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专家答疑:“金三角”能否改善舒张性心衰或右心衰预后?

2018-12-09 朱燕林、方理刚 北京协和医院心内科 中国心血管杂志

“金三角”治疗即肾素-血管紧张素系统抑制剂(血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂,ACEI/ARB)、β受体阻滞剂和醛固酮受体拮抗剂。诸多循证医学证据确立了“金三角”治疗适用于左室射血分数(LVEF)下降的心衰患者,是治疗LVEF减低心衰患者的基石,可以降低此类患者的全因死亡、心血管死亡、猝死和心衰住院风险,但其在舒张性心衰或右心衰治疗中的作用尚需探索。

“金三角”治疗即肾素-血管紧张素系统抑制剂(血管紧张素转换酶抑制剂、血管紧张素Ⅱ受体拮抗剂,ACEI/ARB)、β受体阻滞剂和醛固酮受体拮抗剂。诸多循证医学证据确立了“金三角”治疗适用于左室射血分数(LVEF)下降的心衰患者,是治疗LVEF减低心衰患者的基石,可以降低此类患者的全因死亡、心血管死亡、猝死和心衰住院风险,但其在舒张性心衰或右心衰治疗中的作用尚需探索。

舒张性心衰即射血分数保留的心力衰竭(HFpEF),其诊断标准为左室射血分数(LVEF)50%或以上、利钠肽(BNP)升高,并合并左室肥厚和(或)左房扩大或心脏舒张功能异常。同时需要排除患者症状是由非心脏疾病引起的。在诊断不明确时,可进行超声心动图或有创检查明确左室充盈压是否升高。心房颤动、高血压、冠状动脉粥样硬化性心脏病、糖尿病、慢性肾脏疾病可以作为HFpEF的基础疾病。因基础疾病的不同,病理生理机制差异很大,对于HFpEF的患者需要注意个体化和综合性治疗。

有液体潴留的HFpEF患者应使用利尿剂治疗。TOPCAT研究亚组分析显示,螺内酯可以降低HFpEF患者的因心衰住院风险。因此,对于BNP升高或1年内因心衰住院的HFpEF患者,可考虑使用醛固酮受体拮抗剂。

针对引起HFpEF的基础疾病治疗非常重要:

--高血压是最重要及最常见的HFpEF病因,有效控制血压可以降低心衰住院、心血管事件及死亡率。

--合并冠心病的HFpEF患者应积极药物治疗或联合血运重建术。

--房颤患者控制心室率或尝试恢复并维持窦性心律。

--糖尿病患者积极治疗并有效控制血糖。

临床研究如PEP-CHF、CHARM-Preserved、I-Preserve、J-DHF等未能证实ACEI/ARB、β受体阻滞剂能改善HFpEF患者的预后和降低病死率。

新的药物沙库巴曲缬沙坦可能为HFpEF的治疗带来转机。PARAMOUNT试验表明,沙库巴曲缬沙坦可改善HFpEF患者的左心室心肌形变能力,降低N末端B型利钠肽原(NT-proBNP),缩小左房体积。在PARAMOUNT试验基础上的PARAGON-HF研究以心血管疾病死亡或心衰住院为硬终点,有望明确沙库巴曲缬沙坦在HEpEF人群中是否优于血管紧张素Ⅱ受体拮抗剂。

引起右心衰竭的病因包括伴有右室受累的原发心肌病、右心室心肌缺血和梗死、各种引起右心室容量负荷增加的疾病(先天性心脏病、瓣膜性心脏病)以及压力负荷增加的疾病(各种原因所致的肺动脉高压、肺动脉瓣狭窄)。目前尚无针对右心衰竭治疗的大规模随机临床试验,而且缺乏促进右心室功能稳定和恢复的特异性治疗。治疗原则为积极治疗导致右心衰竭的上述原发疾病,减轻右心前后负荷和增强心肌收缩力,维持心脏收缩同步性。同时纠正感染、妊娠或分娩、高原反应等诱发因素。可以选择利尿剂降低前负荷,血管活性药物改善脏器灌注。而“金三角”治疗尚缺乏改善右心衰预后的证据。

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    2019-01-02 topnew

    厉害厉害继续学习

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    2018-12-09 医者仁心5538

    学习了

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1937708, encodeId=8de8193e708db, content=<a href='/topic/show?id=562738645ec' target=_blank style='color:#2F92EE;'>#右心衰#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38645, encryptionId=562738645ec, topicName=右心衰)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93e223, createdName=bluefate121, createdTime=Sun Mar 31 11:27:00 CST 2019, time=2019-03-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=356980, encodeId=a0fd35698086, content=厉害厉害继续学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ef781002, createdName=topnew, createdTime=Wed Jan 02 10:51:42 CST 2019, time=2019-01-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2026418, encodeId=4d1d202641899, content=<a href='/topic/show?id=b2cb9614253' target=_blank style='color:#2F92EE;'>#金三角#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96142, encryptionId=b2cb9614253, topicName=金三角)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5b34252, createdName=chenshujs, createdTime=Fri Apr 26 06:27:00 CST 2019, time=2019-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1391776, encodeId=38d61391e765c, content=<a href='/topic/show?id=2b1b865914c' target=_blank style='color:#2F92EE;'>#舒张性心衰#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=86591, encryptionId=2b1b865914c, topicName=舒张性心衰)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdqq.qlogo.cn/qqapp/1103841572/B389FA68ECBF51BE2FE14093CF61F6AE/100, createdBy=eb8e2500096, createdName=夏天与十三菇凉, createdTime=Tue Dec 11 03:27:00 CST 2018, time=2018-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=354929, encodeId=311a3549296a, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Sun Dec 09 14:44:16 CST 2018, time=2018-12-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=354923, encodeId=d03235492371, content=好文,值得点赞,更值得收藏!慢慢领会学习的。给点个赞!, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7s7ZCKOmmbBTD6nE7gcd5OZpvyGEzkxBP3S275k5ZJVrsPkotZhBglRHM9rKvcj1OgkssqhcnoPw8zIaMZTF8c/0, createdBy=4c441942088, createdName=ylzr123, createdTime=Sun Dec 09 14:26:38 CST 2018, time=2018-12-09, status=1, ipAttribution=)]
    2018-12-09 ylzr123

    好文,值得点赞,更值得收藏!慢慢领会学习的。给点个赞!

    0

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