第17章 治疗充血性心力衰竭药物PPT.pptVIP

第17章 治疗充血性心力衰竭药物 Drugs for Congestive Heart Failure;;Concept: CHF is a complex clinical syndrome characterized by impaired ventricular performance, exercise intolerance, a high incidence of ventricular arrhythmias, and shortened life expectancy ;The signs and symptoms; 心力衰竭不是一种独立的疾病，而是由多种原因引起的心肌收缩和/或舒张功能障碍的综合征。近年来的研究发现，心力衰竭虽然主要表现为心肌收缩和舒张功能障碍，但神经内分泌的改变对其恶性循环的形成和维持有重要的作用。 ;神经体液系统主要改变 Increased sympathetic nervous system activity (and increased plasma catecholamines, b-receptor down regulation ) Increased activity of the renin-angiotensin-aldosterone system Increased release of arginine-vasopressin ;心衰的一些代偿机制 In addition to the effects shown, angiotensin II increases sympathetic effects by facilitating norepinephrine release. ;心衰的分级（NYHA标准） Ⅰ级：心功能代偿完全，体力活动不受限，日常活动无乏力，心悸，呼吸困难等症状； Ⅱ级：轻度代偿不全，活动轻度受限，休息时无症状； Ⅲ级：中度代偿不全，体力活动明显受限，日常活动即可产生症状。限于室内活动； Ⅳ级：严重代偿不全，休息时亦有症状，不能从事任何体力活动。 ;慢性心衰的药物治疗： 应减轻负荷，降低能耗，保护心脏。达到改善血流动力学；改善运动耐量；延长生命。 ? 而不是病马加鞭，只增强心肌收缩力 心衰的血流动力学指标： 压力指标：LVEDP，±dP/dtmax； 容积指标：SV，CO，CI，EF（正常0.67, 心衰 0.45, 严重心衰0.3 ） 时间指标：PEP，LVET，T-dP/dtmax;使用抗心衰药物后心功能曲线的改变;pharmacologic intervention in CHF;Consensus recommendations for the management of CHF;fluid retention - a diuretic. ACE inhibitor and beta-blocker should be initiated and maintained unless specifically contraindicated. （Patients with severe heart failure should probably not receive a beta-blocker） Digoxin - in patients with rapid atrial fibrillation. Spironolactone, an aldosterone antagonist, may reduce mortality in patients with severe heart failure ;Inotropic Drugs- digitalis;;The recent Digitalis Investigation Group (DIG) clinical trial indicated digoxin did not reduce overall mortality in patients with heart failure (who were receiving diuretics and ACE inhibitors), but did reduce the rate of hospitalization;Other inotropic agents;ACE inhibitors;ARBs - angiotensin receptor blockers;Beta-Blockers and CHF;Though beta-blockers were widely considered to be contraindicated for patients with heart failure