急性主動(dòng)脈夾層的降壓藥物選擇課件整理

急性主動(dòng)脈夾層的降壓藥物選擇——從證據(jù)到臨床實(shí)踐上海交通大學(xué)醫(yī)學(xué)院附屬仁濟(jì)醫(yī)院心血管外科CIU謝波急性主動(dòng)脈夾層的降壓藥物選擇1急性主動(dòng)脈夾層急性主動(dòng)脈夾層2AAD:臨床特征發(fā)病急,病情極其兇險(xiǎn)!·發(fā)病前48h,每小時(shí)死亡率增加約1.4%(48h內(nèi)總死亡率接近70%)發(fā)病時(shí)劇烈胸痛和/或腹痛,伴高血壓急癥AAD:臨床特征3高血壓急癥短時(shí)期內(nèi)(數(shù)小時(shí)或數(shù)天)血壓重度升高,舒張壓>120mmHg和(或)收縮壓>180mmHg,伴有重要器官組織如心臟、腦、腎、眼底、大動(dòng)脈的嚴(yán)重功能障礙或不可逆性損害·發(fā)病機(jī)制:交感神經(jīng)張力亢進(jìn)和縮血管活性物質(zhì)增加;局部或全身小動(dòng)脈持續(xù)痙攣高血壓急癥4控制性降壓原則:降低左室射血速度(dp/dt)和降低收縮壓,嬴得治療(手術(shù)或介入)時(shí)機(jī)并預(yù)防主動(dòng)脈夾層破裂及其他并發(fā)癥需要更緊急、更快速的降壓,治療緊急度15min控制性降壓從急診疑診主動(dòng)脈夾層即應(yīng)開(kāi)始,并貫穿于整個(gè)治療過(guò)程中(急診ICU手術(shù)中術(shù)后)控制性降壓5診療流程HistoryEmergencyroomPhysipulse,signsandsymptomsofheart控制性降壓failure,WBC,Hb,CRP.D-dimessectionAarbicvalveregurgitation?CT.TEEDocumentedacuteSuspectedStanfordAFollow-uFollow-upConservatlveJCsguidelines,2019診療流程6指南:主動(dòng)脈夾層的血壓管理2019ACCF/AHA/AATSGuidelinesfortheDiagnosisandmanagementofPatientswithThoracicAorticdi2011GuidelinesfordiagnosisandTreamentofAorticAneurysmandAorticDissection(JCS2019)·2019中國(guó)急診高血壓臨床實(shí)踐指南,中國(guó)醫(yī)師協(xié)會(huì)急診醫(yī)師分會(huì)指南:主動(dòng)脈夾層的血壓管理7ACCF/AHAGuideline2019ACCF/AHAAATSACRASASCAACAISIRSTS/SYMGuidelinesfordiagnosisandtreatmentofaorticGuidelinesfortheDiagnosisandManagementofPatientsWithAneurysmandAorticDissection(CS20I1)ThoracicaorticdiseaseAReportftheAmericanCollegeofCardiologyFoundationAmericanHeartassociationlaskForceonPracticeGuidelines,AmericanAssociationforThoracicSurgery.AmericanCollegeofRadiolog,AmericanStrokeAssociaon.SocityofCardioascularAnesthesiologists,SocietyforCardiovascularAngiographyandIntervention,SocietyafInterventionalRading,SocietyfThoroSurgons,andSocietyforVascularMedicineIVMedicalTreatment1.AorticDissection1.ManagementintheAcutePhase(1)BloodPressureControlThemostimportantaspectsoftreatmentinthehyperacutephaseThemostimportantaspectofmedicalmanagementistocon-arecontrolofhypertensiondeaar,TotoTzummHgss293trolbloodpressure.p-blockersarereportedtoreducedissec.pulseratecontrol,painrelief,andresouldbeusedsimultaneouslywithantihypertensivetherapytoachieveeuaggressivepulseratecontrol,andanalgesicorsedativethera-pyshouldbeusedtomanagepersistentpa2.ManagementintheChronicPhaseADLegvderemaepe(tiwismieraThemajorgoalsofpatientmanagementinthechronicphaseACCF/AHAGuideline8中國(guó)急診高血壓臨床實(shí)踐指南(2019)其他高血壓急癥類型相比,急性主動(dòng)脈夾層短期的病死率和致殘率較高,故應(yīng)當(dāng)給予特殊的關(guān)注。主動(dòng)脈夾層患者需要更緊急、快速的降壓,一旦疑診主動(dòng)脈夾層,必須立即使患者血壓快速地降至正常偏低水平主動(dòng)脈壁所受剪切力大小取決于心室搏動(dòng)的力度和速率以及每搏血流量,選擇的藥物必須有助于降低這三個(gè)因素的水平并且當(dāng)降壓時(shí)需要特別積極地控制反射性心動(dòng)過(guò)速·推薦主動(dòng)脈夾層患者需要將收縮壓在20分鐘內(nèi)降至100~120mHg,心率60~80次/min治療緊急度15~30min中國(guó)急診高血壓臨床實(shí)踐指南(2019)9指南總結(jié)·優(yōu)先控制心率:60~70次min,靜脈β受體阻滯劑是首選藥物緊急、快速控制性降壓:靜脈降壓藥,收縮壓目標(biāo)100~120mmHg,治療緊急度15~20min聯(lián)合應(yīng)用鎮(zhèn)靜、鎮(zhèn)痛劑用藥過(guò)程中注意生命體征、特別是血壓監(jiān)測(cè),有創(chuàng)血壓監(jiān)測(cè)為宜,無(wú)創(chuàng)血壓監(jiān)測(cè)至少每5min重復(fù)指南總結(jié)10急性主動(dòng)脈夾層的降壓藥物選擇課件整理11急性主動(dòng)脈夾層的降壓藥物選擇課件整理12急性主動(dòng)脈夾層的降壓藥物選擇課件整理13急性主動(dòng)脈夾層的降壓藥物選擇課件整理14急性主動(dòng)脈夾層的降壓藥物選擇課件整理15急性主動(dòng)脈夾層的降壓藥物選擇課件整理16急性主動(dòng)脈夾層的降壓藥物選擇課件整理17急性主動(dòng)脈夾層的降壓藥物選擇課件整理18急性主動(dòng)脈夾層的降壓藥物選擇課件整理19急性主動(dòng)脈夾層的降壓藥物選擇課件整理20急性主動(dòng)脈夾層的降壓藥物選擇課件整理21急性主動(dòng)脈夾層的降壓藥物選擇課件整理22急性主動(dòng)脈夾層的降壓藥物選擇課件整理23急性主動(dòng)脈夾層的降壓藥物選擇課件整理24急性主動(dòng)脈夾層的降壓藥物選擇課件整理25急性主動(dòng)脈夾層的降壓藥物選擇課件整理26急性主動(dòng)脈夾層的降壓藥物選擇課件整理27急性主動(dòng)脈夾層的降壓藥物選擇課件整理28急性主動(dòng)脈夾層的降壓藥物選擇課件整理29急性主動(dòng)脈夾層的降壓藥物選擇課件整理30急性主動(dòng)脈夾層的降壓藥物選擇課件整理31急性主動(dòng)脈夾層的降壓藥物選擇課件整理32急性主動(dòng)脈夾層的降壓藥物選擇課件整理33急性主動(dòng)脈夾層的降壓藥物選擇課件整理34急性主動(dòng)脈夾層的降壓藥物選擇課件整理35急性主動(dòng)脈夾層的降壓藥物選擇課件整理36急性主動(dòng)脈夾層的降壓藥物選擇課件整理37急性主動(dòng)脈夾層的降壓藥物選擇課件整理38急性主動(dòng)脈夾層的降壓藥物選擇課件整理39急性主動(dòng)脈夾層的降壓藥物選擇課件整理40急性主動(dòng)脈夾層的降壓藥物選擇課件整理41急性主動(dòng)脈夾層的降壓藥物選擇課件整理42急性主動(dòng)脈夾層的降壓藥物選擇課件整理43急性主動(dòng)脈夾層的降壓藥物選擇——從證據(jù)到臨床實(shí)踐上海交通大學(xué)醫(yī)學(xué)院附屬仁濟(jì)醫(yī)院心血管外科CIU謝波急性主動(dòng)脈夾層的降壓藥物選擇44急性主動(dòng)脈夾層急性主動(dòng)脈夾層45AAD:臨床特征發(fā)病急,病情極其兇險(xiǎn)!·發(fā)病前48h,每小時(shí)死亡率增加約1.4%(48h內(nèi)總死亡率接近70%)發(fā)病時(shí)劇烈胸痛和/或腹痛,伴高血壓急癥AAD:臨床特征46高血壓急癥短時(shí)期內(nèi)(數(shù)小時(shí)或數(shù)天)血壓重度升高,舒張壓>120mmHg和(或)收縮壓>180mmHg,伴有重要器官組織如心臟、腦、腎、眼底、大動(dòng)脈的嚴(yán)重功能障礙或不可逆性損害·發(fā)病機(jī)制:交感神經(jīng)張力亢進(jìn)和縮血管活性物質(zhì)增加;局部或全身小動(dòng)脈持續(xù)痙攣高血壓急癥47控制性降壓原則:降低左室射血速度(dp/dt)和降低收縮壓,嬴得治療(手術(shù)或介入)時(shí)機(jī)并預(yù)防主動(dòng)脈夾層破裂及其他并發(fā)癥需要更緊急、更快速的降壓,治療緊急度15min控制性降壓從急診疑診主動(dòng)脈夾層即應(yīng)開(kāi)始,并貫穿于整個(gè)治療過(guò)程中(急診ICU手術(shù)中術(shù)后)控制性降壓48診療流程HistoryEmergencyroomPhysipulse,signsandsymptomsofheart控制性降壓failure,WBC,Hb,CRP.D-dimessectionAarbicvalveregurgitation?CT.TEEDocumentedacuteSuspectedStanfordAFollow-uFollow-upConservatlveJCsguidelines,2019診療流程49指南:主動(dòng)脈夾層的血壓管理2019ACCF/AHA/AATSGuidelinesfortheDiagnosisandmanagementofPatientswithThoracicAorticdi2011GuidelinesfordiagnosisandTreamentofAorticAneurysmandAorticDissection(JCS2019)·2019中國(guó)急診高血壓臨床實(shí)踐指南,中國(guó)醫(yī)師協(xié)會(huì)急診醫(yī)師分會(huì)指南:主動(dòng)脈夾層的血壓管理50ACCF/AHAGuideline2019ACCF/AHAAATSACRASASCAACAISIRSTS/SYMGuidelinesfordiagnosisandtreatmentofaorticGuidelinesfortheDiagnosisandManagementofPatientsWithAneurysmandAorticDissection(CS20I1)ThoracicaorticdiseaseAReportftheAmericanCollegeofCardiologyFoundationAmericanHeartassociationlaskForceonPracticeGuidelines,AmericanAssociationforThoracicSurgery.AmericanCollegeofRadiolog,AmericanStrokeAssociaon.SocityofCardioascularAnesthesiologists,SocietyforCardiovascularAngiographyandIntervention,SocietyafInterventionalRading,SocietyfThoroSurgons,andSocietyforVascularMedicineIVMedicalTreatment1.AorticDissection1.ManagementintheAcutePhase(1)BloodPressureControlThemostimportantaspectsoftreatmentinthehyperacutephaseThemostimportantaspectofmedicalmanagementistocon-arecontrolofhypertensiondeaar,TotoTzummHgss293trolbloodpressure.p-blockersarereportedtoreducedissec.pulseratecontrol,painrelief,andresouldbeusedsimultaneouslywithantihypertensivetherapytoachieveeuaggressivepulseratecontrol,andanalgesicorsedativethera-pyshouldbeusedtomanagepersistentpa2.ManagementintheChronicPhaseADLegvderemaepe(tiwismieraThemajorgoalsofpatientmanagementinthechronicphaseACCF/AHAGuideline51中國(guó)急診高血壓臨床實(shí)踐指南(2019)其他高血壓急癥類型相比,急性主動(dòng)脈夾層短期的病死率和致殘率較高,故應(yīng)當(dāng)給予特殊的關(guān)注。主動(dòng)脈夾層患者需要更緊急、快速的降壓,一旦疑診主動(dòng)脈夾層,必須立即使患者血壓快速地降至正常偏低水平主動(dòng)脈壁所受剪切力大小取決于心室搏動(dòng)的力度和速率以及每搏血流量,選擇的藥物必須有助于降低這三個(gè)因素的水平并且當(dāng)降壓時(shí)需要特別積極地控制反射性心動(dòng)過(guò)速·推薦主動(dòng)脈夾層患者需要將收縮壓在20分鐘內(nèi)降至100~120mHg,心率60~80次/min治療緊急度15~30min中國(guó)急診高血壓臨床實(shí)踐指南(2019)52指南總結(jié)·優(yōu)先控制心率:60~70次min,靜脈β受體阻滯劑是首選藥物緊急、快速控制性降壓:靜脈降壓藥,收縮壓目標(biāo)100~120mmHg,治療緊急度15~20min聯(lián)合應(yīng)用鎮(zhèn)靜、鎮(zhèn)痛劑用藥過(guò)程中注意生命體征、特別是血壓監(jiān)測(cè),有創(chuàng)血壓監(jiān)測(cè)為宜,無(wú)創(chuàng)血壓監(jiān)測(cè)至少每5min重復(fù)指南總結(jié)53急性主動(dòng)脈夾層的降壓藥物選擇課件整理54急性主動(dòng)脈夾層