Diuretic strategies in patients with acute decompensated heart failure.
Diuretic strategies in patients with acute decompensated heart failure.
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DOI：
10.1056/nejmoa1005419
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发表时间：
2011-03-03
期刊：
影响因子：
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通讯作者：
NHLBI Heart Failure Clinical Research Network
中科院分区：
文献类型：
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作者：
Felker GM;Lee KL;Bull DA;Redfield MM;Stevenson LW;Goldsmith SR;LeWinter MM;Deswal A;Rouleau JL;Ofili EO;Anstrom KJ;Hernandez AF;McNulty SE;Velazquez EJ;Kfoury AG;Chen HH;Givertz MM;Semigran MJ;Bart BA;Mascette AM;Braunwald E;O'Connor CM;NHLBI Heart Failure Clinical Research Network
循环利尿剂是急性失代偿性心力衰竭患者治疗的重要组成部分，但很少有前瞻性数据来指导其使用。在一项前瞻性、双盲、随机试验中，我们分配了308例急性失代偿性心力衰竭患者接受静脉滴注呋塞米，每12小时注射一次或连续输注一次，低剂量（相当于患者先前口服剂量）或高剂量（相当于先前口服剂量的2.5倍）。该方案允许在48小时后调整指定剂量。主要终点是患者对症状的总体评估，量化为72小时内视觉模拟量表评分的曲线下面积（AUC），以及血清肌酐水平从基线到72小时的变化。两组患者总体症状评估（平均AUC分别为4236±1440和4373±1404，P = 0.47）和肌酐水平平均变化（分别为0.05±0.3 mg /分升[4.4±26.5 μmol /升]和0.07±0.3 mg /分升[6.2±26.5μmol /升]，P = 0.45）差异无统计学意义。在高剂量策略与低剂量策略的比较中，高剂量组患者总体症状评估的改善趋势不显著（平均AUC， 4430±1401比4171±1436；P = 0.06）。各组肌酐水平的平均变化（高剂量组为0.08±0.3 mg /分升[7.1±26.5 μmol /升]，低剂量组为0.04±0.3 mg /分升[3.5±26.5 μmol /升]，P = 0.21）无显著差异。在一些次要措施中，高剂量策略与更大的利尿和更有利的结果有关，但也与肾功能的短暂恶化有关。在急性失代偿性心力衰竭患者中，大剂量与小剂量给药与连续输注利尿剂相比，大剂量给药与连续输注利尿剂相比，患者对症状的总体评估或肾功能的改变没有显著差异。（由国家心脏，肺和血液研究所资助；ClinicalTrials.gov号码，NCT00577135。）
Loop diuretics are an essential component of therapy for patients with acute decompensated heart failure, but there are few prospective data to guide their use. In a prospective, double-blind, randomized trial, we assigned 308 patients with acute decompensated heart failure to receive furosemide administered intravenously by means of either a bolus every 12 hours or continuous infusion and at either a low dose (equivalent to the patient's previous oral dose) or a high dose (2.5 times the previous oral dose). The protocol allowed specified dose adjustments after 48 hours. The coprimary end points were patients' global assessment of symptoms, quantified as the area under the curve (AUC) of the score on a visual-analogue scale over the course of 72 hours, and the change in the serum creatinine level from baseline to 72 hours. In the comparison of bolus with continuous infusion, there was no significant difference in patients' global assessment of symptoms (mean AUC, 4236±1440 and 4373±1404, respectively; P = 0.47) or in the mean change in the creatinine level (0.05±0.3 mg per deciliter [4.4±26.5 μmol per liter] and 0.07±0.3 mg per deciliter [6.2±26.5μmol per liter], respectively; P = 0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients' global assessment of symptoms in the high-dose group (mean AUC, 4430±1401 vs. 4171±1436; P = 0.06). There was no significant difference between these groups in the mean change in the creatinine level (0.08±0.3 mg per deciliter [7.1±26.5 μmol per liter] with the high-dose strategy and 0.04±0.3 mg per deciliter [3.5±26.5 μmol per liter] with the low-dose strategy, P = 0.21). The high-dose strategy was associated with greater diuresis and more favorable outcomes in some secondary measures but also with transient worsening of renal function. Among patients with acute decompensated heart failure, there were no significant differences in patients' global assessment of symptoms or in the change in renal function when diuretic therapy was administered by bolus as compared with continuous infusion or at a high dose as compared with a low dose. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT00577135.)