【高血压英文课件】高血压-Hypertension

HypertensiveEmergencyDanielJ.McFarlaneM.D.DivisionofHospitalMedicineJanuary2011OutlineEpidemiologyDefinitionsPathophysiologyDiagnosisandRecognitionTreatmentSpecialCircumstancesEpidemiologyWhyshouldwecareabouthypertension?OneofthemostcommonchronicmedicalconcernsintheUSAffects>30%ofthepopulation>age20RiskfactorforCardiovasculardiseaseandmortalityCerebrovasculardiseaseandmortalityEndstagerenaldiseaseOtherendorgandamageDefinitionsHypertension(accordingtoJNCVII)NormalBP <120/<80Prehypertension 121-139/80-89StageIHTN 140-159/90-99StageIIHTN >160/>100(SevereHTN >180/>110)SevereHTNisnotaJNCVIIdefinedentityDefinitionsHypertensiveEmergencyAcute,rapidlyevolvingend-organdamageassociatedwithHTN(usu.DBP>120)BPshouldbecontrolledwithinhoursandrequiresadmissiontoacriticalcaresettingHypertensiveUrgencyDBP>120thatrequirescontrolinBPover24to48hoursNoendorgandamageMalignantHypertensionisnolongerusedDefinitionsEnd-OrganDamage(%ofcases)Cerebralinfarction…… 24%Hypertensiveencephalopathy……16%Intracranialhemorrhage……………4.5%Acuteaorticdissection………………2%Acutecoronarysyndrome/myocardialinfarction…12%Pulmonaryedemawithrespiratoryfailure…………22%Severeeclampsia/HELLPsyndrome………………2%Acutecongestiveheartfailure……14%Acuterenalfailure……9%PathophysiologyHypertensiveEmergencyFailureofnormalautoregulatoryfunctionLeadstoasharpincreaseinsystemicvascularresistanceEndovascularinjurywitharteriolenecrosisIschemia,plateletdepositionandreleaseofvasoactivesubstancesFurtherlossofautoregulatorymechanismExposesorganstoincreasedpressureDiagnosisandRecognitionPresentationAlwayspresentwithanewonsetsymptomTakeagoodhistoryHistoryofHTNandpreviouscontrolMedicationswithdosageandcomplianceIllicitdruguse,OTCdrugsDiagnosisandRecognitionPhysicalConfirmBPinmorethanoneextremityEnsureappropriatecuffsizePulsesinallextremitiesLungexam—lookforpulmonaryedemaCardiac—murmursorgallops,angina,EKGRenal—renalarterybruit,hematuriaNeurologic—focaldeficits,HA,alteredMSFundoscopicexam—retinopathy,hemorrhageDiagnosisandRecognitionLaboratory/RadiologicevaluationsBasicMetabolicPanel(BUN,Cr)CBCwithsmear(hemolyticanemia)Urinalysis(proteinuria,hematuria)EKGtolookforischemiaCXRtolookforpulmonaryedemaifdyspneaHeadCTforhemorrhageifHAoralteredMSMRIchestifunequalpulsesandwidemediastinumtolookforaorticdissectionTreatmentHypertensiveUrgencyNoend-organdamage—NOTemergentLookforreactiveHTNandtreatthisfirstDrugs,pain,anxiety,cocaine,withdrawalUseoralmedicationstolowerBPgraduallyover24-48hours,likely2agentsneededMaybechronic,decreaseBPslowlytoavoidhypoperfusionoforgansAvoidsublingualandIMadministrationduetounpredictableabsorptionTreatmentHypertensiveUrgencyAppropriatefollowupforasymptomaticpatientswithnoend-organdamage BPrange ActionPlan140-159/90-99 Observe,confirmBP2mos160-179/100-109 Confirm,treatwithin1mo180-209/110-119 Confirm,treatwithin1wk210+/120+ Confirm,treatnow,closef/uMedicationsOraldrugchoicesoftenbasedoncomorbidconditionsHeartfailure—TH,BB,ACEI,ARB,ALDOPostMI—BB,ACEI,ALDOHighCVDrisk—TH,BB,ACEI,CCB Diabetes—TH,BB,ACEI,ARB,CCBChronicRenalFailure—ACEI,ARBRecurrentstrokeprevention—TH,ACEIKEY:ACEI,angiotensinconvertingenzymeinhibitor;ALDO,aldosteroneantagonist;ARB,angiotensinreceptorblocker;BB,bblocker;CCB,calciumchannelblocker;TH,thiazide.TreatmentHypertensiveEmergencyActQuicklyStartIVgoaldirectedpharmacologictherapyContinuousinfusion:shortactingtitratablemedsInitiatecriticalcaremonitoringIntraorticBPmonitoringmaybenecessaryStartSLOW:LimitinitialloweringofBPto20%belowpretreatmentlevelDuetoincreasedthresholdofhypoperfusionoftheorgansfromabnormalautoregulationGoal:LowerDBPby10-15%in30-60minInitiateoraltherapyandtitrateIVmedicationsdownMedicationsIV,shortacting,titratable.ArterialVasodilatorsHydralazine,fenoldepam,nicardipine,enalaprilVenousVasodilatorsNitroglycerineMixedArterialandVenousVasodilatorsSodiumnitroprussideNegativeInotrope/ChronotropeLabetolol(alsovasodilates),EsmololAlphablockers(inc.sympatheticactivity)PhentolamineMedicationsPreferredagentsbyusageLabetolol>Esmolol>Nicardipine>Fenoldopam(espinpheochromocytoma)PreferredagentsbyendorgandamagePulmonaryEdema(systolic)—NicardipinePulmonaryEdema(diastolic)—EsmololAcuteMI—LabetololorEsmololHypertensiveEncephalopathy—LabetololAcuteAorticDissection—LabetololEclampsia—LabetololorNicardipineAcuteRenalFailure—FenoldopamSympatheticCrisis/Cocaine—VerapamilorDiltiazemSpecialCircumstancesAcuteAorticDissectionStartIVmedsSTATtolowerpulsitileloadandaorticstresstolessenthedissectionVasodilatorsalonemayreflextachycardiaUsebetablockerANDvasodilatorEsmololandNitroprussideSurgicalevaluationTypeAallgotosurgeryTypeBonlyifrupture/leak.TreatwithaggressiveBPcontrolSpecialCircumstancesStrokeNumberonecauseofpermanentdisabilityHTNisaprotectivephysiologiceffecttomaintainbloodflowtobrainOnestudyshowedbetteroutcomeifhypertensiveuponpresentationofstrokeTreatHTN“rarelyandcautiously”LowerBP10-15%infirst24hours(not>20%)HemorrhagicstrokeTreatif>200/>110,butstillwithmodestloweringofBPbecausestillworseoutcomewithlowBPSpecialCircumstancesEclampsiaVasoconstrictedandhemoconcentratedVolumeexpand,magnesiumsulfate,andaggressiveBPcontrol.DeliveryisonlydefinitivetreatmentLabetololorNicardipinearedrugsofchoice.Hydralazinewasfirstlinebutslowonsetandunpredictablesomayleadtohypotension