心衰现状及治疗进展ppt课件.pptVIP

Aldosterone’s Role in Heart Failure Aldosterone a Arterial compliance a Baroreceptor function a Norepinephrine uptake a Endothelial function á PAI-1 a K+ a Mg++ á Fibrosis a Norepinephrine Uptake a Heart rate variability á LV mass fibrosis á Na+ á Oedema á Remodeling á Arrhythmia á Ischaemic Events Progression of HF Sudden cardiac death RALES(Randomized Aldactone Evaluation Study)研究1999 用醛固酮拮抗剂（螺旋内酯 Spironolactone）对严重CHF患者评估对患病率和死亡率的影响。 入组NYHA III-IV级心力衰竭患者，在已用ACEI及利尿剂的基础上，随机入螺旋内酯组822例（25mg/d）或安慰剂组841例，经平均24个月随访。结果治疗组较安慰剂组死亡率下降30%。 18 0 3 6 9 1 2 15 21 24 27 30 36 33 Months Probability of Survival Placebo Spironolactone 0.30 0.50 0.70 0.80 0.90 0.40 0.60 1.00 39 Risk Reduction 30% (- 18 - 40) P 0.001 Pitt et al NEJM 1999 RALES: All-cause Mortality 1,663 Patients randomised to placebo/spironolactone 95% background ACEI 11% background ? blocker EPHESUS 所有原因死亡率 心梗后3－14天给予依普利酮治疗 Pitt B. et al., N Engl J Med 2003; 348:1309-21. 0 5 10 15 20 25 30 35 40 0 3 6 9 12 15 18 21 24 27 30 33 36 累计发生率 (%) P=0.008 RR=0.85 (95% CI, 0.75-0.96) 随机分组后时间（月） 安慰剂 依普利酮 双盲、安慰剂对照试验， 依普利酮 对AMI伴有左室 功能不全和心衰患者的保护作用 3313 例患者服用依普利酮 (25 mg, 滴定最大剂量为 50 mg/d; vs 3319 例患者服用安慰剂） 总死亡率－下降15 % CV死亡率－下降17 % 猝死率－下降21 % 因HF住院率－下降23 % 慢性心力衰竭现代治疗方案 NYHA 分类 I II III IV 利尿剂 ACEI β-blocker* Digoxin 醛固酮拮抗剂 活动/他汀类 * In stage IV use β-blocker only if patient is stable Gomberg-Maitland, et al. Arch Intern Med. 2001; 161: 342-352 Treatment of heart failure has resulted in major survival benefits during the last 10-15 years The challenge facing the medical community remains to ensure that ACE-inhibitors and ? blockers are used in all appropriate patients Inhibition of aldosterone seems to carry further benefits Addition of an ARB could be considered To optimise neurohormonal blockade, care delivery structures need to be revisited ACE inhibitor Fluid retention Diuretics No fluid retent