慢性心力衰竭藥物治療新進(jìn)展

1、王王XXXX慢性心力衰竭藥物治療慢性心力衰竭藥物治療新新 進(jìn)進(jìn) 展展第三軍醫(yī)大學(xué)大坪醫(yī)院心血管內(nèi)科第三軍醫(yī)大學(xué)大坪醫(yī)院心血管內(nèi)科重慶市心血管病研究所重慶市心血管病研究所中國心力衰竭流行病學(xué)調(diào)查及患病率. 中華心血管病雜志, 2003, 31(1):3-6.InterASIAInterASIA研究：中國研究：中國35-7435-74歲歲的人群中，的人群中，CHFCHF患病率為患病率為0.9%0.9%估計(jì)全國約有估計(jì)全國約有400400萬患者萬患者CHFCHF患者住院患者住院30d30d死亡率死亡率5.4%5.4%A期心衰高?；颊邿o結(jié)構(gòu)性心臟病變無心衰癥狀B期有結(jié)構(gòu)性心臟病變無心衰癥狀或體征C期有

2、結(jié)構(gòu)性心臟病變既往或現(xiàn)有心衰癥狀D期頑固性心衰，需要特殊干預(yù)結(jié)構(gòu)性心臟病變出現(xiàn)心衰癥狀靜息時(shí)有頑固的心衰癥狀高血壓動(dòng)脈粥樣硬化糖尿病肥胖代謝綜合征.既往心肌梗死左室重塑，包括左室肥厚和射血分?jǐn)?shù)降低無癥狀瓣膜病結(jié)構(gòu)性心臟病變氣短、乏力、運(yùn)動(dòng)耐量降低經(jīng)過最大劑量藥物治療情況下靜息時(shí)仍有明顯癥狀（如反復(fù)住院、不接受特殊干預(yù)無法安全出院的患者） 無結(jié)構(gòu)性 心臟病變防止和延緩心室重構(gòu) 改善癥狀 提高生活質(zhì)量有結(jié)構(gòu)性心臟病變既往或現(xiàn)有心衰癥狀頑固性心衰，需要特殊干預(yù)高血壓動(dòng)脈粥樣硬化糖尿病肥胖代謝綜合征.降低再住院率 改善預(yù)后非藥物非藥物治療治療藥物藥物治療治療1.1.再同步化治療再同步化治療2.ICD2

3、.ICD植入植入3.3.左心輔助裝置左心輔助裝置4.4.心臟移植心臟移植5.5.人工心臟人工心臟1.1.神經(jīng)內(nèi)分泌神經(jīng)內(nèi)分泌 拮抗劑拮抗劑2.2.強(qiáng)效利尿劑強(qiáng)效利尿劑3.3.輔助治療藥物輔助治療藥物4.4.正性肌力藥物正性肌力藥物ACEIACEI：能降低心衰患者病死率的首選藥物，循證醫(yī)：能降低心衰患者病死率的首選藥物，循證醫(yī)學(xué)證據(jù)累積最多、公認(rèn)的治療心衰的學(xué)證據(jù)累積最多、公認(rèn)的治療心衰的基石基石。小量起始逐漸滴定最終達(dá)標(biāo)神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑-ARB（替補(bǔ)）（替補(bǔ)）神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑-B小量起始逐漸滴定最終達(dá)標(biāo)1.LVEF1.LVEF35%35%、NYHA II-IVN

4、YHA II-IV級(jí)患者；級(jí)患者；2.2.已使用已使用ACEI/ARBACEI/ARB和和BBBB治療，仍持續(xù)有癥狀的患者（治療，仍持續(xù)有癥狀的患者（3.AMI3.AMI后、后、LVEFLVEF40%40%，有心衰癥狀或既往有糖尿病史（，有心衰癥狀或既往有糖尿病史（神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med.1999;341:709-17.神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑Eplerenone,

5、 a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med. 2003 ;348:1309-21神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med. 2003 ;348:13

6、09-21神經(jīng)內(nèi)分泌拮抗劑神經(jīng)內(nèi)分泌拮抗劑Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study.Lancet.2010 ;376:875-85. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study.Lancet.2010 ;376:875-85. A 期B 期C 期D 期心衰高?；颊邿o心臟結(jié)構(gòu)或功能異常無心衰癥狀和（或）

7、體征有結(jié)構(gòu)性心臟病變無心衰癥狀和（或）體征有基礎(chǔ)的結(jié)構(gòu)性心臟病變以往或目前有心衰癥狀和（或）體征有進(jìn)行性心臟病需要特殊干預(yù)金三角金磚四國常用利尿劑：利尿劑抵抗：利尿劑抵抗的處理：Short-term Clinical Effects of Tolvaptan, an Oral Vasopressin Antagonist, in Patients Hospitalized for Heart Failure.JAMA. 2007;297:1332-1343Effects of Oral Tolvaptan in Patients Hospitalized for Worsening Heart

8、 Failure。 JAMA. 2007;297:1319-1331統(tǒng)A multicenter, randomized, double-blind, parallel-group, placebo-controlled study of the effects of qili qiangxin capsules in patients with chronic heart failure J Am Coll Cardiol.2013;62:1065-72. A multicenter, randomized, double-blind, parallel-group, placebo-con

9、trolled study of the effects of qili qiangxin capsules in patients with chronic heart failure J Am Coll Cardiol.2013;62:1065-72. A multicenter, randomized, double-blind, parallel-group, placebo-controlled study of the effects of qili qiangxin capsules in patients with chronic heart failure J Am Coll

10、 Cardiol.2013;62:1065-72. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial). Lancet.2008;372:1223-30. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial). Lancet.2008;372:1223-30. Additional use of

11、trimetazidine in patients with chronic heart failure: a meta-analysis J Am Coll Cardiol. 2012;59:913-22. A.曲美他嗪對(duì)全因死亡率的影響B(tài).曲美他嗪對(duì)心衰住院率的影響Additional use of trimetazidine in patients with chronic heart failure: a meta-analysis J Am Coll Cardiol. 2012;59:913-22. Effect of coenzyme Q supplementation on heart failure: a meta-analysis. Am J Clin Nutr.2013;97:268-75. Effect of coenzyme Q supplementation on heart failure: a meta-analysis. Am J Clin Nutr.2013;97:268-75. Effect of coenzyme Q supplementation on h