选择性醛固酮封锁需与瞬态或永久心脏的急性心肌梗死住院期间衰竭患者PPT.ppt

Take home messagePatients post-MI with heart failure are at high risk of death, even when treated with primary PCI early after presentation. Early initiation of therapy, i.e. before hospital discharge, can save lives ! Weber. N Engl J Med. 1999;341:752-755. Aldosterone “escapes” ACE-inhibitor suppression May be caused by Inability of standard doses to fully suppress angiotensin-regulated adrenal production of aldosterone Patient lifestyle may counter (by stimulating renin release) Upright posture, physical activity, restriction of dietary sodium Aldosterone secretion can be independent of RAAS Potassium-dependent aldosterone secretion Reduced metabolic clearance of aldosterone and biologic activity of its metabolites Aldosterone “Escape” and Independence of RAAS EPHESUS: Baseline Therapy* Eplerenone(n = 3319) Placebo(n = 3313) ACE inhibitor/ARB 86% 87% Beta-blockers 75% 75% Diuretics 60% 61% Aspirin 88% 89% Statins 47% 47% Reperfusion therapy or revascularization 45% 45% *At randomization (3 to 14 days after MI). Pitt B et al. N Engl J Med. 2003;348:1309-1321. EPHESUS:Hospitalizations for Heart Failure Pitt B et al. N Engl J Med. 2003;348:1309-1321. 0 100 200 300 400 500 600 700 No. of Patients No. of Episodes P = .002 618 477 P = .03 391 345 Eplerenone + standard care Placebo + standard care 15% risk reduction 23% risk reduction Stepwise logistic regression identified 4 independent risk factors for ?K (K+ 5.5 mmol/L): Elevated baseline serum creatinine Low baseline creatinine clearance History of diabetes mellitus Baseline use of antiarrhythmics These risk factors were not associated with a significant differential adverse effect of eplerenone vs placebo for: All-cause mortality CV death/CV hospitalization CV death Sudden cardiac death EPHESUS: Risk Factors for Hyperkalemia Bakris G et al. American Heart Association Scientific Sessions; 2004. EPHESUS: Worst-Case Analysis: Hyperkalemia and Mortality Bakris G et al. American Heart Association Sci