pulmmed_CE) November 17, 2022
49) And now go grab your #CME/CE certificate. You earned it! It's at https://t.co/ffiymbZc34. FOLLOW US and EARN MORE!! I am @AlbertaPHdoc. Tip o' the hat to @SarahMedrek @HelpMyBreathing @mark_toshner @SudarRajagopal @3CPRCouncil @ATS_PC
— pulmmed_ce (@Pulmmed_CE) November 17, 2022