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ACEP-APS-SlideCAST.ppt

ACEP-APS-SlideCAST

delooz
2010-09-29 0人阅读 举报 0 0 暂无简介

简介:本文档为《ACEP-APS-SlideCASTppt》,可适用于自然科学领域

AcutePressureSyndromesCharlesVPollackJr,MA,MD,FACEP,FAAEMProgramChairmanChairman,DepartmentofEmergencyMedicinePennsylvaniaHospitalProfessorofEmergencyMedicineUniversityofPennsylvaniaSchoolofMedicinePhiladelphia,PennsylvaniaAcutePressureSyndromesEvidenceBasedManagementofAcuteBloodPressureElevationAcrossMultipleDiseaseStatesOptimizingTherapyforLifeThreateningVascularDysfunctionSyndromesConnectingtheDotsFromThreattoTherapyAYearEMUpdateCMEaccreditedsymposiumjointlysponsoredbytheUniversityofMassachusettsMedicalSchoolandCMEducationResources,LLCCommercialSupport:SponsoredbyanindependenteducationalgrantfromTheMedicinesCompanyMissionstatement:Improvepatientcarethroughevidencebasededucation,expertanalysis,andcasestudybasedmanagementProcesses:Strivesforfairbalance,clinicalrelevance,onlabelindicationsforagentsdiscussed,andemergingevidenceandinformationfromrecentstudiesCOI:FullfacultydisclosuresprovidedinsyllabusandatthebeginningoftheprogramCMEaccreditedsymposiumjointlysponsoredbytheUniversityofMassachusettsMedicalSchoolandCMEducationResources,LLCCommercialSupport:SponsoredbyanindependenteducationalgrantfromTheMedicinesCompanyMissionstatement:Improvepatientcarethroughevidencebasededucation,expertanalysis,andcasestudybasedmanagementProcesses:Strivesforfairbalance,clinicalrelevance,onlabelindicationsforagentsdiscussed,andemergingevidenceandinformationfromrecentstudiesCOI:FullfacultydisclosuresprovidedinsyllabusandatthebeginningoftheprogramWelcomeandProgramOverviewProgramEducationalObjectivesProgramEducationalObjectivesAsaresultofthissession,physicianswil:LearntoidentifyunderlyingchronicandacuteprecipitantsofacuteelevationsinsystemicbloodpressureandhowthesesyndromespresentsintheEDacrossmultiplediseasestatesandpatientpopulationsLearntoassessandimplementoptimalpharmacologicinterventionsintheEDforpatientspresentingwithmanifestationsofacutepressuresyndromes,includingelevatedsystolicordiastolicbloodpressure,endorgandysfunction,andothercardiovascular,renovascular,andorneurovascularderangementsLearntocharacterize,identify,andevaluatemyriad,acutediseasestatesproducingseriousandorlifethreateningelevationsinsystemicbloodpressure,amongthem:hypertensiveurgency,hypertensivecrisis,ischemicstroke,druginducedacutepressuresyndromes,subarachnoidhemorrhage,intracerebralhemorrhage,pulmonaryedema,andrelatedconditionsProgramEducationalObjectivesProgramEducationalObjectivesLearntounderstandthespecificadvantagesandpotentialdisadvantagesofcurrentlyavailableintravenouslyadministeredpharmacologicagentsusedintheEDtoreduceacute,serious,andorlifethreateningelevationsinsystemicbloodpressureLearntoidentifytheidealpropertiesofintravenousagentsusedintheEDtoprovideemergencyandcriticalcarebasedloweringofpotentiallyseriousandorlifethreateningelevationsinsystemicbloodpressureLearntodiscussandassesstheimpactthatnewtrialsandnovelagentsarelikelytohaveonfuturemanagementofpatientswithacutepressuresyndromesLearntoapplynationalguidelinesandexpert,consensusbasedrecommendationsintheEDinordertooptimizeemergencybasedtherapyofpatientswithserious,systemicelevationsinbloodpressureProgramFacultyProgramChairman CharlesVPollackJr,MA,MD,FACEP,FAAEMChairman,DepartmentofEmergencyMedicinePennsylvaniaHospitalProfessorofEmergencyMedicineUniversityofPennsylvaniaSchoolofMedicinePhiladelphia,Pennsylvania DistinguishedPresentersJamesFergusonIII,MD,FACCAssociateDirector,CardiologyResearchTexasHeartInstituteatStLuke’sEpiscopalHospitalAssociateProfessorBaylorCollegeofMedicineClinicalAssistantProfessorUniversityofTexasHealthScienceCenteratHoustonHouston,Texas FrankPeacock,MD,FACEPProfessorofEmergencyMedicineDepartmentofEmergencyMedicineClevelandClinicHospitalsandClinicsCleveland,Ohio FacultyDisclosures CharlesVPollackJr,MA,MD,FACEP,FAAEMGrantResearchSupport:GlaxoSmithKlineConsultant:TheMedicinesCo,ScheringPlough,SanofiAventis,BMS,GenentechSpeaker’sBureau:ScheringPlough,SanofiAventis,BMS,GenentechJamesFergusonIII,MD,FACCGrantResearchSupport:Eisai,TheMedicinesCompany,ViatronMedtronicConsultant:BMS,Eisai,Prism,SanofiAventis,ScheringPlough,Takeda,TheMedicinesCo,TheroxSpeaker’sBureau:BMS,SanofiAventis,ScheringPloughFrankPeacock,MD,FACEPGrantResearchSupport:Abbott,Accumetrics,Biosite,CHFSolutions,Inovise,Inverness,Scios,TheMedicinesCo,VitalSensorsConsultant:Abbott,BeckmanCoulter,Biosite,Inovise,Inverness,OrthoClinicalDiagnostics,PDL,Scios,TheMedicinesCo,VitalSensorsSpeaker’sBureau:Abbott,Scios,PDL,BiositeMajorShareholder:VitalSensors ACUTEPRESSURESYNDROMESHypertensiveUrgenciesandEmergenciesCurrentChallengesfortheEmergencyPhysicianACUTEPRESSURESYNDROMESHypertensiveUrgenciesandEmergenciesCurrentChallengesfortheEmergencyPhysicianCharlesVPollack,Jr,MA,MD,FACEPProgramChairmanChairman,EmergencyMedicine,PennsylvaniaHospitalProfessorofEmergencyMedicine,UniversityofPennsylvania,PhiladelphiaIntroductionandChairman’sOverviewHypertensionAnEpidemicHypertensionAnEpidemicAffectsatleastmillionAmericansAffectsatleastBILLIONindividualsworldwideMostcurrent()evidencebasisforchronicmanagementTheSeventhReportoftheJointNationalCommitteeonthePrevention,Detection,Evaluation,andTreatmentofHighBloodPressureHypertension(JNC)lacksguidanceforacutemanagementofpatientspresentingtoanEDwithhypertension,especiallysevereacuteelevationsofBPJNC,JAMA:HypertensiveUrgenciesandEmergenciesHypertensiveUrgenciesandEmergenciesEpidemiologicdataarelargelylackingItisthoughtthat~ofpatientswithhypertensionwilleventuallypresenttotheEDinhypertensivecrisisInasinglecenterItalianstudy,HUorHEaccountedforofallmedicineadmissionsandofallmedicalemergenciesHU:HEratioof:inthatstudyPatientswithHUmuchmorelikelytobeunawareoftheirhypertensiondiagnosisthanthosewithHEZampaglioneetal,Hypertension:PresentingSymptomsPresentingSymptomsHypertensiveUrgenciesArrhythmiaEpistaxisHeadachePsychomotoragitationUsualPrimaryEDDiagnosisHypertensionHypertensiveEmergenciesChestpainDyspneaNeurologicdeficitsUsualPrimaryEDDiagnosisCVAAcutepulmonaryedemaHypertensiveencephalopathyAcuteheartfailureZampaglioneetal,Hypertension:JNCNomenclatureJNCNomenclatureNormalBP:Systolic<,Diastolic<Prehypertension:S=,D=Stagehypertension:S=,D=Stagehypertension:S>,D>Stagehypertension(JNC):Systolic>,Diastolic>Functionally,thisis“hypertensiveurgency”Whatabout“crisis,”“emergency,”and“urgency”JNC,JAMA:JNCNomenclatureJNCNomenclatureUsingJNCnomenclature,“hypertensivecrisis”isanacute,severe,stageorelevationinbloodpressureCrisisisthendifferentiatedintohypertensive“emergencies”(involvingsomeendorgandamage)and“urgencies”(noendorgandamage)JNC,JAMA:“EndOrganDamage”“EndOrganDamage”CardiopulmonaryAcuteheartfailureAcutecoronarysyndromeAcutepulmonaryedemawithrespiratoryfailureDissectingaortaCNSHypertensiveencephalopathyCVAOcularExudatesPapilledemaRetinalhemorrhagesRenalAcuterenalfailureJNC,JAMA:CausesofHypertensiveCrisesCausesofHypertensiveCrisesEssentialhypertensionMedicationnoncomplianceSecondaryhypertensionAorticcoarctationCushing’ssyndromeElevatedICPRenaldysfunctionPregnancyHyperparathyroidismHyperthyroidismPheochromocytomaPrimaryaldosteronismJNC,JAMA:GoalsofEDTherapyofHypertensiveCrisesGoalsofEDTherapyofHypertensiveCrisesHUcangenerallybemanagedwithoralmedicationsandrequiresBPloweringoverhoursImportanttopreventtoorapidloweringduetoautoregulationofflowbypressureinbrain,heart,andkidneysGoalinhypertensiveurgencyistoreduceMAPbyandortoaDBPofwithinonehourAorticdissectionrequiresevenmorerapidloweringOnceinitialreductionachieved,transitiontooralagentsDugofchoiceforinitialtherapyoftendependsonwhichendorgansystemisaffectedandoncomorbiditiesJNC,JAMA:WhyAreWeHereTodayWhyAreWeHereTodaySeverehypertensionisincreasinglyprevalentaspopulationagesandobesityanddiabetesbecomemorecommonCurrentlyavailableagentsforthemanagementofacutesevereBPelevationleavemuchtobedesiredadvancementsarepossibleThereisanewagentonthehorizonthathasbeentestedspecificallyintheEDWelcometoThisProgram!WelcometoThisProgram!Wewillreviewthescope,pathophysiology,andepidemiologyofhypertensionaswellashypertensiveurgenciesandemergenciesastheypresentintheEDWewillreviewandassesscurrenttherapyandgoalsofBPmanagementintheEDWewilllooktothenearfutureofmanagementofacuteseverehypertensionTheEmergencyDepartmentArmamentariumforHypertensionTherapyTheGoodandBadNewsAboutCurrentTreatmentOptionsTheEmergencyDepartmentArmamentariumforHypertensionTherapyTheGoodandBadNewsAboutCurrentTreatmentOptionsFrankPeacock,MD,FACEPProfessorofEmergencyMedicineDepartmentofEmergencyMedicineClevelandClinicHospitalsandClinicsCleveland,OhioFromHypertensionThreattoTherapyAYearEMUpdateEstablishedthemodernmethodofmeasuringBPInKarlVierdordt()EDHypertensiveEmergenciesEDHypertensiveEmergenciesHypertensiveemergenciesandurgenciesAccountforofallEDvisitsAn“InternalMedicine”EDN=,hadamedicalurgencyoremergencyofthesewerehypertensivecrisesClinicaltreatmentpracticesvarywidelyKitiyakaraC,GuzmanNJAmSocNephrol:ZampaglioneB,etalHypertension:CherneyD,StraussSJGenInternMed:HypertensionintheEDHypertensionintheEDFourCategoriesofPresentationEmergenciesUrgenciesMild,uncomplicatedTransientHypertensionFrequencyHypertensionFrequencyCategoryFrequencyEmergenciescerebralandcardiacshift)UrgenciesMild,uncomplicatedshiftTransientWhocaresHistoryandPhysicalHistoryandPhysicalUSObesityEpidemic<exercisemorethanoccasionallyColoradothethinneststate,onlyobeseToosmallacufffalselyelevatesBPDefinitionsofHypertensionDefinitionsofHypertensionMild,UncomplicatedHTNDiastolicBP<mmHgwithoutendorgansymptomsEducate,donottreat,arrangefollowupTransientHTNAreactiontosomeconditionPain,fright,epistaxis,drugODTreattheconditionDefinitionofHypertensionHypertensiveUrgencyBPatalevelthatmaybepotentiallyharmful,butwithoutfocalfindingsUsuallysustaineddiastolic>mmHg(mmHg)CommonlyduetononcomplianceIgnoresystolicBP:MAP=(Diastolicsystolic)LowerBPoverhours(givethemaRx)AvoidrapidBPreductionsHistory,physical,andtimemaybeallthatisneededDefinitionofHypertensionHypertensionTreatmentandSymptomsHypertensionTreatmentandSymptomsListofallthestudiesdemonstratingacutelyloweringtheBPinapatientwithoutsymptomshasANYbenefit:Isolatedheadacheisnotamanifestationofendorgandamage)GardnerJW,MountainGE,HinesEATherelationshipofmigrainetohypertensionandtohypertensionheadachesAmJMedSci:)BadranTHA,WeirRJ,McGuinessJBHypertensionandheadacheScottMedJ:)BulpittCJ,DolleryCT,CarneSChangeinsymptomsofhypertensivepatientsafterreferraltoahospitalclinicBrHeartJ:)JaillardAS,MazettiP,KalaEPrevalenceofmigraineandheadacheinahighaltitudetownofPeru:apopulationbasedstudyHeadache:)MarcouxS,BerubeS,BrissonJ,etalHistoryofmigraineandriskofpregnancyinducedhypertensionEpidemiol:)MarkushRE,HerbertRK,HeymanA,etalEpidemiologicstudyofmigrainesymptomsinyoungwomenNeurology:)CirilloM,StellatoD,LombardiC,etalHeadacheandcardiovascularriskfactors:positiveassociationwithhypertensionHeadache:)FeatherstoneHJMedicaldiagnosisandproblemsinindividualswithrecurrentidiopathicheadachesHeadache:)ZieglerDK,HassaneinRS,CouchJRCharacteristicsoflifeheadachehistoriesinanonclinicpopulationNeurology:)AtkinsJBMigraineasasequeltoinfectbyLicterohaemorrhagiaeBMJ:)FrancesschiM,ColomboB,RossiP,etalHeadacheinapopulationbasedelderlycohortAnancillarystudytotheItalianlongitudinalstudyofaging(ILSA)Headache:StudiesShowingNoRelationBetweenBPandHeadache)WatersWEHeadacheandbloodpressureinthecommunityBMJ:)WeissNSRelationofhighbloodpressuretoheadache,epistaxis,andselectedothersymptomsNEnglJMed:)ScheleR,AhlborgB,EkbomKPhysicalcharacteristicsandallergichistoryinyoungmenwithmigraineandotherheadachesHeadache:)KottkeTE,TuomilehtoJ,PuskaP,etalTherelationshipofsymptomsandbloodpressureinapopulationsampleIntJEpidemiol:)AbramsonJH,HoppC,EpsteinLMMigraineandnonmigrainousheadaches:acommunitysurveyinJerusalemJEpidemiolCommunityHealth:)PaulinJM,WaalManningJ,SimpsonFO,etalTheprevalenceofheadacheinasmallNewZealandtownHeadache:)ChenTC,LevitonA,EdelsteinS,etalMigraineandotherdiseasesinwomenofreproductiveageTheinfluenceofsmokingonobservedassociationsArchNeurol:)HaleWE,etalHeadacheintheelderly:anevaluationofriskfactorsHeadache:)D'Alessandro,BenassiG,LenziPL,etalEpidemiologyofheadacheintherepublicofSanMarinoJNeurolNeurosurgPsychiatry:)CouchJRHeadacheasriskfactorinatherosclerosisrelateddiseasesHeadache:)RasmussenBK,OlesenJSymptomaticandnonsymptomaticheadachesinageneralpopulationNeurology:)WangSJ,FuhJL,LiuCY,etalChronicdailyheadacheinChineseelderly:prevalence,riskfactors,andbiannualfollowupNeurology:)HoKH,OngBKPerceivedheadacheassociationsinSingaporeResultsofarandomizednationalsurveyHeadache:StudiesShowinganAssociationBetweenBPandHeadacheIsolatedSystolicHypertensionIsolatedSystolicHypertensionRCT:DoubleblindplacebovsactivetreatmentforisolatedsystolicHTNinpts>yrsoldpts,SBP>,DBP<mmHgExcludedHTNemergencyandsecondarycausesofHTNyearfollowupTreatment:NitrendipineStaessenJALancet,:IsolatedSystolicHypertension(Reportedinpatientyears)IsolatedSystolicHypertension(Reportedinpatientyears)Cardiovascular(HF,MI)placebo,Tx(p=)CVAplacebo,vsTx(p=)TotalMortalityplacebovsTx(p=)Difference=ptyrsMorbidityStaessenJALancet,:DefinitionofHypertensiveEmergencyDefinitionofHypertensiveEmergencyHypertensiveEmergencyIncreasedBPWITHendorgandamageAtrisk:Brain,heart,kidneysNospecificBPcriteriaAcuteBPManagementConsiderationsAcuteBPManagementConsiderationsWhatisthemagnitudeof:DiseaseriskTreatmentbenefitTreatmentriskHowpersistentisthebenefitWhatimprovedoutcomeisthereforthepatientYearOldStockBrokerComplainsOfChestPainMVOMAPxHRBPHemodynamicsandMyocardialIschemiaHemodynamicsandMyocardialIschemiaAdaptedfromBraunwaldE,edHeartDisease:ATextbookofCardiovascularMedicinethedWBSaundersCoAfterloadorSVRWorkOconsumption↓MyocardialBloodFlowOdelivery↑LeftVentricular(LV)WallTensionAfterloadorSVRMyocardialIschemiaIncreasedAfterloadIncreasesOConsumptionandDecreasesODeliverytotheHeartAcuteMyocardialInfarctionAcuteMyocardialInfarctionNTGRelievesonlychestpainNomortalitydifferencein,patientsblockersAntiplatelets:ASA,clopidogrelAnticoagulants:LMWH,UFHGPIIbIIIaantagonistorDTIwclopidogrelAHAACCGuidelinesNitroglycerinNitroglycerinArterialandcoronaryvenodilatorMechanism:cGMPOnset,minutes,t½minutesDuration,minutesDose:StartatgminTitratebygminqminutesMaycauseheadache,HR,vomiting,methemoglobinemiaSpecialconsiderationsTachyphylaxiswithinhoursCoronaryischemiaIVformrequiresspecialdeliverysystemThethReportoftheJNCJAMA:NitroglycerinPCWPversusTimeNitroglycerinPCWPversusTimen=(hr)n=(>hr)AddedtostandardtherapyTime(hr)NitroglycerinDose(mcgmin)ChangeinPCWP(mmHg)NTGdoseChangeinPCWP*******P<vsbaselineElkayamUetalAmJCardiol:OrganicNitrates:ToleranceTheoriesOrganicNitrates:ToleranceTheoriesDecreasedbioconversiontonitricoxideCellulardepletionofsulfhydrylgroups,NeurohumoraladaptationsSuperoxideanionproductionUpregulationofendothelinMünzelTAmJCardiol:CCParkerJD,ParkerJONEnglJMed:NeedlemanP,JohnsonEMJJPharmacolExpTher:MünzelT,etalJAmCollCardiol:MünzelT,etalJClinInvest:MünzelT,etalProcNatlAcadSci:NitroprussideMechanismNitroprussideMechanismSpontaneouslyreleasesnitricoxide(NO)NOactivatesguanylylcyclase,increasingcGMPcGMPactivatesmyosinlightchainphosphatase(MLCP)MLCPdephosphorylatesmyosinlightchainsLeadstorelaxationNitroprussideNitroprussideArterialandvenodilatorDecreasespreloadandafterloadNochronotropiceffect,butHR(baroreceptors)Onsetminutes,t½minutesStartgkgmin,thentitrateAverageeffectivedoseisgkgmin(gkgmin)ThethReportoftheJNCJAMA:Nitropusside:IssuesandConcernsNitropusside:IssuesandConcernsBPMaycauseNV,twitching,sweatingMetabolizedtoCN,thenthiocyanateRFissueBADNESSPregnancyCoronarystealDosedependentinCBFCautionwithhighICPHypoxia(VaQmismatch)RequiresspecialdeliverysystemUsuallyrequiresdirectarterypressuremonitoringNitrovasodilatorsNitroprussideversusNitroglycerinNitrovasodilatorsNitroprussideversusNitroglycerinPepineCJClinTher:CyanideToxicityCyanideToxicityTachyphylaxisImportantsignofimpendingtoxicityNeurologicalmanifestationsHyperpneaHeadache,VertigoAlteredmentalstatusComa,SeizuresLaboratorymanifestationsLacticacidosisIncreasedbasedeficitSipeEK,etalAmSurg:VerydyspneicBPRalesCoolskinYearOldFemaleProfilesandTherapiesofAdvancedHeartFailureProfiles

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