Congestive heart failure: what should be the initial therapy and why?
Congestive heart failure: what should be the initial therapy and why?
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DOI：
10.2165/00129784-200202010-00001
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发表时间：
2002-01-01
期刊：
影响因子：
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通讯作者：
Chatterjee, Kanu
中科院分区：
文献类型：
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作者：
Chatterjee, Kanu
左心室收缩功能障碍与神经激素激活相关，神经激素激活导致进行性心室重塑和临床心力衰竭恶化。肾素-血管紧张素-醛固酮和交感神经系统不仅在临床上明显的心力衰竭患者中被激活，而且在无症状或症状轻微的左心室收缩功能障碍患者中也被激活。血管紧张素和肾上腺素能系统的激活对全身和冠状动脉血流动力学产生有害影响，促进肌细胞肥大和成纤维细胞生长，以及肌细胞坏死和凋亡。因此，心力衰竭的治疗应包括药物治疗，不仅要缓解症状，还要预防和减轻心室重构和进行性心力衰竭，从而改善预后。对于有症状的患者，与单独使用利尿剂或联合使用利尿剂和洋地黄相比，ACE 抑制剂与洋地黄和利尿剂作为初始治疗（三联疗法）更有可能改善运动耐量并降低治疗失败的发生率。不应考虑单独使用利尿剂进行长期治疗，因为血浆肾素活性、血管紧张素 II、醛固酮、去甲肾上腺素和加压素水平可能会升高。 ACE抑制剂可降低左心室收缩功能障碍导致的心力衰竭患者的死亡率。目前的研究结果表明，在生存获益方面，血管紧张素 II 受体阻滞剂 (ARB) 与 ACE 抑制剂相比没有任何优势，但可能具有更好的耐受性。在ACE抑制剂中添加β-肾上腺素能受体拮抗剂的长期肾上腺素能抑制与心室重塑的减弱、心室功能和临床分类的改善以及有症状的收缩性左心室衰竭患者的生存相关。因此，收缩性心力衰竭的初始药物治疗应包括：ACE抑制剂的最大耐受剂量；如果由于顽固性咳嗽或血管性水肿而不能耐受ACE抑制剂，则使用ARB；如果不能耐受ACE抑制剂或ARB，则应使用足够剂量的肼屈嗪和硝酸异山梨酯；如果没有禁忌症，则使用相对较低剂量的地高辛（血清浓度<或= 1.0 ng/dl）；和利尿剂以缓解充血症状。在ACE抑制剂中添加螺内酯可以显着降低有症状的严重心力衰竭患者的猝死风险。缺血性心脏病引起的心肌梗死是收缩性左心室衰竭的最常见原因，初始治疗中还应包括可能降低心肌梗死风险的治疗方式，例如改变危险因素、充分控制糖尿病和高血压、抗血小板药物和降脂药物。
Left ventricular systolic dysfunction is associated with neurohormonal activation which contributes to progressive ventricular remodeling and worsening clinical heart failure. Renin-angiotensin-aldosterone and sympathetic nervous systems are activated, not only in patients with clinically overt heart failure, but also in patients with asymptomatic or minimally symptomatic left ventricular systolic dysfunction. Activation of the angiotensin and adrenergic systems produces deleterious effects on systemic and coronary hemodynamics, promotes myocyte hypertrophy and fibroblast growth, and myocyte necrosis and apoptosis. Thus, therapy of heart failure should consist of pharmacologic agents not only to relieve symptoms but also to prevent and attenuate ventricular remodeling and progressive heart failure, thereby improving prognosis. In patients who are symptomatic, ACE inhibitors along with digitalis and diuretics as initial therapy (triple therapy) have the greater potential to improve exercise tolerance and decrease the incidence of treatment failure compared with diuretics alone or a combination of diuretics and digitalis. Diuretics alone should not be considered for long-term therapy as plasma renin activity, angiotensin II, aldosterone, norepinephrine and vasopressin levels may increase. ACE inhibitors decrease mortality in patients with heart failure resulting from left ventricular systolic dysfunction. The results of presently available studies indicate that angiotensin II receptor blockers (ARBs) do not provide any advantage over ACE inhibitors regarding survival benefit but may be better tolerated. Long-term adrenergic inhibition with the use of ss-adrenoceptor antagonists added to ACE inhibitors is associated with attenuation of ventricular remodeling, improvement in ventricular function and clinical class and survival of patients with symptomatic systolic left ventricular failure. Thus, initial pharmacotherapy for systolic heart failure should consist of: maximal tolerated dosages of ACE inhibitors;ARBs if ACE inhibitors are not tolerated because of intractable cough or angioedema;adequate dosages of hydralazine and isosorbide dinitrate if ACE inhibitors or ARBs are not tolerated; relatively low dosages of digoxin (serum concentrations of < or = 1.0 ng/dl) if not contraindicated; and diuretics to relieve congestive symptoms. Addition of spironolactone to ACE inhibitors can result in a significant reduction in the risk of sudden death in patients with symptomatic severe heart failure. Myocardial infarction resulting from ischemic heart disease is the most common cause of systolic left ventricular failure and the therapeutic modalities with potential to reduce the risks of myocardial infraction, such as risk factor modification, adequate control of diabetes and hypertension, antiplatelet agents and lipid-lowering agents, should also be included in the initial therapy.