急性主动脉夹层的降压药物选择课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,急性主动脉夹层的降压药物选择,从证据到临床实践,上海交通大学医学院附属仁济医院,心血管外科CIU谢波,急性主动脉夹层的降压药物选择,1,急性主动脉夹层,急性主动脉夹层,2,AAD:临床特征,发病急,病情极其凶险!,发病前48h,每小时死亡率增加约1.4%,(48h内总死亡率接近70%),发病时剧烈胸痛和/或腹痛,伴高血压急症,AAD:临床特征,3,高血压急症,短时期内(数小时或数天)血压重度升高,舒张,压120mmHg和(或)收缩压180mmHg,伴有,重要器官组织如心脏、脑、肾、眼底、大动脉的,严重功能障碍或不可逆性损害,发病机制:交感神经张力亢进和缩血管活性物质,增加;局部或全身小动脉持续痉挛,高血压急症,4,控制性降压,原则:降低左室射血速度(dp/dt)和降低,收缩压,嬴得治疗(手术或介入)时机并预,防主动脉夹层破裂及其他并发症,需要更紧急、更快速的降压,治疗紧急度,15min,控制性降压从急诊疑诊主动脉夹层即应开,始,并贯穿于整个治疗过程中(急诊ICU手,术中术后),控制性降压,5,诊疗流程,History,Emergency room,Physi,pulse, signs and symptoms of heart,控制性降压,failure, WBC, Hb, CRP. D-dime,ssection,Aarbic valve regurgitation?,CT. TEE,Documented acute,Suspected,Stanford A,Follow-u,Follow-up,Conservatlve,JCs guidelines, 2019,诊疗流程,6,指南:主动脉夹层的血压管理,2019 ACCF/AHA/ AATS Guidelines for the,Diagnosis and management of Patients with Thoracic,Aortic di,201 1 Guidelines for diagnosis and Treament of,Aortic Aneurysm and Aortic Dissection(JCS 2019),2019中国急诊高血压临床实践指南,中国医师协,会急诊医师分会,指南:主动脉夹层的血压管理,7,ACCF/AHA Guideline,2019 ACCF/AHAAATSACRASASCAACAISIRSTS/SYM,Guidelines for diagnosis and treatment of aortic,Guidelines for the Diagnosis and Management of Patients With,Aneurysm and Aortic Dissection (CS 20I1),Thoracic aortic disease,A Report f the American College of Cardiology Foundation American Heart association,lask Force on Practice Guidelines, American Association for Thoracic Surgery. American,College of Radiolog, American Stroke Associa on. Socity of Cardio ascular,Anesthesiologists, Society for Cardiovascular Angiography and Intervention, Society af,Interventional Rading, Society f Thoro Surgons, and Society for Vascular Medicine,IV Medical Treatment,1. Aortic Dissection,1. Management in the Acute Phase,(1)Blood Pressure Control,The most important aspects of treatment in the hyperacute phase The most important aspect of medical management is to con-,are control of hypertension deaar, To to TzummHgss293 trol blood pressure. p-blockers are reported to reduce dissec.,pulse rate control, pain relief, and res,ould be,used simultaneously with antihypertensive therapy to achieve eu,aggressive pulse rate control, and analgesic or sedative thera-,py should be used to manage persistent pa,2. Management in the Chronic Phase,ADL egv dere ma e pe (tiw is miera,The major goals of patient management in the chronic phase,ACCF/AHA Guideline,8,中国急诊高血压临床实践指南(2019),其他高血压急症类型相比,急性主动脉夹层短期的病死率和致残率较,高,故应当给予特殊的关注。主动脉夹层患者需要更紧急、快速的降,压,一旦疑诊主动脉夹层,必须立即使患者血压快速地降至正常偏低,水平,主动脉壁所受剪切力大小取决于心室搏动的力度和速率以及每搏血流,量,选择的药物必须有助于降低这三个因素的水平并且当降压时需要,特别积极地控制反射性心动过速,推荐主动脉夹层患者需要将收缩压在20分钟内降至100120mHg,心率6080次/min,治疗紧急度1530min,中国急诊高血压临床实践指南(2019),9,指南总结,优先控制心率:6070次min,静脉受体阻滞剂是首,选药物,紧急、快速控制性降压:静脉降压药,收缩压目标,100120mmHg,治疗紧急度1520min,联合应用镇静、镇痛剂,用药过程中注意生命体征、特别是血压监测,有创血压,监测为宜,无创血压监测至少每5min重复,指南总结,10,急性主动脉夹层的降压药物选择课件,11,急性主动脉夹层的降压药物选择课件,12,急性主动脉夹层的降压药物选择课件,13,急性主动脉夹层的降压药物选择课件,14,急性主动脉夹层的降压药物选择课件,15,急性主动脉夹层的降压药物选择课件,16,急性主动脉夹层的降压药物选择课件,17,急性主动脉夹层的降压药物选择课件,18,急性主动脉夹层的降压药物选择课件,19,急性主动脉夹层的降压药物选择课件,20,急性主动脉夹层的降压药物选择课件,21,急性主动脉夹层的降压药物选择课件,22,急性主动脉夹层的降压药物选择课件,23,急性主动脉夹层的降压药物选择课件,24,急性主动脉夹层的降压药物选择课件,25,急性主动脉夹层的降压药物选择课件,26,急性主动脉夹层的降压药物选择课件,27,急性主动脉夹层的降压药物选择课件,28,急性主动脉夹层的降压药物选择课件,29,急性主动脉夹层的降压药物选择课件,30,急性主动脉夹层的降压药物选择课件,31,急性主动脉夹层的降压药物选择课件,32,急性主动脉夹层的降压药物选择课件,33,急性主动脉夹层的降压药物选择课件,34,急性主动脉夹层的降压药物选择课件,35,急性主动脉夹层的降压药物选择课件,36,急性主动脉夹层的降压药物选择课件,37,急性主动脉夹层的降压药物选择课件,38,急性主动脉夹层的降压药物选择课件,39,急性主动脉夹层的降压药物选择课件,40,急性主动脉夹层的降压药物选择课件,41,急性主动脉夹层的降压药物选择课件,42,急性主动脉夹层的降压药物选择课件,43,