受体阻滞剂在慢性心衰中的作用（英文）课件幻灯.pptVIP

Beta Blockers in CHF AJIT BHAGWAT MD, DM, FACC, FISE, FCSI, FSCAI Diplomate, American Board of Cardiology Kamalnayan Bajaj Hospital Aurangabad, INDIA Adrenergic Receptors in Normal vs Failing Left Ventricles Effects of Initiation of BB Therapy First Generation BB (Propranolol): No Beta adrenergic support, Profound reduction in CO (Reduced LV contractility increased PVR) Second Generation BB (Metoprolol, Bisoprolol): Selective Beta-1 blockade, Beta-2 support intact + less vasoconstriction. Better tolerated better perfusion Third Generation BB (Carvedilol): Additional Alpha blocking action, Afterload reduction, Frequent orthostatic symptoms Afterload reduction with carvedilol is not long term Initial Carvedilol Trials in the US MOCHA PRECISE Mild Carvedilol Severe Carvedilol SCD: ACE Inhibitors MERIT-HF: Total Mortality COMET: Blood pressure COMET Trial: Questions Raised 1. Metoprolol IR 50 mg BID is not an effective treatment. 2. Metoprolol IR 50 mg BID does not provide the same degree of b1 blockade as carvedilol 25 mg BID. 3. Metoprolol IR 50 mg BID is a less effective b -blocker than metoprolol XL. Copernicus: Mortality The Benefits Improvement in LVEF in 3 months Reverse Remodeling (normalization of LV mass shape): 4-12 months Survival Benefit Decrease in SCD Decreased Hospitalizations BEST: All-Cause Mortality by Race CIBIS III: Hypothesis Initiation of treatment of patients with CHF with the β1-selective β-blocker bisoprolol (to which an ACE inhibitor is subsequently added) is as effective and safe as a regimen beginning with the ACE inhibitor enalapril (to which bisoprolol is subsequently added). CIBIS III End points Primary endpoint Combined endpoint of mortality (all cause) and all cause hospitalization at study end (time to event analysis) Secondary endpoints (selected) Individual components of the primary endpoint at study end + at end of monotherapy phase Combined primary endpoint at end of monotherapy phase All Cause Hospitalizations over the