高血压精品英文课件

WelcometoCardiologyBootCamp BoardReviewSession 1SteveMadhavan MDBrendaFortunate DO HypertensionPearls StartwithdiureticorbetablockerIfnoresponse trydrugfromdifferentclassorasecondagentfromadifferentclass adddiureticifnotalreadyused Diureticsreducemortality strokeriskinelderlywithisolatedsystolichypertensionACEinhibitorsreducemortalityinCAD prolongsurvivalinCHF postMILVdysfunction preserverenalfunctioninDM Initialtreatmentofhypertensiondependsonriskgroupdeterminants Targetorgandamage TOD Stroke TIA nephropathy peripheralarterialdisease hypertensiveretinopathyClinicalCardiovascularDisease CCD LVH angina priorMI priorCABG CHF BloodPressureStages CategorySystolicDiastolic mmHg mmHg Optimal 120and 80Normal 130and 85HighNormal130 139or85 89Stage1HTN140 159or90 99Stage2HTN160 179or100 109Stage3HTN180 or110 HTNTreatmentRecommendations Nomajorriskfactors TOD CCD treatstage1withlifestylemodificationupto12months stages2 3 adddrugsOnemajorriskfactorbutnoDM TOD CCD treatstage1withlifestylemodificationupto6monthsbeforeaddingdrugs adddrugsearlierifmultipleriskfactors Begindrugtherapyimmediatelyforhigh normalpressureifDM TOD CCD HypertensionPearls Again StartwithdiureticorbetablockerIfnoresponse trydrugfromdifferentclassorasecondagentfromadifferentclass adddiureticifnotalreadyused Diureticsreducemortality strokeriskinelderlywithisolatedsystolichypertensionACEinhibitorsreducemortalityinCAD prolongsurvivalinCHF postMILVdysfunction preserverenalfunctioninDM Whichofthefollowingstatementismostaccurateregardinghypertensiveencephalopathy FunduscopicexamwillbenormalItisusuallysecondarytoanadrenaltumorImmediateuseofhypotensivedrugsisindicatedlumbarpuncturemaybenecessary Whichofthefollowingstatementismostaccurateregardinghypertensiveencephalopathy FunduscopicexamwillbenormalItisusuallysecondarytoanadrenaltumorImmediateuseofhypotensivedrugsisindicatedlumbarpuncturemaybenecessary Hypertensiveencephalopathy severehypertensioncharacterizedbyheadache nausea vomiting convulsions confusionprogressingtostupororcoma Bythetimeneurologicmanifestationsoccur hypertensionhasreachedmalignantstage FundoscopicExam RetinalhemorrhagesExudatesPapilledema Causesofhypertensiveencephalopathy Essentialhypertensionchronicrenaldiseaseacuteglomerulonephritisacutetoxemiaofpregnancy PheochromocytomaACTHtoxicity soldassupplementorfromadrenaltumor Cushingsyndromenon compliancewithmedicationincludingabruptcessationofalphablockers HypertensiveEncephalopathy cont LoweringBPwithdrugsmayreversepicturein1 2days IfBPnotcontrolled thismaybefatal LumbarpunctureiscontraindicatedandmaycausedeathduetoincreasedICP Reference Harrison s ed14 pp 1392 94 Whichismostlikelytocauseseriousmalfunctionofatransvenouspacemaker CervicalMRIscan theoreticallypace3000beatsperminute MicrowaveovensElectrosurgeryforremovalofskinlesionExtracorporealshock wavelithotripsyAirportmetaldetectors Whichismostlikelytocauseseriousmalfunctionofatransvenouspacemaker CervicalMRIscan theoreticallypace3000beatsperminute MicrowaveovensElectrosurgeryforremovalofskinlesionExtracorporealshock wavelithotripsyAirportmetaldetectors Pacemakers Electrocauterycancausetemporarysensingproblemsorreprogramming Checktoconfirmproperfunctionaftercompletionofprocedure Lithotripsymaycauseproblemswithdualchamberpacing Monitorpatient Reprogrammingmaybeneeded Reference AnnalsInternalMedicine1993 828 835andCecils ed21 P 204 WhichstatementregardingtreatmentofAMIiscorrect Reference Hennekensetal NEJM1996 335 22 1660 7 BetaBlockersreduceinfarctsizeandchestpainwhengivenforAMI CCB sreducemortalityfromAMI ACEinhibitorscauseCHFifgivenduringAMI TheypreventCHF NeitherlidocaineormagnesiumareroutinelyindicatedafterAMI Theydonotreducemortality BetaBlockersreduceinfarctsizeandchestpainwhengivenforAMI CCB sreducemortalityfromAMI ACEinhibitorscauseCHFifgivenduringAMI TheypreventCHF NeitherlidocaineormagnesiumareroutinelyindicatedafterAMI Theydonotreducemortality AcuteCoronarySyndrome Definedasunstableangina non ST segmentelevationMIcheckCPKforsuspectedre infarct Reference 2003FamilyPracticeBoardReviewCourse AcuteCoronarySyndromeadjunctivetreatments tPAwithIVheparinisfibrinolyticofchoiceStreptokinasewithoutIVheparinif75 SublingualnitroIVnitroforrefractorypain keepSBP 105 110mmHgIVmorphineisanalgesicofchoiceOxygenonlyifhypoxemic Whichoneofthefollowingstatementsistrueregardingthedeterminationofbloodpressure Reference JAmericanBoardofFamilyPractice1998 11 4 252 8 Measurebloodpressureinseatedpositionwithpatient sbacksupported Whenindoubtaboutcuffsize itisbettertousealargecuff Alargecuffcausesnegligibledifference asmallcuffmayoverestimatepressureby4 9 5mmHg Allowatleast30seconds not5minutes betweenmeasurements Measurepressureinbotharms repeatinarmwithhigherpressure Donotaverage Measurebloodpressureinseatedpositionwithpatient sbacksupported Whenindoubtaboutcuffsize itisbettertousealargecuff Alargecuffcausesnegligibledifference asmallcuffmayoverestimatepressureby4 9 5mmHg Allowatleast30seconds not5minutes betweenmeasurements Measurepressureinbotharms repeatinarmwithhigherpressure Donotaverage Whichisassociatedwithhighserumcholesterol Diabetesinsipidus correct diabetesmellitus AmyloidosisMultipleSclerosisNephroticsyndrome alongwithhypertension proteinuria edema hyperthyroidism correct hypothyroidismwhichshouldbecorrectedbeforeinitiatingtx Whichisassociatedwithhighserumcholesterol Diabetesinsipidus correct diabetesmellitus AmyloidosisMultipleSclerosisNephroticsyndrome alongwithhypertension proteinuria edema hyperthyroidism correct hypothyroidismwhichshouldbecorrectedbeforeinitiatingtx A72yearoldsmokerwithseveredegenerativearthritis diabetes cardiovasculardiseasecomplainsofbilaterallegpainthatoccursafterwalking200yards Restimproveshissymptoms Whichisthemostappropriatetest AnklebrachialindexMRIoflumbarspineUltrasoundofthelowerextremitiesElectromyelogramofthelowerextremitiesArteriogramofthelowerextremities Whichisthemostappropriatetest AnklebrachialindexMRIoflumbarspineUltrasoundofthelowerextremitiesElectromyelogramofthelowerextremitiesArteriogramofthelowerextremities Ref Fauci Braunwald etal Harrisons 16thed 2005 1486 1 3Calcifiednoncompressibleartery1 0 1 3Normal0 4 0 9Usualrangeclaudication 0 4Advancedischemia AnkleBrachialIndex Whichismostappropriateforinitialtreatmentofclaudication Warfarin coumadin VasodilatingagentsChelationRegularexercise Whichismostappropriateforinitialtreatmentofclaudication Warfarin coumadin VasodilatingagentsChelationRegularexercise Ref Santillietal AmerFamilyPhysician1996 53 4 1245 53 Duringahealthmaintenanceexam a54yearoldsmokerstatesheistakingbetacarotenebecauseitwasrecommendedbyalocalhealthfoodstorespecializinginnaturalsupplements Heaskswhatyourecommendwithregardtothissupplement Heshouldnottakethebetacarotene Althoughbetacarotenehasnotbeenprovenbeneficial thereisnoharmintakingit Betacarotenesupplementationhasbeenshowntopreventlungcancer Betacarotenesupplementationhasbeenshowntodecreasecoronaryarterydisease Heshouldnottakethebetacarotene Althoughbetacarotenehasnotbeenprovenbeneficial thereisnoharmintakingit Betacarotenesupplementationhasbeenshowntopreventlungcancer Betacarotenesupplementationhasbeenshowntodecreasecoronaryarterydisease TheBeta Carotene RetinolEfficacyTrialwasterminatedprematurelybecauseofasignificantincreaseinlungcancermortality insignificantincreaseinCAD Ref Adams60 3 895 904 Youarechiefofstaffofasmallcommunityhospital TheheadofyourEDwantstodevelopaprotocolforuseoftissueplasminogenactivator tPA forstrokevictims Whichisthe 1reasonaspecificstroketeamprogramwouldhavelittleimpactoncommunityhealth TheuseoftPAincreasesshort termmortality TheusesotPAdoesnotreducelong termdisability MRIscanningwouldnotbeavailablewithin3hours VeryfewpatientswouldbeeligiblefortPAevenifastroketeamandprotocolwereinplace ItisoftendifficulttoobtaintPAwithin3hours TheuseoftPAincreasesshort termmortality TheusesotPAdoesnotreducelong termdisability MRIscanningwouldnotbeavailablewithin3hours VeryfewpatientswouldbeeligiblefortPAevenifastroketeamandprotocolwereinplace ItisoftendifficulttoobtaintPAwithin3hours Ref Luisi11 2 145 51 Discussion Fewpatientseligibleeitherbecausetheypresentmorethan3hoursaftersymptomonsetorhavecontrastotPAMRIscannotneeded 24hourCTscanwithexpertinterpretationneeded rt PAmayincreaseearlymorbidity mortalitybutdecreaseslongtermdisability CentersinNINDSstudyhadonly2 5eligiblepatients Aninspiratoryincreaseinjugularvenouspressure Kussmaul ssign isassociatedwith CirrhosisoftheliverChronicconstrictivepericarditiscorpulmonalepatentductusarteriosusarteriovenousfistula Aninspiratoryincreaseinjugularvenouspressure Kussmaul ssign isassociatedwith CirrhosisoftheliverChronicconstrictivepericarditiscorpulmonalepatentductusarteriosusarteriovenousfistula Ref Goldman Bennett eds CecilTextofIM ed21 pp252 3 Discussion Large moderatepatentductuscauseswidepulsepressure boundingpulses Incorpulmonaleadvancedpulmonarydiseaseisusuallypresent venouspressurefallswithinspiration Congestivehepatomegaly ascitesmayoccurwithconstrictivepericarditis Distendedneckveinsshouldpromptsearchforcardiacdisease Dissectionofthedescendingaortaismostlikelytoproduce Unequalbloodpressureinthearmsdecreasedrightcarotidpulseparadoxicalpulseof25mmHgearlydiastolicmurmuralongleftsternalborderseverepainasthepresentingsymptom Dissectionofthedescendingaortaismostlikelytoproduce Unequalbloodpressureinthearmsdecreasedrightcarotidpulseparadoxicalpulseof25mmHgearlydiastolicmurmuralongleftsternalborderseverepainasthepresentingsymptom Ref Goldman Bennett eds Cecils ed21 2000 pp354 6 Dissectionofthedescendingaortaordinarilybeginsjustbeyondtheoriginofthesubclavianarteryandproceedsdistally Hemopericardium aorticregurgitationoftenfoundinascendingaorticdissectionsdonotoccur Patientstakingticlopidine Ticlid asforstrokeprophymustinitiallybemonitoredq2weekswith CBC asneutropeniawithanabsolutecount 450 mm3mayoccurbetween1st 3rdmonthoftherapy LipidPanelUrinalysisSerumCreatinine Patientstakingticlopidine Ticlid asforstrokeprophymustinitiallybemonitoredq2weekswith CBC asneutropeniawithanabsolutecount 450 mm3mayoccurbetween1st 3rdmonthoftherapy LipidPanelUrinalysisSerumCreatinine DCifneutropenic Ref MolonyB arisk benefitanalysisofticlopidineinstrokeprophy Stroke1992 34 874 30 Whichisnotconsideredariskfactorformyocardialinfarction alcoholismhomocystinemia