心衰基础知识与治疗.ppt

* * 在心力衰竭模型方面，我们已经从20世纪60年代流行的“血流动力学模型”转变为80年代流行的“神经－内分泌模型“，神经激素的激活使心肌、血管平滑肌、血管内皮细胞等发生一系列变化，即细胞和组织的重构，使心衰加重，预后不良。因此，理想的心衰治疗药物应能针对心衰的神经－体液模型，干预在心衰发生和发展过程中被过度激活的神经－体液系统，才能真正改善心衰病人的预后，降低死亡率。 * 利钠肽系统： ANP – 心钠肽 BNP – 脑钠肽 * * * 充血性心力衰竭: 在临床上是否易于诊断? * * * 根据年龄分层的“诊断”界值 * Several large clinical trials have shown ACE inhibitor treatments to reduce mortality in heart failure patients with mild, moderate or severe heart failure. The benefits from ACE inhibitors appear to be independent of age, sex, use of diuretics, aspirin and ? blockers. Based on the clinical studies, ACE inhibitors and b blockers are recommended as cornerstone treatment for heart failure. Despite the reduction in mortality with ACE inhibitor therapy, mortality rates remain unacceptably high. Mortality in large clinical trials is close to 40% over a four-year period. * 对32项ACEI用于有症状心衰患者（NYHA心功能II或IV级）的试验所作的荟萃分析表明，ACEI能显著降低心衰患者的总死亡率达23％，降低死亡率和住院率达35％。同时ACEI有减少心肌梗死、脑卒中和肺栓塞的趋势。射血分数最低的患者因心衰死亡和住院事件降低幅度最大。 试验中包括几种不同的ACEI，每种ACEI均具有相似的益处，在基于年龄、性别、心衰病因以及NYHA心功能分级等因素的不同亚组中，ACEI的作用是一致的。ACEI能降低总死亡率、心衰死亡率、住院率、左室功能障碍的进展、症状严重程度，并能增加运动耐量。因此，有症状的心衰和无症状的左室功能障碍或有心梗后发生心衰危险因素的患者均能从ACEI的应用中获益。 * 但是ACE抑制剂不时宜在心衰的急性阶段使用 * * Packer et al. NEJM 1996; CIBIS II Invest. Lancet 1999; MERIT HF Study Gp. Lancet 1999 BEST Investigators. Lancet 1999; Packer et al. NEJM 2001 * Treatment of heart failure. Digoxin: Effect on survival The results obtained from 3 controlled studies which included patients at low risk (The German and Austrian Xamoterol Study Group, 1988; The Captopril-Digoxin Multicenter Research Group, 1988; DiBianco et al., 1989) indicate that the mortality was similar in the group of patients with placebo. The results of the Digitalis Investigator Group-DIG study, which included 7788 patients with heart failure in sinus rhythm, functional class II-III and LVEF 45%. Thepatients were treated with digoxin or placebo, in addition to conventional therapy over a mean of 37 months (28 - 58 months). No differences in mortali