心力衰竭治疗近况培训课件.ppt

1、国人不同性别、年龄组成人的心衰患病率国人不同性别、年龄组成人的心衰患病率(%)(%)年龄男女合计35440.30.50.445540.6 1.3*1.055641.31.41.365741.11.51.3合计0.7 1.0*0.9心力衰竭治疗近况10/14/20221国人心衰病因国人心衰病因z高血压z缺血性心脏病z心肌病z糖尿病z先心z风湿性心脏病z高血压z心肌病z先心z营养性心肌病z肺心病z缺血性心脏病心力衰竭治疗近况10/14/20222缺血性心脏病缺血性心脏病心肌病心肌病糖尿病糖尿病高血压高血压风湿性心脏病风湿性心脏病先心先心肺心病肺心病心衰心衰外在机制：机械、负荷、外在机制：机械、负荷

2、、代谢、营养代谢、营养Why?内在机制：细胞、内在机制：细胞、分子、基因分子、基因心力衰竭治疗近况10/14/20223WhyWhy?-?-心衰新概念心衰新概念z心室重塑：心室重塑：一系列复杂的分子和细胞机制导致心一系列复杂的分子和细胞机制导致心肌结构、功能和表型的变化。肌结构、功能和表型的变化。胚胎基因和蛋白胚胎基因和蛋白质再表达质再表达心肌细胞肥大、凋亡，心肌心肌细胞肥大、凋亡，心肌细胞外基质量和组成变化细胞外基质量和组成变化心肌质量、心室心肌质量、心室容积和形状改变容积和形状改变心力衰竭治疗近况10/14/20224心衰新概念心衰新概念z心衰：心衰：血流动力学障碍血流动力学障碍 神经内分

3、泌失调。神经内分泌失调。治疗关键：治疗关键：调控调控神经内分泌。神经内分泌。z如果一种药物能够改善疾病进程，不管这如果一种药物能够改善疾病进程，不管这种药物是否能够缓解症状，都应尽早使用。种药物是否能够缓解症状，都应尽早使用。z如果一种药物仅对于缓解症状有效而不能如果一种药物仅对于缓解症状有效而不能改善疾病进程，那么最好将这种药物保留改善疾病进程，那么最好将这种药物保留到出现症状时再用，而非早期使用。到出现症状时再用，而非早期使用。心力衰竭治疗近况10/14/20225心力衰竭药物治疗历史心力衰竭药物治疗历史z洋地黄和利尿剂时代洋地黄和利尿剂时代z血管扩张剂时代血管扩张剂时代 -受体阻滞剂、硝

4、酸酯类、小动脉受体阻滞剂、硝酸酯类、小动脉扩张剂及钙通道阻滞剂等扩张剂及钙通道阻滞剂等z非洋地黄类正性肌力药时代非洋地黄类正性肌力药时代 -受体激动剂（多巴受体激动剂（多巴酚丁胺等）；磷酸二酯酶抑制剂酚丁胺等）；磷酸二酯酶抑制剂z抗神经内分泌激活时代抗神经内分泌激活时代 ACEI；-受体阻滞剂；醛受体阻滞剂；醛固酮拮抗剂。固酮拮抗剂。心力衰竭治疗近况10/14/20226心力衰竭的现代药物治疗心力衰竭的现代药物治疗zI级：级：ACEIzII级：级：ACEI利尿剂利尿剂受体阻滞剂地受体阻滞剂地高辛（？）高辛（？）zIII级：级：ACEI利尿剂利尿剂受体阻滞剂地受体阻滞剂地高辛高辛zIV级：级：A

5、CEI利尿剂利尿剂受体阻滞剂受体阻滞剂(慎用慎用)地高辛安体舒通地高辛安体舒通心力衰竭治疗近况10/14/20227ACEACE抑制剂抑制剂z心衰药物治疗的基石心衰药物治疗的基石10/14/20228SOLVDSOLVD（S Studies tudies OOf f L Left eft V Ventricular entricular D Dysfunctionysfunction）结果）结果0 02020404060608080总死亡率总死亡率心血管死亡率心血管死亡率心衰进展死亡心衰进展死亡死亡或因心衰住院死亡或因心衰住院EnalaprilEnalaprilPlaceboPlacebo心力

6、衰竭治疗近况10/14/20229ACEACE抑制剂抑制剂z迄今为止，已有迄今为止，已有39个（个（8308例）例）ACEI治治疗心衰的临床研究，结果都能改善症状、疗心衰的临床研究，结果都能改善症状、延缓重塑、降低死亡危险性。延缓重塑、降低死亡危险性。z这些研究奠定了这些研究奠定了ACEI作为心衰治疗的基石作为心衰治疗的基石和首选药物地位。和首选药物地位。心力衰竭治疗近况10/14/202210为什么医生不按实证医学使用为什么医生不按实证医学使用ACEIACEI？z没有认识到心衰是一种值得治疗的公众健康难题没有认识到心衰是一种值得治疗的公众健康难题 z没有充分体会到没有充分体会到ACEI 在心

7、衰治疗中的好处和重在心衰治疗中的好处和重要性要性 z没有理解应用没有理解应用AECI所带来的临床益处是超值的所带来的临床益处是超值的 z对对ACEI 副作用的考量超过对其临床益处的估计副作用的考量超过对其临床益处的估计z认为临床试验中观察到的益处并不能转化到临床认为临床试验中观察到的益处并不能转化到临床实践中实践中z没有认识到没有认识到ACEI能够延缓和改善心衰进程能够延缓和改善心衰进程J.McMurray:Eur Heart J 1998;19(suppl.L):L15-L21Failure to Practice Evidence-Based Medicine:Why Do Physici

8、ans Not Treat Patients with Heart Failure with ACE Inhibitors?心力衰竭治疗近况10/14/202211ACEIACEI使用要点使用要点z除非有禁忌或不能耐受均应用（包括除非有禁忌或不能耐受均应用（包括I级）级）z必须告知病人必须告知病人y疗效数周或数月才出现，即使症状未改善，仍疗效数周或数月才出现，即使症状未改善，仍可延缓疾病进展可延缓疾病进展y副作用可能早期出现，但不妨碍长期应用副作用可能早期出现，但不妨碍长期应用y从小剂量开始，最好用至最大耐受量从小剂量开始，最好用至最大耐受量y需无限期、终生服用需无限期、终生服用z长期治疗出现

9、长期治疗出现“醛固酮逃逸醛固酮逃逸”心力衰竭治疗近况10/14/202212ACEIACEI使用要点使用要点z血血Cr4mg/dl而未透析者不宜而未透析者不宜z对血对血Cr1.5mg/dl者，虽然肾小球内压降低可者，虽然肾小球内压降低可使使GFR在短期内下降，但有利于长期更好地维持在短期内下降，但有利于长期更好地维持GFRz血血Cr升高升高0.51mg：不必停药；常在：不必停药；常在12周左周左右趋于稳定或下降右趋于稳定或下降z血血Cr升高升高1mg：应减少：应减少ACEI及利尿剂剂量及利尿剂剂量z容易引起血容易引起血Cr升高的情况：大剂量利尿、重度心升高的情况：大剂量利尿、重度心衰、肾动脉狭

10、窄、低血压衰、肾动脉狭窄、低血压心力衰竭治疗近况10/14/202213常用常用ACEIACEI的参考目标剂量的参考目标剂量 药物药物 起始剂量起始剂量 目标剂量目标剂量z卡托普利卡托普利 6.25mg、tid 2550mg、tidz依那普利依那普利 2.5mg、qd 10mg、bidz培哚普利培哚普利 2mg、qd 4mg、qdz苯那普利苯那普利 2.5mg、qd 510mg、bidz福辛普利福辛普利 10mg、qd 2040mg、qdz西拉普利西拉普利 0.5mg、qd 2.5mg、qd心力衰竭治疗近况10/14/202214ARBARB与与ACEIACEI比较的优点比较的优点z作用具特异

11、性，副反应较小作用具特异性，副反应较小z仍保持循环反射，体位性低血压少仍保持循环反射，体位性低血压少z不论形成不论形成AII酶的途径如何酶的途径如何,均可阻滞均可阻滞AII作用作用z能完全、直接阻断循环、局部组织能完全、直接阻断循环、局部组织AII作用作用z使使AII增加，升高的增加，升高的AII加强对加强对AT2的作用的作用z不影响缓激肽，无咳嗽副作用不影响缓激肽，无咳嗽副作用z但缓激肽亦有益处：增加扩血管的前列腺素、抗但缓激肽亦有益处：增加扩血管的前列腺素、抗增生（增生（ACEI合用合用ASA减低效果）减低效果）心力衰竭治疗近况10/14/202215ARBARB的临床应用建议的临床应用建

12、议z未用过未用过ACEI和能耐受和能耐受ACEI者，仍以者，仍以ACEI为首选为首选z用于用于ACEI不耐受者（少有咳嗽、血管性水不耐受者（少有咳嗽、血管性水肿，其余不良反应同肿，其余不良反应同ACEI）z对对 受体阻滞剂有禁忌时，受体阻滞剂有禁忌时，ACEI联用代联用代文文心力衰竭治疗近况10/14/202216利尿剂利尿剂心力衰竭治疗近况10/14/202217利尿剂的应用要点（利尿剂的应用要点（1 1）z控制心衰体液潴留唯一可靠方法控制心衰体液潴留唯一可靠方法 z应用于所有伴有体液潴留的、症状性心力衰竭应用于所有伴有体液潴留的、症状性心力衰竭z治疗中若出现低血压或治疗中若出现低血压或氮质

13、血症氮质血症，应减量或暂停，应减量或暂停z确定剂量和疗效的最好方法确定剂量和疗效的最好方法:小剂量开始逐渐加小剂量开始逐渐加量，使体重每日减轻量，使体重每日减轻0.51kgz双克双克100mg/d无意义无意义;速尿量效呈线性关系速尿量效呈线性关系z病情稳定（浊音、水肿消失，体重稳定）后以小病情稳定（浊音、水肿消失，体重稳定）后以小剂量剂量长期维持长期维持心力衰竭治疗近况10/14/202218利尿剂的应用要点（利尿剂的应用要点（2 2）z影响几乎所有抗心衰药物的疗效和毒性影响几乎所有抗心衰药物的疗效和毒性z剂量不足导致液体潴留剂量不足导致液体潴留y减弱减弱ACEI疗效疗效y增加增加阻滞剂的危险

14、阻滞剂的危险 z剂量过大导致血容量不足剂量过大导致血容量不足y增加增加ACEI与硝酸盐等低血压的危险与硝酸盐等低血压的危险y增加增加ACEI与与ARB治疗中肾功能不全的危险治疗中肾功能不全的危险心力衰竭治疗近况10/14/202219利尿剂的应用要点（利尿剂的应用要点（3 3）z利尿剂抵抗（伴心衰加重）的对策利尿剂抵抗（伴心衰加重）的对策y静脉给药（速尿可持续滴注）静脉给药（速尿可持续滴注）y改袢利尿剂改袢利尿剂y联合用药联合用药y短期应用增加肾脏血流量的药物（小剂量多巴短期应用增加肾脏血流量的药物（小剂量多巴胺、多巴酚丁胺）胺、多巴酚丁胺）y停用非甾体类抗炎药停用非甾体类抗炎药心力衰竭治疗近

15、况10/14/202220 受体阻滞剂受体阻滞剂10/14/202221卡维地洛对重度慢性心衰卡维地洛对重度慢性心衰存活率的影响存活率的影响Effect of Carvedilol on Survival in Severe Chronic Heart Failurez Carvedilol Prospective Randomized Cumulative Survival Study Groupz N Engl J Med 2001；344：1651 10/14/202222存活率 KaplanMeier Analysis of Time to Death in the Placebo G

16、roup and the Carvedilol Group.The 35%lower risk in the carvedilol group was significant:P=0.00013(unadjusted)and P=0.0014(adjusted).心力衰竭治疗近况10/14/202223总死亡和首次住院率KaplanMeier Analysis of Time to Death or First Hospitalization for Any Reason in the Placebo Group and the Carvedilol Group.The 24%lower ri

17、sk in the carvedilol group was significant(P0.001).心力衰竭治疗近况10/14/202224撤药率KaplanMeier Analysis of the Time to Permanent Withdrawal of the Study Medication because of Adverse Reactions or for Reasons Other Than Death in the Placebo Group and the Carvedilol Group.心力衰竭治疗近况10/14/202225结论结论z倍他受体阻滞剂不但能够降低

18、轻到中度心倍他受体阻滞剂不但能够降低轻到中度心衰病人的病残率和死亡率，对重度心衰病衰病人的病残率和死亡率，对重度心衰病人也同样有效。人也同样有效。心力衰竭治疗近况10/14/202226-受体阻滞剂的使用要点受体阻滞剂的使用要点z 适应证适应证y所有慢性收缩性心衰、心功能所有慢性收缩性心衰、心功能II、III级、病情稳定级、病情稳定z 禁忌证禁忌证y支气管痉挛支气管痉挛y心动过缓，心动过缓，II、III度度AVBy急性心衰、难治性心衰急性心衰、难治性心衰z 需向患者交代需向患者交代y症状改善需症状改善需23月月y即使症状未改善，亦可延缓疾病进展即使症状未改善，亦可延缓疾病进展y早期可出现不良反

19、应，不影响治疗早期可出现不良反应，不影响治疗心力衰竭治疗近况10/14/202227-受体阻滞剂的使用要点受体阻滞剂的使用要点z “干体重干体重”:充分利尿，处于利尿剂维持阶段充分利尿，处于利尿剂维持阶段z 起始剂量：美托洛尔起始剂量：美托洛尔6.25mg、bid；比索洛尔；比索洛尔1.25mg、qd；卡维地洛；卡维地洛3.125mg、bid、每、每24周酌情增加周酌情增加z 剂量宜个体化剂量宜个体化,不按治疗反应来定。达到最大耐受量或目不按治疗反应来定。达到最大耐受量或目标剂量后长期维持。标剂量后长期维持。z 参考目标剂量：美托洛尔参考目标剂量：美托洛尔75100mg、bid;比索洛尔比索洛

20、尔10mg、qd；卡维地洛；卡维地洛25mg、bid心力衰竭治疗近况10/14/202228-受体阻滞剂治疗时应监测受体阻滞剂治疗时应监测z液体潴留（体重增加）和心衰恶化：加大液体潴留（体重增加）和心衰恶化：加大利尿利尿z心动过缓和房室阻滞：心动过缓和房室阻滞：55次次/分减量或停分减量或停药药z低血压：低血压：ACEI或扩血管药减量，不减利尿或扩血管药减量，不减利尿剂剂心力衰竭治疗近况10/14/202229地高辛地高辛z唯一不增加死亡率的正性肌力药唯一不增加死亡率的正性肌力药物物10/14/202230The Effect of Digoxin on Mortality The Effec

21、t of Digoxin on Mortality and Morbidity in Patients with and Morbidity in Patients with Heart FailureHeart Failurez The Digitalis Investigation Group10/14/202231zBackground The role of cardiac glycosides in treating patients with chronic heart failure and normal sinus rhythm remains controversial.We

22、 studied the effect of digoxin on mortality and hospitalization in a randomized,double-blind clinical trial.zMethods In the main trial,patients with left ventricular ejection fractions of 0.45 or less were randomly assigned to digoxin(3397 patients)or placebo(3403 patients)in addition to diuretics a

23、nd angiotensin-convertingenzyme inhibitors(median dose of digoxin,0.25 mg per day;average follow-up,37 months).In an ancillary trial of patients with ejection fractions greater than 0.45,492 patients were randomly assigned to digoxin and 496 to placebo.zResults In the main trial,mortality was unaffe

24、cted.There were 1181 deaths(34.8 percent)with digoxin and 1194 deaths(35.1 percent)with placebo(risk ratio when digoxin was compared with placebo,0.99;95 percent confidence interval,0.91 to 1.07;P=0.80).In the digoxin group,there was a trend toward a decrease in the risk of death attributed to worse

25、ning heart failure(risk ratio,0.88;95 percent confidence interval,0.77 to 1.01;P=0.06).There were 6 percent fewer hospitalizations overall in that group than in the placebo group,and fewer patients were hospitalized for worsening heart failure(26.8 percent vs.34.7 percent;risk ratio,0.72;95 percent

26、confidence interval,0.66 to 0.79;P0.001).In the ancillary trial,the findings regarding the primary combined outcome of death or hospitalization due to worsening heart failure were consistent with the results of the main trial.心力衰竭治疗近况10/14/202232 Digoxin 和 Placebo 组总死亡率：地高辛不降低总死亡率心力衰竭治疗近况10/14/20223

27、3心衰恶化死亡率心衰恶化死亡率 Mortality Due to Worsening Heart Failure in the Digoxin and Placebo Groups.心力衰竭治疗近况10/14/202234因心衰恶化而死亡或住院：因心衰恶化而死亡或住院：地高辛降低因心衰恶化住院率因心衰恶化住院率 Incidence of Death or Hospitalization Due to Worsening Heart Failure in the Digoxin and Placebo Groups.心力衰竭治疗近况10/14/202235地高辛的长期作用地高辛的长期作用z减少住

28、院次数减少住院次数z生存率与安慰剂量相仿生存率与安慰剂量相仿z增加严重心律失常增加严重心律失常z增加心肌梗死增加心肌梗死心力衰竭治疗近况10/14/202236地高辛应用要点地高辛应用要点z推荐用于改善收缩性心衰的临床症状推荐用于改善收缩性心衰的临床症状z应与其它三种标准药物联用应与其它三种标准药物联用z用于伴快心室率房颤者（控制运动时心室用于伴快心室率房颤者（控制运动时心室率率阻滞剂效果更好）阻滞剂效果更好）z根据血浓度决定用药量根据血浓度决定用药量依据不足依据不足z小剂量亦有效小剂量亦有效z多数心衰患者能耐受多数心衰患者能耐受心力衰竭治疗近况10/14/202237醛固酮受体阻断剂：醛固酮

29、受体阻断剂：SpironolactoneSpironolactone10/14/202238The Effect of Spironolactone on Morbidity The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart and Mortality in Patients with Severe Heart FailureFailurez The Randomized Aldactone Evaluation Study Investigators N Engl J M

30、ed 1999:341:709-17 10/14/202239zBackground and Methods Aldosterone is important in the pathophysiology of heart failure.In a double-blind study,we enrolled 1663 patients who had severe heart failure and a left ventricular ejection fraction of no more than 35 percent and who were being treated with a

31、n angiotensin-convertingenzyme inhibitor,a loop diuretic,and in most cases digoxin.A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily,and 841 to receive placebo.The primary end point was death from all causes.zResults The trial was discontinued early,after a mean

32、 follow-up period of 24 months,because an interim analysis determined that spironolactone was efficacious.There were 386 deaths in the placebo group(46 percent)and 284 in the spironolactone group(35 percent;relative risk of death,0.70;95 percent confidence interval,0.60 to 0.82;P0.001).This 30 perce

33、nt reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from progressive heart failure and sudden death from cardiac causes.The frequency of hospitalization for worsening heart failure was 35 percent lower in the spironolactone group

34、than in the placebo group(relative risk of hospitalization,0.65;95 percent confidence interval,0.54 to 0.77;P0.001).In addition,patients who received spironolactone had a significant improvement in the symptoms of heart failure,as assessed on the basis of the New York Heart Association functional cl

35、ass(P0.001).Gynecomastia or breast pain was reported in 10 percent of men who were treated with spironolactone,as compared with 1 percent of men in the placebo group(P0.001).The incidence of serious hyperkalemia was minimal in both groups of patients.心力衰竭治疗近况10/14/202240存活率：Spironolactone group vs p

36、lacebo group:The risk of death was 30%lower(P0.001).心力衰竭治疗近况10/14/202241Relative Risks of Death from All Causes and According to Demographic and Clinical Characteristics.The horizontal lines indicate 95 percent confidence intervals.心力衰竭治疗近况10/14/202242结论结论 在标准治疗基础上，加用醛固酮受体阻在标准治疗基础上，加用醛固酮受体阻断剂（断剂（螺内酯

37、，spironolactone），可有），可有效降低效降低重度重度心衰发病率和死亡率。心衰发病率和死亡率。心力衰竭治疗近况10/14/202243螺内酯应用要点螺内酯应用要点z用量：用量：12.525mg、qdz目前仅用于目前仅用于IV级心功能的治疗级心功能的治疗z螺内酯为非特异性盐皮质激素受体阻断剂，螺内酯为非特异性盐皮质激素受体阻断剂，还阻断孕激素和雄激素，副作用大还阻断孕激素和雄激素，副作用大心力衰竭治疗近况10/14/202244机制机制z抑制促进纤维化的机制：抑制促进纤维化的机制：PAI1表达，导表达，导致血管纤溶的改变；刺激致血管纤溶的改变；刺激TGFa1、刺激、刺激氧自由基氧自由

38、基心力衰竭治疗近况10/14/202245非洋地黄强心剂非洋地黄强心剂10/14/202246维司力农治疗重度心衰：死亡率呈剂量依赖性增加维司力农治疗重度心衰：死亡率呈剂量依赖性增加A Dose-Dependent Increase in Mortality with Vesnarinone among A Dose-Dependent Increase in Mortality with Vesnarinone among Patients with Severe Heart FailurePatients with Severe Heart Failurez The Vesnarinone

39、（维司力农）维司力农）Trial Investigators 10/14/202247维司力农治疗重度心衰：死亡率呈剂量依赖性增加维司力农治疗重度心衰：死亡率呈剂量依赖性增加zBackground Vesnarinone（维司力农）,an inotropic drug,was shown in a short-term placebo-controlled trial to improve survival markedly in patients with severe heart failure when given at a dose of 60 mg per day,but there

40、 was a trend toward an adverse effect on survival when the dose was 120 mg per day.In a longer-term study,we evaluated the effects of daily doses of 60 mg or 30 mg of vesnarinone,as compared with placebo,on mortality and morbidity.zMethods We enrolled 3833 patients who had symptoms of NYHA class III

41、 or IV HF and a left ventricular EF of 30%or less despite optimal treatment.The mean follow-up was 286 days.zResults There were significantly fewer deaths in the placebo group(242 deaths,or 18.9%)than in the 60-mg vesnarinone group(292 deaths,or 22.9%)and longer survival(P=0.02).The increase in mort

42、ality with vesnarinone was attributed to an increase in sudden death,presumed to be due to arrhythmia.The quality of life had improved significantly more in the 60-mg vesnarinone group than in the placebo group at 8 weeks(P0.001)and 16 weeks(P=0.003)after randomization.Trends in mortality and in mea

43、sures of the quality of life in the 30-mg vesnarinone group were similar to those in the 60-mg group but not significantly different from those in the placebo group.Agranulocytosis occurred in 1.2%of the patients given 60 mg of vesnarinone per day and 0.2%of those given 30 mg of vesnarinone.心力衰竭治疗近况

44、10/14/202248安慰剂、维司力农存活率比较安慰剂、维司力农存活率比较维司力农维司力农心力衰竭治疗近况10/14/202249 Subgroup Analysis of Hazard Ratios and 95 Percent Confidence Intervals for Death from Any Cause among Patients Assigned to Receive 60 mg of Vesnarinone per Day as Compared with Those Assigned to Receive Placebo.The dotted line(hazard

45、 ratio,1.0)indicates the risk of death in the placebo group.心力衰竭治疗近况10/14/202250结论结论 维司力农（维司力农（Vesnarinone）：虽然可）：虽然可以在改善重度心衰患者短期生活质量，但以在改善重度心衰患者短期生活质量，但死亡率呈剂量依赖性增加，可能与心律失死亡率呈剂量依赖性增加，可能与心律失常有关。常有关。心力衰竭治疗近况10/14/202251非洋地黄类正性肌力药应用要点非洋地黄类正性肌力药应用要点z不主张对慢性心衰长期、间歇静滴不主张对慢性心衰长期、间歇静滴z35天的短期支持：等待心脏移植者、心脏手术天的短

46、期支持：等待心脏移植者、心脏手术后、难治性心衰后、难治性心衰z推荐用量推荐用量y多巴酚丁胺：多巴酚丁胺：25g/min/Kg（615mg/h）y米力农：负荷量米力农：负荷量50g/min/Kg，继以，继以0.3750.75 g/min/Kg 维持维持心力衰竭治疗近况10/14/202252血管扩张剂血管扩张剂心力衰竭治疗近况10/14/202253血管扩张剂的使用要点血管扩张剂的使用要点(1)(1)各种病因所致慢性心衰，在血容量正常，静脉各种病因所致慢性心衰，在血容量正常，静脉回流充足前提下，都可应用血管扩张剂。回流充足前提下，都可应用血管扩张剂。(2)(2)初始剂量宜小，逐渐增至最大耐受量，

47、以达到初始剂量宜小，逐渐增至最大耐受量，以达到最佳临床效果。最佳临床效果。(3)(3)某些某些血管扩张药物可致体液潴留，应加利尿剂血管扩张药物可致体液潴留，应加利尿剂或醛固酮拮抗剂。或醛固酮拮抗剂。(4)(4)不宜突然停药，以防反应性血管收缩不宜突然停药，以防反应性血管收缩(5)(5)目前常用者为硝酸盐类，可减轻肺淤血和心肌目前常用者为硝酸盐类，可减轻肺淤血和心肌缺血，但对生存率未证明有益缺血，但对生存率未证明有益心力衰竭治疗近况10/14/202254抗心律失常药抗心律失常药心力衰竭治疗近况10/14/202255心衰伴心律失常的治疗要点心衰伴心律失常的治疗要点z无症状、非持续心律失常不用无症状、非持续心律失常不用z持续性持续性VT、Vf、猝死复苏后、室上性心律、猝死复苏后、室上性心律失常伴快心室率者治疗原则：同非心衰失常伴快心室率者治疗原则：同非心衰z胺碘酮不增加总死亡率，需要用时首选，胺碘酮不增加总死亡率，需要用时首选，但不推荐用于预防，特别是已用但不推荐用于预防，特别是已用ACEI及及 受体阻滞剂者。受体阻滞剂者。I类、类、IV类原则上不用。类原则上不用。心力衰竭治疗近况10/14/202256