Evaluation and management of pulmonary hypertension in the emergency department setting.
- 作者列表："Simon E","Bridwell RE","Montrief T","Koyfman A","Long B
BACKGROUND:Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and pulmonary arterial pressure and is associated with significant morbidity and mortality. OBJECTIVE:This narrative review evaluates PH, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population. DISCUSSION:Approximately 10-20% of individuals in the United States suffer from PH. Each year nearly 12,000 PH patients seek care in the ED for a variety of symptoms which may or may not be related to PH. There are 5 classes of PH, some of which respond to particular therapies outlined in this review. As presenting complaints are frequently vague and non-specific, emergency physicians must recognize manifestations of PH and complications related to PH to deliver appropriate care. Early imaging with chest radiograph, bedside echocardiogram, and computed tomography can assist in determining the underlying etiology of PH exacerbation. Restarting oral or intravenous PH medications that may have been discontinued is crucial in initial management. Immense care should be taken to avoid hypoxia and hypercarbia as well as maintaining right ventricular preload support. In addition to correction of underlying precipitants, judicious vasopressor and inotrope use can help to correct pathophysiology and avoid further airway intervention. CONCLUSIONS:An understanding of the pathophysiology of PH and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease. Restarting maintenance PH medications and proper selection of vasopressors and inotropes will benefit decompensating patients with PH.
背景: 肺动脉高压 (PH) 以肺血管阻力和肺动脉压力增加为特征，与显著的发病率和死亡率相关。 目的: 本叙述性综述评估PH，概述复杂的病理生理紊乱，并解决该患者群体的急诊科 (ED) 管理。 讨论: 在美国大约10-20% 的人患有PH。每年有近12,000名PH患者因各种可能与PH相关或无关的症状在ED中寻求护理。有5类PH，其中一些响应于本综述中概述的特定疗法。由于提出的投诉往往是模糊的和非特异性的，急诊医生必须认识到PH的表现和与PH相关的并发症，以提供适当的护理。通过胸片、床旁超声心动图和计算机断层扫描的早期成像可以帮助确定PH恶化的潜在病因。重新开始可能已经停用的口服或静脉内PH药物在初始管理中至关重要。应注意避免缺氧和高碳酸血症，并保持右心室前负荷支持。除了纠正潜在的沉淀剂外，明智的血管加压药和强心剂的使用有助于纠正病理生理学并避免进一步的气道干预。 结论: 了解PH的病理生理学和可用的急诊治疗可以帮助急诊临床医生降低与该疾病相关的即时发病率和死亡率。重新开始维持PH药物和适当选择血管加压药和肌力药将有益于PH失代偿患者。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.