26 慢性心力衰竭的治疗进展PPT.ppt

ACE抑制剂在心力衰竭的应用 剂量问题 ●必需从极小剂量开始 ●如能耐受则每3-7天剂量加倍 ●滴定剂量的过程需个体化 ●只要病人能耐受，可一直增加到最大耐受量。 ●一旦达到最大耐受量后，即可长期维持应用。 ACE抑制剂在心力衰竭的应用 注意事项 ● 防止低血压和晕厥 ● 监测肾功能 ● 监测血钾，防止高血钾 ● 血管性水肿 ● 干咳（可耐受，不可耐受） V-HeFT II study： 去 甲 肾 上 腺 素 水 平 与 死 亡 率 的 关 系V-HeFT II study : Relationship between plasma norepinephrine and mortality Cumulative mortality (%) 0 18 30 42 60 Months 100 80 60 40 20 0 6 12 24 36 48 54 PNE 900 pg/ml PNE 600–900 pg/ml PNE 600 pg/ml Two year p0.0001 Overall p0.0001 Vasodilator-Heart Failure Trial II. Francis (1993) 神 经 激 素 在 心 衰 进 展 中 的 作 用 LV dysfunction 左 室 功 能 不 全 Neurohormonal stimulation 神 经 激 素 刺 激 Vasoconstriction ? Impedance 血 管 收 缩 阻 抗? LV remodelling ? 左 室 重 构 Cohn (1995) Impaired myocardial function 影 响 心 肌 功 能 MERIT-HF Mode of Death by NYHA Class The MERIT-HF Study Group, ACC, March 1999 CHF 12% SD 64% SD 59% CHF 26% SD 33% No. of deaths n=103 No. of deaths n=232 No. of deaths n=27 CHF 56% Other 24% Other 15% Other 11% Biological model of sudden death Myocardial infarction Primary myocardial disease Structural electrical abnormality Hypertrophy* Transient ischemia/ Reperfusion* Neurophysiological* Interactions Neuroendocrine activation* PVC VT/VF * Factors affected by betablockade Stressful Event - Defence Reaction 1. Leads to vagal withdrawal (CNS) Reduces electrical stability of the heart 2. Increased sympathetic drive (Heart) Heart rate Contractility Systolic blood pressure Development of ischemia and High Risk for Ventricular Fibrillation b1 b1 25% 20% 15% 10% 5% 0% Percent mortality 0 6 12 18 24 30 36 42 48 months placebo SOLVD - Mortality due to Progressive Heart Failure or Arrhythmias Heart Failure P=0.0045 Arrhythmias erases Emotional Stress and the Triggering of Sudden Death The Northridge Earthquake January 17. 1994, at 4.31 am 30 20 10 0 Relative Risk 5.2 (p0.001) Mean age of victims 68 years 75% men 25% women Number of Sudden Deaths January 1994 11 14 17 20 23 Lace et al, NEJM 1996 Effects of betablockers on autonomic nerve syst