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杨达雅 中山一院心血管内科 郭晓刚 中山一院黄埔院区心血管内科 王月刚 南方医院心血管内科

杨达雅 中山一院心血管内科 郭晓刚 中山一院黄埔院区心血管内科 王月刚 南方医院心血管内科. 66yr/F HPI Exertional dyspnea and edema of lower extremities for one month PE BP 162/98 mmHg, HR 100 bpm. Moderately distended jugular vein Fine crackles over lower lung fields. Enlarged heart boarder

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杨达雅 中山一院心血管内科 郭晓刚 中山一院黄埔院区心血管内科 王月刚 南方医院心血管内科

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  1. 杨达雅 中山一院心血管内科 郭晓刚 中山一院黄埔院区心血管内科 王月刚 南方医院心血管内科

  2. 66yr/F • HPI • Exertional dyspnea and edema of lower extremities for one month • PE • BP 162/98 mmHg, HR 100 bpm. • Moderately distended jugular vein • Fine crackles over lower lung fields. • Enlarged heart boarder • A III/VI diastolic murmur over LLSB • A symmetric pitting edema of legs and ankles

  3. PMH • Hypertension for 10+ yrs, inadequately controlled (150-160/80-90mmHg) • Type 2 DM for 7 yrs, well controlled with Insulin • Ischemic stroke 5 yrs ago, well recovered, with minimal neurological sequelae • Gout for 3 yrs, several acute attacks • Current medications: • Nifedipine GITS 30 mg P.O., QD • Aspirin 100 mg P.O., QD • Multiple-component Insulin Regimen

  4. LABs : • ↑ BNP 3102 pg/mL • ↑ SCr 240 µmol/L ↑ Serum UA 540 µmol/L • ↑ U-PRO 3.9 g/d • ↑ LDL-C 3.7 mmol/L • GHbA1c 6.8% • Ancillary findings: • CXR: a dilated heart silhouette and mild pulmonary effusion. • ECG: paroxysmal Afib • Echo: LA 36 mm, LV 50 mm, IVS 15 mm; LVEF 41%, no wall motion abnormalities; mild AR • CAG: Not Available

  5. Working Diagnoses: • Acute LV Failure • Hypertension • Paroxysmal Afib • Type 2 DM – Diabetic Nephropathy • Prior Stroke • Gout • Treatments: • Oxygen Rx, IV furosemide, digitalis, and IV nitroglycerine, etc. all of which was well-responded. • Metoprolol was added and titrated after stablization

  6. Adequate BP Control • Antithrombotic Rx for Paroxysmal Afib

  7. BP Target: <130/80mmHg • HF, Afib and probably stroke are more or less the direct results of, or at least precipitating factors of, inadequate BP control • Benefits of BP control concerning CV mortality are well-established and overwhelming

  8. 2007 Guidelines for the management of arterial Hypertension. EHJ 2007;28:1462-1536

  9. 2007 Guidelines for the management of arterial Hypertension. EHJ 2007;28:1462-1536

  10. 2007 Guidelines for the management of arterial Hypertension. EHJ 2007;28:1462-1536

  11. Serum UA <357 μmol/L - ↓ risk of gouty attacks • Losartan has uricosuric effects (7-8%), though evidence on the clinical outcome of gout is less well established. Perez-Ruiz F, Lioté F. Lowering serum uric acid levels: what is the optimal target for improving clinical outcomes in gout? Arthritis Rheum 2007;57:1324-8 Takahashi S, Moriwaki Y, Yamamoto T, Tsutsumi Z, Ka T, Fukuchi M. Effects of combination treatment using anti-hyperuricaemic agents with fenofibrate and/or losartan on uric acid metabolism. Ann Rheum Dis 2003;62:572-5

  12. “Multi-tasking” • Compelling Indications: • HF, DM, proteinuria, Afib • ACEI / ARB class • Hyperuricemia • Losartan 50mg Qd

  13. The indication for Oral Anticoagulant (OAC) is independent of the types of Afib. 2010 Guidelines for the management of atrial fibrillation. EHJ(31):2369-2429

  14. CHADS2: • Cardiac Failure • Hypertension • Age > 75yrs • Diabetes • Stroke / TIA (doubled) • If >=2, VKA indicated (for an INR of 2.0-3.0) • If <2, Aspirin indicated

  15. Lasix 20mg Qd • Spiranolactone 20mg Qd • Amlodipine 5mg Qd • Losartan 50mg Qd • Metoprolol 12.5mg Qd • Digoxin 0.125mg Qd • Warfarin 3mg Qd • Rosuvastatin 10mg QN • Insulin Rx

  16. If target BP control is not achieved by monotherapy, a combinational approach is warranted. • Choice of anti-hypertensive drugs should be dictated by associated clinical co-morbidities. • Risk of stroke for pts with paroxysmal Afib is similar as in other types of Afib. • The CHADS2 Score is used clinically as an initial, rapid, easy-to-remember means of assessing stroke risk for Afib.

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