高血压英文ppt精品课件board

Board Review Vikram Chhokar MD University of Tennessee Division of Cardiology Question An 80-year-old Asian woman awakens at 2 a.m. feeling as if she were being smothered. She is brought to the ED and is found to be in pulmonary edema. She has a history of a heart murmur, discovered 20 years before. Prior to this episode she says she was in good health, although she has not been physically active due to arthritic discomfort for the past 5 years. On careful questioning she admits to brief episodes of pressure-like sensation in her chest especially when she becomes aggravated. Question Physical examination: BP 150/110 mmHg, pulse 120/min, respirations 24/min. Neck veins 10cm. Lungs have rales 3/4 the way up posteriorly bilaterally. Carotids are difficult to feel. PMI is in the 5th intercostal space just outside the midclavicular line and sustained. There is a grade II/VI systolic ejection murmur at the base and a grade II/VI diastolic blowing murmur at the 3rd left intercostal space. There is an S4 and an S3 gallop. There is no hepatomegaly and no pedal edema. Question Laboratory : Chest X-ray: slightly enlarged cardiac silhouette, pulmonary vascular redistribution and pulmonary edema. ECG: QS in V1, a small r in V2, a 25mm R wave in V5 and a 30mm R wave in V6. There is 2mm ST-segment depression in V4-6 . Echo: estimated EF 55%, first troponin 70 yrs old) Bicuspid Aortic Valve The most common congenital cardiac abnormality is bicuspid aortic valve affecting 1-2% of the U.S. population. Over time, one-third to one-half of such valves become stenotic, with significant narrowing of the aortic orifice typically developing in the 5th and 6th decades of life. Aortic Stenosis Key Points MCC of AS is senile degenerative changes In patients with AS due to rheumatic dz r/o “silent” mitral stenosis. Bicuspid or rheumatic should be suspected in pt with AS presenting in 5th or 6th decade of life. Pathophysiology Increase in afterload Decrease in systemic and coronary flow from obstruction Progressive hypertrophy Classic symptom triad Dyspnea Angina Syncope Classic symptom triad Once any of these classic symptoms develop, prognosis dramatically worsens. Thus, within 5 years of the development of angina, approximately 50% of patients will die unless aortic valve replacement is performed. For syncope, 50% survival is 3 years For congestive heart failure, 50% survival is only 2 years unless the valve is replaced. Angina 5, Syncope 3, and CHF 2. Characteristic Physical findings Dampened upstroke of carotid artery Sustained bifid left ventricular impulse Absent A2 Late-peaking systolic ejection murmur A concomitant systolic thrill indicates the presence of AS (mean gradient 50mm Hg) Of note if you have significant Physical finding and symptoms, you must rule out severe AS. Aortic Stenosis Patients with the physical findings of AS should undergo selected laboratory examinations, including an ECG, a chest x- ray, and an echocardiogram. The 2-D echocardiogram is valuable for confirming the presence of aortic valve disease and determining left ventricular (LV) size and function, degree of hypertrophy, and presence of other associated valve disease. EKG Usually shows NSR with LVH Note: If AF is present, concomitant mitral valve disease or thyroid dz must be suspected. Recommendations for Echocardiography in AS Class 1 Diagnosis and assessment of severity of AS. Assessment of LV size, function, and/or hemodynamics. Reevaluation of patients with known AS with changing symptoms or signs. Assessment of changes in hemodynamic severity and ventricular compensation in patients with known AS during pregnancy. Reevaluation of asymptomatic patients with severe AS. Class IIa Reevaluation of asymptomatic patients with mild to moderate AS and evidence of LV dysfunction or hypertrophy. Class III Routine reevaluation of asymptomatic adult patients with mild AS having stable physical signs and normal LV size and function. ECHO Modified Bernoulli equation (P=4v2) used to calculate gradient. A maximal instantaneous and mean AV gradient is derived from the continuous- wave Doppler velocity across the aortic valve. AVA can be estimated by continuity equation: AVA=LVOTarea LVOTTVI AVTVI ECHO/Doppler Pit Falls Will underestimate AS if Doppler beam is not parallel to AS velocity jet. Will rarely over-estimate mean gradient Severe anemia (hemoglobin 1.5 Moderate 25-50 1-1.5 Severe 50 80 4.5m/sec. E. TVI (AV)/TVI (LVOT) 4.5m/sec across the aortic valve would correspond to a peak pressure gradient of 81 mmHg, which would be consistent with severe aortic stenosis. Question You are responsible for the care of a vigorous 72-year-old man with acquired degenerative calcific valvular aortic stenosis, accompanied by mitral regurgitation and calcification of the mitral annulus. He has survived infective endocarditis with multiple positive cultures for Streptococcus mutans, which you judged to be of dental origin although there had been no specific dental intervention related temporally with the onset of symptoms. Based on catheterization data completed during his antibiotic course, you feel that aortic valve replacement and inspection of the mitral valve and adjacent structures are indicated. The patient has 11 remaining teeth that are in poor repair. Question Which one of the following is the best plan? A. Ignore the dental status in deference to the more serious valvular heart disease. B. Discharge the patient to the care of his dentist to permit cautious dental extraction of one to two teeth per visit. C. Schedule full-mouth extraction well in advance of the anticipated cardiac surgery. D. Schedule full-mouth extraction synchronous with cardiac surgery, thus avoiding a second anesthesia. E. Delay all dental procedures until after the cardiac surgery. Answer The correct answer is C. This patients dental hygiene probably is the source of his endocarditis, demonstrating that a dental procedure is indeed not required for endocarditis to occur. In terms of his ongoing risk for recurrent endocarditis, proper management of his dentistry preoperatively is perhaps the most important factor. Once his prosthetic valve is implanted, he is then forever maximally at “high risk“ such that any issues that can be addressed safely and reasonably before cardiac surgery should be done. Removal of all his teeth at once is a procedure that dental surgeons can accomplish with little difficulty, thereby undertaking the risk of extraction- related bacteremia once rather that several times. The serial approach, in addition to being unnecessary, would raise the additional issue of cumulative antibiotic resistance via the chemoprophylaxis regimens, which would need to be given for each of the procedures. Answer Performing this procedure in conjunction with the cardiac surgery (in any sequence) would simply add unnecessary stress (as well as bacteremia) to a time that is already high- risk in and of itself. Delaying the dentistry would simply make likely the occurrence of prosthetic valve endocarditis (PVE) via the same mechanisms responsible for the original infectious illness. Careful preoperative dental evaluation is recommended so that required dental treatment can be completed at least several weeks prior to cardiac surgery whenever possible. Such measures may decrease the incidence of late postoperative endocarditis. Question Catheter-delivered balloon expansion techniques are now the treatment of choice for which one of the following lesions in adults? A. Valvular pulmonic stenosis. B. Valvular aortic stenosis. C. Coarctation of the aorta. D. Ebsteins anomaly of the tric