Critical care clinics
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Mortality rates in patients with cardiogenic shock remain frustratingly high. Its pathophysiology involves a downward spiral in which ischemia causes myocardial dysfunction, which in turn worsens ischemia. Areas of viable but nonfunctional myocardium can contribute to the development of cardiogenic shock. ⋯ The SHOCK multicenter randomized trial has provided important new data that support a strategy of emergent cardiac catheterization and revascularization with angioplasty or coronary surgery when feasible. This strategy can improve survival and represents standard therapy at this time. In hospitals without direct angioplasty capability, stabilization with IABP and thrombolysis followed by transfer to a tertiary care facility may be the best option.
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In summary, patients presenting with a true hypertensive emergency should be diagnosed quickly and promptly started on effective parenteral therapy (typically nitroprusside 0.5 microgram/kg/min or fenoldopam 0.1 microgram/kg/min) in an intensive care unit. Blood pressure should be reduced about 25% gradually over 2 to 3 hours. Oral antihypertensive therapy (often with an immediate-release calcium antagonist) can be instituted after 6 to 12 hours of parenteral therapy, and consideration should be given to secondary causes of hypertension after transfer out of the intensive care unit. Because of advances in antihypertensive therapy and management, "malignant hypertension" should be truly malignant no longer.
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Technology continues to advance at a pace that produces a new innovation daily. To move forward, clinicians must assess these potential technological solutions adequately for their clinical, financial, and customer satisfaction efficacies. Whether the payers, the patients, or health care will find these systems acceptable has yet to be established completely. ⋯ Telemedicine is progressing quickly from a strange rare subtype of medicine into something that is part and parcel of the practice of medicine in general. Cardiology and intensivist practices have been impacted directly by this technology. As it matures it will be intertwined with daily practice.