Postgraduate medicine
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This article reviews 4 categories of hypertensive disorders of pregnancy: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. It focuses on the diagnosis and management of preeclampsia with emphasis on the pharmacologic management of blood pressure during pregnancy. Preeclampsia is one of the most common medical disorders affecting pregnancy, with significant maternal and fetal morbidity and mortality. The most serious maternal complications of preeclampsia include intracerebral hemorrhage, eclampsia, and renal failure, as well as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and posterior reversible encephalopathy syndrome (PRES).
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Postgraduate medicine · Jan 2009
ReviewThe potential role of prasugrel in secondary prevention of ischemic events in patients with acute coronary syndromes.
Acute coronary syndromes (ACS) are life-threatening manifestations of coronary artery disease, occurring when a thrombus forms at the site of atherosclerotic plaque rupture or fissuring. Almost all patients discharged from the hospital after an ACS (myocardial infarction or unstable angina) in the United States receive antiplatelet therapy. Current recommendations for post-ACS antiplatelet therapy are aspirin 75 to 162 mg/day indefinitely for all patients, plus a thienopyridine (currently clopidogrel 75 mg/day) for > or = 12 months in those receiving stents unless there is a high risk of bleeding. ⋯ In clinical trials, the combination of prasugrel + aspirin reduced the risk of a second ischemic event by 19% compared with clopidogrel + aspirin. There is a small increase in the risk of bleeding with dual antiplatelet therapy, but the benefit still outweighs the risk in most patients. Patients with a history of transient ischemic attack or stroke should not receive prasugrel + aspirin because of increased risk of events.
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Postgraduate medicine · Jan 2009
ReviewAppropriate secondary prevention of acute atherothrombotic events and strategies to improve guideline adherence.
The use of guideline-recommended secondary prevention measures is essential for reducing the risk of subsequent events and mortality in patients who have survived an acute atherothrombotic event or have peripheral arterial disease. Although initial hospitalization provides an ideal environment to initiate such therapies, implementation of effective longterm prevention strategies is hindered by the absence of a systematic approach. ⋯ Recognizing the importance of a systematic approach to discharge planning, numerous hospital-based initiatives have been established. In conjunction with effective lines of communication between hospital and primary care teams, initiation of the most effective secondary prevention strategy at the time of hospital discharge will help to ensure optimal long-term management of patients after an atherothrombotic event.
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Age-related macular degeneration is the leading cause of irreversible blindness in older persons of the developed world. Addressing treatable risk factors reduces the incidence and progression of this condition. Recent advances in understanding and treating macular degeneration have dramatically improved the visual prognosis.
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Hypertension (HTN) is one of the most common chronic medical conditions, affecting nearly 72 million people in the United States. A systolic blood pressure (BP) > 180 mm Hg or a diastolic BP > 120 mm Hg is considered a "hypertensive crisis." Hypertensive crises are categorized as either hypertensive emergencies or urgencies depending on the degree of BP elevation and presence of end-organ damage. The primary goal of intervention in a hypertensive crisis is to safely reduce BP. ⋯ Newer agents such as clevidipine have considerable advantages compared with other available agents in the management of hypertensive crises. Sodium nitroprusside is an extremely toxic drug, and its use in the treatment of hypertensive emergencies should be avoided. Likewise, nifedipine, nitroglycerin, and hydralazine should not to be considered first-line therapies in the management of hypertensive crises because these agents are associated with significant toxicities and/or side effects.