Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_2899_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

15.09.2026

Размер:

12 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 509 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

https://t.me/med1917

•

Fig. 6.2 Pharmacological treatment of hypertension. ACEi, angiotensin-converting enzyme inhibitor; ARB,angiotensinreceptorblocker;BP,bloodpressure;CCB,calciumchannelblocker.

Specialistreferral

Evaluationofsecondaryhypertensionbyaspecialistshouldbeconsideredinpatients<40 yearswithhypertension.

Complications

Hypertensionisa common andmajor risk factor for cardiovasculardiseases,CKD,and prematuredeath.

Monitoringandfollow-up

Targetclinicbloodpressuremeasurementsareagedependentandasfollows:

Age<80years:<140/90mmHg Age≥80years:<150/90mmHg.

ABPM or HBPM can be considered if patient has significant‘whitecoat’ hypertension, withthefollowingtargets:

Age<80years:<135/85mmHg Age≥80years:<145/85mmHg.

Reviewofbloodpressurecontrolandothercardiovascularriskfactorsshouldtakeplace atleastannually.

If an ACE inhibitor or an ARB are used concurrently with multiple diuretics, close

monitoring(initiallyat1month)ofelectrolytesandrenalfunctionisrequired.

Specialconsiderations

Pregnancy

Pregnantwomenwithchronichypertensionshouldbereferredtoaspecialist(seeChapter

62).

Chronickidneydisease

https://t.me/med1917

Targetbloodpressureis<140/90mmHgifACRis<70mg/mmol.IfACRis>70mg/mmol, targetbloodpressureis<130/80mmHg.AnACEinhibitor,ARB,ordirectrenininhibitor shouldbeusedasinitialtherapy(seeChapter47).

Diabetes

Target blood pressure is <135/85 mmHg. If the patient also has CKD, target blood pressure is <130/80mmHg. An ACE inhibitor, ARB, or directrenin inhibitor should be usedasinitialtherapy.

Furtherreading

1. Scottish Intercollegiate Guidelines Network (2017). Risk Estimation and the Prevention of Cardiovascular Disease. Edinburgh: SIGN; 2017. Available at:

https://www.sign.ac.uk/assets/sign149.pdf

2.WilliamsL,ManciaG,SpieringW,etal.(2018).2018ESC/ESHGuidelinesfor the managementof arterial hypertension: the Task Force for the management of arterial hypertension of the European SocietyofCardiology(ESC)andtheEuropeanSocietyofHypertension(ESH).EurHeartJ.39:3021–

1 NICE Clinical Knowledge Summaries. Obesity. Scenario: management. 2017. Available at:

https://cks.nice.org.uk/obesity#!scenario

https://t.me/med1917

Chapter7

Pericardialdiseases

Guideline:ESC(2015ESCGuidelinesforthediagnosisandmanagementof

pericardial diseases):

https://academic.oup.com/eurheartj/article/36/42/2921/2293375

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Pericarditis,pericardialeffusions,cardiactamponade,andconstrictivepericarditisareall forms of pericardial disease. The causes of pericardial disease include infection, myocardial infarction, uraemia, autoimmune disease, sarcoidosis, malignancy, and radiotherapy.Tuberculosis(TB)isacommoncauseinendemiccountries.

Diagnosis

History/diagnosticcriteria

Acutepericarditis

An inflamed pericardium usually causes pericarditic (pleuritic) chest pain, which is improved by sitting up and leaning forward. There may be symptoms suggesting the underlyingaetiology, e.g. fever, weight loss, or cough. Viruses are acommon causeof pericarditis.SeeBox7.1fordiagnosticcriteria.

Box7.1Diagnosticcriteriaforpericarditis(≥2outof4criteriarequired)

https://t.me/med1917

•

Pericarditicchestpain Pericardialrub ECGchanges:newwidespreadSTelevationorPRdepression Pericardialeffusion(neworworsening).

Source:datafrom2015ESCGuidelinesforthediagnosisandmanagementofpericardialdiseases.

Pericardialeffusionandcardiactamponade

Normally, pericardial fluid lubricates the pericardial layers. However, pathological accumulationof pericardialfluidcancompress theheartcausingdyspnoea, orthopnoea, andchestpain.

Cardiactamponadeisamedicalemergencywhererapidpericardialaccumulationof fluid, pus,blood, orgas(e.g.from inflammation,trauma,ruptureof theheart,oraortic dissection) compresses the heart to the point of cardiogenic shock and haemodynamic instability.

Constrictivepericarditis

Atightandfibrosedpericardiumcanconstricttheheart,causingsymptomsofrightheart failure (e.g. peripheral oedema, breathlessness, and abdominal swelling) despite preserved right and left ventricular function. This can occur following any pericardial disease. The risk is low (<1%) following viralor idiopathic pericarditis and high (20– 30%)followingbacterialpericarditis.

Examination

UseanABCDEapproachtoexaminethepatientandassessforhaemodynamicinstability.

Table7.1describessignsassociatedwithdifferentpericardialdiseases.

https://t.me/med1917

•

Table7.1Cardiovascularsignsassociatedwitheachpericardialdisease

Pericarditis Pericardialrub

Cardiactamponade(orlargepericardialeffusion) ↑heartrate

↓bloodpressure Pulsusparadoxus RaisedJVP Muffledheartsounds

Constrictivepericarditis Kussmaulsign(paradoxicalriseinJVPininspiration)

Pericardialknock(high-pitchedearlydiastolicaddedsound) Signsofrightheartfailure:

Peripheraloedema Ascites Hepatomegaly

Lookoutforsignssuggestingtheunderlyingaetiology,e.g.cracklesonauscultationof thechest,lymphadenopathy,orvasculiticrashes.

Investigations

Orderinvestigationstoconfirmdiagnosisofpericardialdisease(Table7.2)andassessfor haemodynamiccompromise.Lookforaetiologyofpericardialdiseaseinallpatientswith ( Box7.2).

Considerviralswabs,sputumcultures,bloodcultures,autoimmunescreen,ortumour markersbasedonhistoryandexaminationfindings.

https://t.me/med1917

•

Table7.2Investigationsforthediagnosisofpericardialdiseases

Category Specificinvestigations Indication

Bedside ECG Assessfor:

New widespread ST elevation or PR depression(pericarditis) Low QRS voltage with electrical alternans (pericardialeffusion)

Bloods Whitecellcount,erythrocytesedimentationrate

(ESR),C-reactiveprotein(CRP)

Tomonitordiseaseactivityandefficacyof therapy

Creatinekinase/troponin Raisedinmyo(peri)carditis

U&E,LFT,TFT Toassessbaselinefunctionandpotentialcause

ofpericarditis

Imaging ChestX-ray Enlargedcardiacsilhouettewithpericardial

effusions>300mL Mayrevealcauseofpericardialdisease(e.g. TB,malignancy)

TTE Identifyandassesspericardialeffusions

Toassessleft/rightventricularfunction

Other CTscan Mayshowpericardialthickening/calcificationin

constrictivepericarditis Mayrevealcauseofpericardialdisease(e.g. TB,malignancy)

CardiacMRI Toconfirmmyocarditis

Mayshowpericardialthickening/calcificationin constrictivepericarditis

Coronaryangiography ToexcludeACSifdiagnosisunclear

Source:datafrom2015ESCGuidelinesforthediagnosisandmanagementofpericardialdiseases.

Box7.2Redflags

Fever>38°C Subacuteonsetofsymptoms(oftenseenwithmalignantpericardialeffusions) Largepericardialeffusionorcardiactamponade Lackofresponseafter>1weekofmedicaltherapy Myocardialinvolvement(elevatedtroponin,ventricularimpairment) Immunosuppression Trauma Oralanticoagulanttherapy.

Source:datafrom2015ESCGuidelinesforthediagnosisandmanagementofpericardialdiseases.

https://t.me/med1917

•

Management

Acutemanagement

Treatunderlying cause of pericardial disease, e.g. give antibioticsin suspected bacterial infections.

Callforhelp?

If there is haemodynamic instability, contact a senior and request urgent cardiology input.

Unstablepatientswithcardiactamponadeneed:

Urgentpericardiocentesis(guidedbyechocardiography):

Aspiratedfluidcanbesentforcytology,culture,andbiochemistry Urgentsurgicaldrainagemayberequiredifthereisbleedingintothepericardium,e.g.following traumaoraorticdissection,orifpercutaneousdrainageisdifficultorimpossible.

Treatmentafterstabilization

Pericarditis

Aspirin750mg–1gTDSfor1–2weeks,thendecreaseby250–500mgevery1–2weeks

Non-steroidalanti-inflammatory drugs(NSAIDs),e.g.ibuprofen600mgTDSfor1–2weeksthen decreaseby200–400microgramsevery1–2weeks Add incolchicine500 micrograms OD (ifweight <70kg) or BD (if weight >70kg) to improve responsetomedicalmanagementandpreventrecurrence If no improvement is seen with these therapies or if they are contraindicated, low-dose prednisolonemaybeused(0.2–0.5mg/kg/day) Restrictphysicalactivityuntilsymptomsandinvestigationsnormalize.

Specialisttreatment

Specialist opinion should be sought in pericardial disease that does not resolve or has sinisteraetiology:

https://t.me/med1917

•

Inrecurrentorchronicpericarditisconsider:

IVimmunoglobulin,anakinra,orazathioprine

Pericardiectomy Inpericardialeffusionconsider:

Pericardiocentesisforpersistent,large,orsymptomaticeffusions

Pericardiectomy(orpericardialwindow)forreaccumulating/loculatedeffusionsorifbiopsy

isrequired

Surgicaldrainageinsuspectedbacterialandneoplasticpericarditis Inconstrictivepericarditisconsider:

Atrialofanti-inflammatoriesandconservativemanagementfor2–3monthsinitially

Pericardiectomyinpatientswithchronicconstrictivepericarditis(andNYHAclassIIIorIV)

butnoteitisassociatedwithsignificantoperativemorbidityandmortality.

Specialconsiderations

Pregnancy

NSAIDs (>20 weeks’ gestation) can constrict the ductus arteriosus and cause fetal renal impairment Colchicineiscontraindicated.

Renalimpairment

NSAIDscanexacerbaterenalimpairment.

Furtherreading

1.Ramrakha P, HillJ (eds)(2012). Pericardialdiseases. In:OxfordHandbookof Cardiology, 2nded (pp. 327–56). Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780199643219.003.0009

https://t.me/med1917

•

Chapter8

Stableangina

Guidelines: NICE CG95 (Recent-onset chest pain of suspected cardiac

origin:assessmentanddiagnosis):https://www.nice.org.uk/guidance/cg95

NICE CG126 (Stable angina: management):

https://www.nice.org.uk/guidance/cg126

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Stable angina is intermittent, stable chest pain caused by flow-limiting disease in the epicardial coronary arteries, known as coronary artery disease (CAD). Unstable angina fallsundertheumbrellatermACSandiscoveredinChapter1.

Diagnosis

Diagnosticcriteria

Stableanginamaybediagnosedwhenthereisanginalpain(see‘History’),AND

There is significant CAD on CT coronary angiography or invasive coronary angiogram (see

‘Other’)OR

Thereisreversiblemyocardialischaemiaduringnon-invasivefunctionalimaging(see‘Other’).

History

https://t.me/med1917

<<< < Предыдущая 1 2 3 4 5 6 7 89 / 509 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
15.09.202613 Мб0Книга_2891_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2892_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2893_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2894_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2897_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2899_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202626 Мб0Книга_29_библиотеки_им_акад_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2901_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2906_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2910_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_2911_Библиотеки_им_академика_М_И_Перельмана.pdf