?p????? fa?

1
?p????? fa?µa?e?t???? a????? st?? ?p??tas?
?. ?a???µat?d??, ?/?t?? ?ef????????? ?µ?µat??
??µ?t????
2
?st????? st???e?a-?
St?? ???, t? 1983, ta d?????t??? ap?te???sa? t??
a????? ?e?ape?a st? 90 t?? pe??pt?se?? se
as?e?e?? µe ?p?a ?p??tas?. ?p? t?te ? ???s? t??
d?????t???? µe?????e ?a? p??a? ta p??te?a ??
a-??? ?a? ?? a?ta????st?? d?a???? asßest??? ?
JNC t? 1977, 1980, 1984 s???st??se ??a ?e?a??d???
d?????t??? ? ??a ß-a?ast???a sa? a????? ?e?ape?a
t?? ?p?a? ?p??tas??. ?? 1988 p??te??e 4 f??µa?a
(d?????t???, ß-ap???e?st??, a-???, a?ta????st??
d?a???? asßest???) ??a ep????? t?? fa?µ????
??a???? t?? ?e?ape?a?. ?? 1993 ta f??µa?a a?t?
????a? 6 (p??st????a? ?? a-ap???e?st?? ?a? ?
s??d?asµ?? a ?a? ß-ap???e?st??) ? ???es? t?? JNC
t? 1997 a?af??e? ?? de? ?p?????? e?d????
e?de??e?? ??a ???? t?p? fa?µ????, p??pe? ?a
ep??e?e? ??a d?????t??? ? ??a? ß-ap???e?st??
3
Ge????? a???? a?t??pe?tas???? ?e?ape?a?
St??? pe??ss?te???? as?e?e?? ? ?e?ape?a p??pe? ?a
a????e? µe µ???? d?s? t?? ep??e???t?? fa?µ????
?a? stad?a?? a???s? t??, a?????a µe t?? ?????a
?a? t?? a?tap????s? t?? as?e????. ?? ?da????
s?e?asµa e??a? a?t? p?? pa???e? 24??? p??stas?a,
se µ?a d?s? t?? ?µ??a -??asfa???eta? ?a??te??
s?µµ??f?s? -?e??????eta? ? ???d???? a?f??d???
?a??t??
4
Ge???? µ?t?a a?t?µet?p?s?? t?? ?p??tas??

1. ???tt?s? s?µat???? ß?????
2. ?e??s? ?ata????s?? ????p?e?µat??
3. ????s? s?µat???? d?ast????t?ta?
4. ??a?t?t???? pe?????sµ?? a?at???
5. ??a??p? ?ap??sµat??
6. ?e??s? ?ata????s?? ??p???

5
Ge????? ?d???e?-?
St?? ep????? t?? a?t??pe?tas???? p??pe? ?a
?aµß????ta? ?p??? -?????????-??????µ????
pa?????te? -?a at?µ??? ?a?a?t???st??? t??
as?e???? -? ßa?µ?? ?a?d?a??e?a??? ???d???? -?
?pa??? a?ep???µ?t?? e?e??e??? -?? s???p?????se?
pa????????? ?atast?se??
6
Ge????? ?d???e?-??

1. ?ta? ??a f??µa?? ap?de???e? a?ap?te?esµat???
   (?p??asd?p?te ?at?????a?) p??pe? ?a
   a?t??a??stata? ?a? ??? ?a a????eta? ? d?s? t??
2. ?? ??a µ??? f??µa?? e??a? e? µ??e?
   ap?te?esµat???, e??a? p??t?µ?te?? ?a p??st??eta?
   se µ???? d?s? ??a de?te??
3. ?e t? s??d?asµ? d?? fa?µ???? d?af??et????
   ep?d??se?? a????eta? t? a?t??pe?tas??? ap?t??esµa
   ?a? µe???eta? ? p??a??t?ta pa?e?e??e???

7
Ge????? ?d???e?-III
G?a ?a ep?te???e? t? µ???st? ap?t??esµa, ta
pe??ss?te?a a?t??pe?tas??? e??a? apa?a?t?t? ?a
????????ta? ap? t? st?µa ep? 3-6 eßd?µ?de?
8
Ge????? ?d???e?-IV

• ? a???? ep????eta? µe ß?s?
• ??? ßa??t?ta t?? ?p??tas??
• ??? p??a?? a?t??pa?????e?a
• ??? ?????a ?a? t? f??? t?? as?e????
• ??? pa???s?a ????? s???d?? ??s?? ? p??ß??µ?t??
• ??? p??a??? pa?e????e?e? t?? fa?µ???? p?? ?a
  d?????

? ???es? t?? JNC t?? 1997 s?µe???e ?t? ? pa???s?a
s???p?????sa? ??s?? ap?te?e? t? ß?s? ??a µ?a
?????? p??s????s? t?? ep?????? t?? a?????? ?a?
t?? ep?µe??? a?t??pe?tas???? fa?µ????
9
Ge????? ?d???e?-V

• ?????st??? ap?t??esµa d?ap?st????e µe t???
  pa?a??t? s??d?asµ???
• ??????t??? (ß-ap???e?st??, a-???,
  a-ap???e?st??)
• ß-ap???e?st?? (a-ap???e?st??, a?ta????st??
  d?a???? asßest???)
• a-??? a?ta????st?? d?a???? asßest???
• a-??? a?ast??e?? t?? ?p?d????? t?? ?G-II

? s??d?asµ?? fa?µa?e?t???? ?a? µ? fa?µa?e?t????
a????? µe???e? t?? a?ep???µ?te? e????e?e? ?a?
ße?t???e? t?? p???t?ta ???? t?? as?e????
10
Ge????? ?d???e?-VI (?p????? a?????)
?? t? p??t? f??µa??, a??µ? ?? a? ep??e?e? µe
ß?s? ta s?st? ???t???a, de? µe???e? p??? t?? ?? ?
s?et??eta? µe e?????t???? pa?e????e?e?, p??pe? ?a
d?a??pteta? ?a? ?a d???µ??eta? ??p??? ????
f??µa?? ????? ?at?????a?
11
Ge????? ?d???e?-VII (St???? ?e?ape?a? ?p??tas??)
?as???? st???? t?? a?t??pe?tas???? ?e?ape?a?
e??a? ?a e?att??e? st? µ???st? ? ?a?d?a??e?a???
???d????, ????? ?a ?p?ßa?µ?s?e? (a? ße?t???e?
a??µ? ?a??te?a) ? p???t?ta ???? t?? as?e????
12
??t??pe?tas??? f??µa?a
13
??????t???
?a?e????e?e? -?p??a??a?µ?a -??ata?a?? a?????
???????? -????a??t?ta -?pe?????ste???a?µ?a,
?pe??????a?µ?a

• ?a d?????t??? se ??????µ????? se µ????? d?se??
  e??a? ap?te?esµat??? ?a? f????
• ???a? ep?s?? ???s?µa sa? de?te?? f??µa??, af??
  a??????? t? a?t??pe?tas??? ap?t??esµa ?????
  fa?µ????

?p?te???sa? s?ed?? p??t?te t?? p??t? ep?????
14
a-???
???a? ?a?? a?e?t? ?a? de? ????? µetaß??????
pa?e????e?e?
-?e?????? ap?te?esµat??? t?? ?a?d?a??e?a??
??s???t?ta ?a? ???s?µ?t?ta -?e?????? t?
??s???t?ta ?a? ???s?µ?t?ta se ?t?µa µe ?a?d?a??
a?ep???e?a ?a? ?p??tas? -?p?ß?ad????? t?? e??????
t?? ?ef????? ß??ß??
??ep???µ?te? e????e?e? -?p?µ???? ?????
ß??a? -???e????d?µa
-?a ap?fe????ta? se st???s? ?ef????? ?µf? -?a
ap?fe????ta? st?? pe???d? t?? ???s??
15
??ta????st?? d?a???? asßest???
?a?e????e?e? -?a???a?d?a -?efa?a???a -?pe?a?µ?a
p??s?p?? (flashing) -??d?µa sf???? -??s??????t?
ta
??att????? ap?te?esµat??? ?a? µe asf??e?a t?? ??
16
?e?t????? d???ta f??µa?a
a-µe????t?pa -?p?te?esµat??? f??µa?? st??
?p??tas? t?? ???s?? -F???? ?a? a??et?
d???µasµ??? -?????? pa?e????e?e?
(?at??????) ?????d??? -????st?µ?a, ?ata???t?s?
????? -??ad??a?d?a, ?p????a, ?ataß??? -??? se
???p??????a?? ap???e?sµ? ??ast??e?? ?p?d?????
?µ?da??????? ?1 (??????d???, ???µe??d???) -???e?
pa?e????e?e? ap? ??S -?e? p???a???? fa???µe??
ap?s??s?? ??ast??e?? ?p?d????? se??t??????
(?eta?se????) -????st?µ?a, ?atast???, ?p????a,
???? ?efa?a???a
Ga?????p?????? ?ese?p??? -?a?? s??s?
??st???/?f????? -?at??????, a???a??t?ta,
?p????a, ?atast??? ??S -???p??aµ?d???
17
?e??fe????? ?µes?? a??e??d?ast??e??
?d?a?a????-µ?????d??? -???et? ap?te?esµat???
a?t??pe?tas??? -?a?e????e?e? (ta???a?d?a,
?efa?a???a, st??????, ?ata???t?s? ?????) -
?pe?t???s? (µ?????d???)
?e??fe????? a1-ap???e?st??
?e?a??s??? -???a? asfa??? ?a? ap?te?esµat???
f??µa?? -?da???? st? ???µ?s? t?? p?es?? a?d???
µe ?pe?t??f?a p??st?t? -?a?e????e?e? -????sta
t??? ?p?tas? (p??t? d?s?) -????, ?ataß???,
?efa?a???a, ?p????a
18
?p????? fa?µ???? ?at? p???s?
19
?ef???e??? ?p??tas?
20
?ef???e??? ?p??tas?
?p??tas? d?ap?st??eta? st? 85 t?? as?e??? µe
?????a ?ef???? ??s?

• Te?ape?t??? µp????? ?a d?????
• ??????t??? ???s??? se Crgt2-3 mg/dl ?a? ?????
• a-??? ???s??? se ?????
• ??ta????st?? asßest???
• ??????d??? ?a s??d???eta? µe ß-ap???e?st? ?a?
  d?????t???

?p???????? ß?????? ? ??a??? d?a?ta ?a? ? µe??s?
t?? ?e???µ?t?? t?? t??f??
21
??e?a spe??aµat??ef??t?da
???? t?? eµfa???? ????? t?? ?e?????, ? ??????s?
a-??? e??a? ap?te?esµat???
??e?a ?ef???? a?ep???e?a
Sp???a ? ?p??tas? ap?te?e? p??ß??µa st?? ???
?ef??pa?e???µat??? ??s??
?? a-??? ???µ????? ??a??p???t??? t?? p?es? ?a?
p??? ???? a?t??pa?????e??? t??
??????st??? ??s?? ?ef???
a-??? ? d?????t??? ? s??d?asµ?? t???
22
?ef???? a?ep???e?a
F??µa?a p?? de? ??e?????ta? p??sa?µ???
d?s?? -F????seµ?d? -?????d??? -?e?a??s??? -ß-a
?ast??e?? -a-??? -??????d??? -??ast??e??
d?a???? asßest??? F??µa?a p?? a?te?de?????ta? -??
dapaµ?d? -Te?a??de? -?e?e?p??? F??µa?a p??
d?d??ta? µe p??s??? -ß-a?ast??e?? (p??s??? st??
?pe??a??a?µ?a) -a-??? (p??s??? st??
?pe??a??a?µ?a) -??t??p??s??? (t??????
µetaß???te? µet? 3 ?µ??e?) -?? e??e?t????
ß-ap???e?st?? (pa?atetaµ??? ?p?????a?µ?a
-? -a-µe????t?pa (a???????ta? µetaß???te?)
23
?etaeµµ???pa?s?a??? ???a??e?
24
?etaeµµ???pa?s?a??? ???a??e?
? ???s? d?????t???? st?? ???a??e? a?t?? ?s??
ap?te?e? t?? ?a??te?? ep?????
25
?p??tas? ???s??
26
?p??tas? ???s??-?
??e?a ?a? ßa??? ?p??tas? 1. ?d?a?a???? (5 mg IV
a????? ?a? µet? 5-10 mg/20-30 min) 2.
?aßeta???? (20 mg ta???? IV ???e 10 min, ?????
d?s? 300 mg) 3. ??a????d? (30 mg IV ta????) 2.
Te???? µa???s??
?????a ?p??tas? ???s?? 1. a-µe????t?pa 2.
ß-ap???e?st?? 3. ??????t??? (sp???a
???s?µ?p?????ta?) 5. ?????stat?sµ?? (?????
µe??s? ?at???? t??f??)
a-??? (a?te?de?????ta? ???? pa?e?e??e??? d???t???
?a?at?f???? ??a t? ?µß???)
27
?p??tas? ???s??-??
Te?ape?a e?????? ??a ?se? s?µp????sa? t?? 34?-36?
eßd?µ?da ???s?? e??a? ? p?????s? t??et??
?? ?p?????? d?ata?a??? t?? ep?p?d?? s??e?d?s??,
?e????????? e???µata, pa???????? ap?te??sµata
st?? d???µas?e? ?pat???? ?e?t?????a? ? µe??µ????
a???µ?? a?µ?peta????, ep?ß???eta? ? t??et?? se
?p???d?p?te st?d?? t?? ???s??
28
Stefa??a?a ??s??
S?µf???t??? ?a?d?a?? a?ep???e?a
?pe?t??f?a a??ste???
29
Stefa??a?a ??s??
-???t?µ??ta? ?? ß-ap???e?st?? (p??s??? ?ta?
?p???e? spasµ?? stefa??a???) -a-??? ?ta? ?p???e?
?p??tas? ?a? ?aµ??? ???sµa e????s??
S?µf???t??? ?a?d?a?? a?ep???e?a
-?d?a?te?? a??a st?? pe??pt?se?? a?t?? ????? ??
a-???, ?? ß-ap???e?st?? (?a?ßed?d???) ?a? ?? ??-1
a?ast??e?? -Se as?e?e?? µe s?st?????
d?s?e?t?????a t?? a??ste??? ?? ap???e?st??
asßest??? p?? p???a???? ß?ad??a?d?a (??fed?p???)
p??pe? ?a ap?fe????ta?. ?? a-??? st?? pe??pt?se??
a?t?? µp??e? ?a p???a??s??? ?p?tas? (µe??s?
p??f??t???)
?pe?t??f?a a??ste???
-?a pe??ss?te?a a?t??pe?tas??? ?p?st??f??? t??
?pe?t??f?a t?? a??ste??? ?a? ?a??te?a ap? ??a ??
a-???
30
??????µ????
31
??????µ????-I

• ??????t??? (p??t? ep?????)
• -???s??? st?? ?p????a?µ?a (???) ?a? ?p??a??a?µ?a
• ??ta????st?? d?a???? asßest???
• -???s??? st?? ?pe?t??f?a p??st?t?
• 3. a-???
• -???s??? st?? ??a??? (???d???? ?p?tas?? ?a?
  ???), st? ?????, st?? p??a?? st???s? ?ef?????
• 4. ß-ap???e?st??
• -???s??? ???d???? ?pe?d?s?????a?

32
??????µ????-II
-? ep????? t?? a????? p??pe? ?a ßas??eta? st??
pa???s?a s???d?? ?atast?se?? -? e?at?µ??e?s? t??
?e?ape?a? e??a? p??t?µ?te?? ap? t?? stad?a??
p??s????s? ß?µa-ß?µa -?? ??????µ???? apa?t??? se
?p???d?p?te a?t??pe?tas??? ?a??te?a ap? t???
?ea??te???? -?a ap?fe????ta? ta f??µa?a p??
e??a? p??a?? ?a p???a??s??? ????stat??? ?p?tas? ?
s?µf???s? st?? p??st?t?
33
??aß?t????
34
??aß?t????-?
?a???a a?t??pe?tas??? de? ??e? ap???t? a?t??de???
st? d?aß?t? ?as??? pa??µet??? ??a t? ???µ?s? t??
?p??tas?? t?? d?aß?t???? e??a? ? µe??s? t??
s?µat???? ß????? ?a? t?? sa?????? t??

1. ??????t??? (ep?de??????? t?? ???µ?s? t?? sa??????
   ???? ?p??a??a?µ?a?)
2. ß-ap???e?st?? (s???a??pt??? t?? ?p?????a?µ?a ?a?
   ?a??ste???? t?? a?????? ap? a?t?)
3. ??fed?p??? (ep?de????e? t?? ?aµp??? sa??????)
4. a-??? (p??s??? st?? ?p??e???a?µ???
   ?p?a?d?ste????sµ?)

35
??aß?t????-??
F?????? ??????????? ?????T?????
????G??? ß-ap???e?st?? ?p?te?esµat???? se
?a??????sa ?p?????a?µ?a stefa??a?a
??s? ?pe?t?????e??da?µ?a ?e??fe????? a?ast??e??
- ????stat??? ?p?tas? ?ata???t
?s? ?at????, ????? ?e?t????? ap???e?st??
?ata???t?s? ?at????, ????? ??ta????st??
asßest??? ?e? ep??e????? ??p?d?a ?p?t?µ? pt?s? ??
(??fed?p???) ?ef??p??stas?a a-??? ?e??s?
?e???µat????a? ?pe??a??a?µ?a ?ef??p??stas?a
?e? ? ??p?d?a, ?, ??????? ??????t??? ?at??????
s? ????s? ???????? ?a??????t??? (???
??a) ?pe?????ste???a?µ?a ????s?
??????? ?sß?st??
36
?pe??????a?µ?a-?????? a????t?da
?e? p??pe? ?a ???s?µ?p?????ta? d?????t??? ???????
?? a-???
37
?p????? fa?µ???? ?at? p???s?
????s? ?????/?? ß-ap??. a-ap??? a-??? a?.
?s ??????µ???? St??????
S?µ. ?a?d,. a?. ?ef??p??e?a
??aß?t?? - ??s??p?da?µ?a
- - ?pe?t. p??st.
38
?a????????? ?atast?se?? - s?µpt?µata - e???µata
39
F?????? ????? ??????? ????????-?????????? ?
?????t??? ?a?d?a?? a?ep???e?a ?pe??????a?µ?a-?????
? a????t?da ??????µ???? ?pe???p?da?µ?a
!! S?st????? ?p??tas? ??d?e? se???a????
e?e??e?? !! ß-ap???e?st?? St?????? ?s?µa-??? ?
et? ?µf?a?µa ?e??fe???? a??e??p??e?a ?a??a????µ
?a ???p??????a??? ap???e?sµ?? ???s? ?pe?t????
??e??da?µ?a !! IDDM !! ?a?d?a??
a?ep???e?a !! ????t?? !! a-??? ?a?d?a??
a?ep???e?a ???s? ?pe?t??f?a a??ste??? St???s?
?ef????? ?µf? ??ta????st?? d?a????
asßest??? St?????? ???s? ?e??fe????
a??e??p??e?a ???p??????a??? ap???e?sµ?? (??-???)
??????µ???? S?st????? ?p??tas? ??sa?e??a
st? ??????? a-ap???e?st?? ?pe?t??f?a
p??st?t? ????stat??? ?p?tas? !! ??sa?e??a st?
???????
40
S????O??-??S?S F?????? OF????? F??????
???????? ?efa?a???a ??ast??e??
asßest??? ?d?a?a???? ?e?t?????
d???ta a-ap???e?st?? ß-ap???e?st?? ??ast??e??
asßest??? Te?µ?? e???e?? ?????d??? ??ast??
e?? asßest??? ????? ß-ap???e?st?? ?e?t
????? d???ta ?ese?p??? ???a???? - ?e
?t???? d???ta ß-ap???e?st?? Se???a????
a???a??t?ta a-??? ??a ta ?p????pa ??s?????
?t?ta - ??ast??e?? asßest??? ??????t???
?e?t????? d???ta ???pe??a ??????d???
?d?a?a???? ??d?µa ??????t??? a-ap???e?st?
? ß-ap???e?st?? ??ta????st??
asßest??? ?d?a?a???? ??????d??? a-µe??
??t?pa
41
??S?S-S????O?? F?????? OF????? ???????????????-???
????? ???????? ?s?µa ???d??p???d??e? ß-ap???e?
st?? ??ast??e?? asßest??? Sa??a??d??
d?aß?t?? a-???, a?as. asßest??? ß-ap???e?st??
??ast??e?? asßest??? ??????t??? ?a??a????µ?e? ß-
ap???e?st?? ?d?a?a???? ??ast??e??
asßest??? ??fed?p??? ?e?t?????
d???ta ??ad?a????µ?e? ?d?a?a???? ?e?t?????
d???ta, ß-ap???e?st?? ?ef???? a?ep???e?a a-???
Te?a??de? ??ast??e?? asßest??? a-??? a-ap?
??e?st?? ??t??p??s??? ??t??p??s??? St???s?
?ef????? ??ast??e?? asßest??? a-??? ß-ap???e?s
t?? ?pet??f?a a??ste??? ??ast??e??
asßest??? ?e?t????? d???ta ??????t???
a-??? ?pe???p?da?µ?a a-ap???e?st?? ??????t?
?? ??ast??e?? asßest??? ß-ap???est?? ?pe??a??a
?µ?a ??????t??? a-???, ?a???s/t???,
ß-ap???e?st?? ?at?????? - ß-ap???e?st??,
a-??? ?e?t????? a-ap???e?st?? ?e?e?p??
?, a-µe????t?pa St?????? ß-ap???e?st?? ?d?a?a???
?, d?????t??? ?a?d?a?? a?ep???e?a a-???,
d?????t??? ß-ap???e?st??, ße?apaµ??? ????stat???
?p?tas? ß-ap???e?st??, ?????d??? ?d?a?a???? ???s?
a-?e????t?pa a-???, d?????t??? ???p?????.
?p???e?sµ?? ?d?a?a???? a-µe????t?pa, a?t.
asßest??? ?pat??? ??s?? - a-µe????t?pa,
?d?a?a???? ?pe??????a?µ?a a-???, a?as. asßest???
??????t???
42
F??µa?? ?a? ???? e?????? ep?d?as?
F?????? ??????? ??????S? ß-ap???e?st?? St???
??? ???p??? ta???a?d?a ???t?pa???
t??µ?? ?pe????e?e?d?sµ?? ?µ???a??a
???e??e???t??? ?p??tas? ??ast??e??
asßest??? ???p??? ta???a?d?a ??aß?t?? µe
?e???µat????a a-??? ?a?d?a??
a?ep???e?a ?e???µat????a a-ap???e?st?? ?pe?
t??f?a p??st?t? Te?a??de? ?ste?p???s?
43
F??µa?? ?a? ???? µ? e?????? ep?d?as?
F?????? ?? ??????? ??????S? ß-ap???e?st?? ?
??????? ?s?µa ???p??????a???
ap???e?sµ?? ??s??p?da?µ?a ?a?d?a??
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