慢性心力衰竭药物治疗新进展课件.ppt

1、王王XXXX慢性心力衰竭药物治疗慢性心力衰竭药物治疗新新 进进 展展第三军医大学大坪医院心血管内科第三军医大学大坪医院心血管内科重庆市心血管病研究所重庆市心血管病研究所中国心力衰竭流行病学调查及患病率.中华心血管病杂志,2003,31(1):3-6.InterASIAInterASIA研究：中国研究：中国35-7435-74岁岁的人群中，的人群中，CHFCHF患病率为患病率为0.9%0.9%估计全国约有估计全国约有400400万患者万患者CHFCHF患者住院患者住院30d30d死亡率死亡率5.4%5.4%A期心衰高危患者无结构性心脏病变无心衰症状B期有结构性心脏病变无心衰症状或体征C期有结构性

2、心脏病变既往或现有心衰症状D期顽固性心衰，需要特殊干预结构性心脏病变出现心衰症状静息时有顽固的心衰症状高血压动脉粥样硬化糖尿病肥胖代谢综合征.既往心肌梗死左室重塑，包括左室肥厚和射血分数降低无症状瓣膜病结构性心脏病变气短、乏力、运动耐量降低经过最大剂量药物治疗情况下静息时仍有明显症状（如反复住院、不接受特殊干预无法安全出院的患者）无结构性 心脏病变防止和延缓心室重构 改善症状 提高生活质量有结构性心脏病变既往或现有心衰症状顽固性心衰，需要特殊干预高血压动脉粥样硬化糖尿病肥胖代谢综合征.降低再住院率 改善预后非药物非药物治疗治疗药物药物治疗治疗1.1.再同步化治疗再同步化治疗2.ICD2.ICD

3、植入植入3.3.左心辅助装置左心辅助装置4.4.心脏移植心脏移植5.5.人工心脏人工心脏1.1.神经内分泌神经内分泌 拮抗剂拮抗剂2.2.强效利尿剂强效利尿剂3.3.辅助治疗药物辅助治疗药物4.4.正性肌力药物正性肌力药物ACEIACEI：能降低心衰患者病死率的首选药物，循证医：能降低心衰患者病死率的首选药物，循证医学证据累积最多、公认的治疗心衰的学证据累积最多、公认的治疗心衰的基石基石。小量起始逐渐滴定最终达标神经内分泌拮抗剂神经内分泌拮抗剂-ARB（替补）（替补）神经内分泌拮抗剂神经内分泌拮抗剂-B小量起始逐渐滴定最终达标1.LVEF1.LVEF35%35%、NYHA II-IVNYHA

4、II-IV级患者；级患者；2.2.已使用已使用ACEI/ARBACEI/ARB和和BBBB治疗，仍持续有症状的患者（治疗，仍持续有症状的患者（3.AMI3.AMI后、后、LVEFLVEF40%40%，有心衰症状或既往有糖尿病史（，有心衰症状或既往有糖尿病史（神经内分泌拮抗剂神经内分泌拮抗剂The effect of spironolactone on morbidity and mortality in patients with severe heart failure.N Engl J Med.1999;341:709-17.神经内分泌拮抗剂神经内分泌拮抗剂Eplerenone,a sel

5、ective aldosterone blocker,in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med.2003;348:1309-21神经内分泌拮抗剂神经内分泌拮抗剂Eplerenone,a selective aldosterone blocker,in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med.2003;348:1309-21神经内分泌拮抗剂

6、神经内分泌拮抗剂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 期心衰高危患者无心脏结构或功能异常无心衰症状和（或）体征有结构性心脏病变无心衰症状和（或）体征

7、有基础的结构性心脏病变以往或目前有心衰症状和（或）体征有进行性心脏病需要特殊干预金三角金砖四国常用利尿剂：利尿剂抵抗：利尿剂抵抗的处理：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 Failure。JAMA.2007;297:1

8、319-1331统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-controlled study of the effects of qil

9、i 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 Cardiol.2013;62:1065-72.Effect of n-3 p

10、olyunsaturated 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 trimetazidine in patients with chronic heart fa

11、ilure:a meta-analysis J Am Coll Cardiol.2012;59:913-22.A.曲美他嗪对全因死亡率的影响B.曲美他嗪对心衰住院率的影响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;97:26

12、8-75.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 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.射CHF（HF-REF）药物治疗流程