高血压英文ppt精品课件hypertensive _1

Hypertensive Crisis . 4 l Urgency/Emergency l l evidence Hypertensive crisis l Hypertensive emergency target organ damage coronary ischemia, disordered cerebral function, cerebrovascular events, pulmonary edema renal failure Hypertensive crisis l Hypertensive urgency progressive target organ dysfunction l hypertensive crisis ( acute cocaine intoxication) Hypertensive crisis l stage 1, 2 HTN Nonadherence l USA 500,000 ( 1% ) Hypertensive crisis Renal disease diseaseParenchymal1. -chronic pyelonephritis -primary glomerulonephritis glomerular -vascular/ disease (SLE, systemic sclerosis) Drugs - central acting alpha2-adrenergic , clonidineagonist ( methyldopa) , phyencyclidine- cocaine intoxication oxidase-DI: monoamine inhibitor , tranylcypromine( phenelzine )selegilline Pregnancy / severe preEclampsia eclampsia- Endocrine Pheochomocytoma- aldosteronism- 1 CNS disorders - CVA hemorragheinfarction/ - Head injury Etiology and Pathophysiology l . l . . SVR hypertensive crisis (triggering) l . l Endothelium (blood pressure homeostasis) Etiology and Pathophysiology l Endothelium (vascular tone) nitric oxide prostacyclin l renin- angiotensin system . l compensatory decompensation endothelium l History & Physical examination.extremely important l Lab + other test (ECG/ Chest radiographpossible end organ damage) History l ? l end organ damage Chest pain MI/ischemia, aortic dissection SOBacute pulmonary edema LVF Back painaortic dissection Neurologic symptoms (headache, blurry vision, N, V ) intracereb ral or subarachnoid hemorrhage/encephalopathy History l l (sympathomimetic, NSAIDs, herbal product, cocain, methamphetamine) l (beta blockers, central sympatholytic agent).rebound hypertension Physical Examination l 2 20 mmHg SBP aortic dissection l BP volume status pressure natriuresis l Head&Neck fundoscopic exam grade IIIflame-shaped hemorrhages, fluffy, white cotton wool spots, yellow white exudate grade IV papilledema with blurring /hemorrhage/exudate l CVS exam Murmursdiastolic murmur+aortic insuff aortic dissection JVP, S3 gallopCHF Rales at lungs pul congestion/edema Smokers renovascular HTN Systolic/diastolic abdominal bruit renovascular disease Delirium/flapping tremor.encephalopathy Lab l CBC: peripheral smear schistocyte microangiopathic hemolytic anemia l Electrolyte, BUN, Scr renal impairment l Hypokalemia metabolic alkalosis intravascular volume depletion secondary hyperaldosteronism Other tests l ECG myocardial ischemia/infarction LVH chronic hypertension l Chest radiograph pulmonary congestion widened mediastinum aortic dissection l CT without contrast neurologic symptoms ( mental status, focal neurologic signs cerebrovascular accident/hemorrhage l Urgency/Emergency target organ damage Hypertensive Urgency l oral antihypertensive agents . hypotension ( peipheral vascular disease, atherosclerotic cardiovascular and intracranial disease) Initial goal: 160/110 mmHg Mean arterial pressure 25% 24 Mean arterial pressure l MAP = (CO x SVR) + CVP l l MAP = DP + 1/3(PP) l MAP = DP + 1/3( SP-DP) l MAP = (2DP+SP)/3 Hypertensive Urgency l ACEI: Captopril onset 15-30 min (max BP drop 30, 90 ) l Captopril: 25 mg oral / 50- 100mg 90-120 l ADR: hypotension, angioedema, renal failure bilateral renal artery stenosis Hypertensive Urgency l CCB: nicardipine placebo Oral dose 30 mg 8 Onset 0.5-2 ADR palpitation, flushing, headache, dizziness Hypertensive Urgency l CCB: nifedipine Peak effect: 10-20 Short acting FDA stroke 1995 Ad hoc panel National Heart, Lung, and Blood Institute evidence Hypertensive Urgency l BB: Labetalol Alpha1 and beta adrenergic blockers Onset 1-2 hours randomizations 200 mg oral 3-4 ADR: nausea, dizzness Hypertensive Urgency l Clonidine: central acting adrenergic agent (alpha2-receptor agonist) Onset 15-30 Peak 2-4 hours Regimen: 0.1-0.2 mg loading dose 0.05-0.1 mg q hr (max dose: 0.7 mg) ADR: sedation, dry moth, orthostatic hypotension, Hypertensive Emergency l end-organ damage IV, ICU 1 MAP 10% 2-3 MAP 15% Pressure natriuresis volume depletion hypertensive emergency vasodilator IV saline renin-angiotension- aldosterone system Neurologic emergency l Hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke l Intracerebral hemorrhage: autoregulation systemic perfusion pressure l AHA: intracerebral bleed 180/105 mmHg MAP 130 mmHg Neurologic emergency l Ischemic stroke Perfusion pressure Systemic pressure pre-ischemic blood pressure control cerebral ischemia TIA l 1-2 hr l MAP 130 mmHg, SBP 220 mmHg l MAP 15-20% Cardiac emergency l Myocardial ischemia, MI, pul edema, aortic dissection l MI: Nitrogylcerine myocardial oxygen consumption flow sig HF, betablockers (labetalol, esmolol) l Pulmonary edema: IV diuretics ACEI ( enalaprilate) nitroglycerine Na nitroplusside Hyperadrenergic state l catecholamine Pheochromocytoma, cocaine amphetamien overdose, momoamine oxidase inhibitor-induced HTN, clonidine withdrawal syndrome l Pheochromocytoma: IV Na nitroprusside () IV phentolamine (ganglion-blocking agent) BB block alpha Hyperadrenergic state l HTN Clonidine clonidine l Cocaine intoxication Benzodiazepine anxiolytic effect ischemia l Acute kidney injury Proteinuria, microscopic hematuria, oliguria, anuria IV nitroprusside cyanide/thiocyanide toxicity Fenoldopam mesylate (dopamine1 receptor agonist) l Hypertensive crisis crisis target organ damage cocaine Hypertensive emergency target organ damage Hypertensive urgency target organ damage 160/90-140/90 mmHg uncontrolled HTN. hypertensive urgency ( slide 7) l crisis (.) target organ damage Lab + other test target organ damagec l Hypertensive urgency oral: ACEI captopril 25 mg 160/110 mmHg - MAP 25% Hypertensive em