心力衰竭药物治疗新证据与新视野.ppt

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1、心力衰竭药物治疗新证据与新视野李勇复旦大学附属华山医院心脏科上海200040治疗心力衰竭的药物1、强心苷类药物2、利尿剂3、ACE抑制剂及血管紧张素II（AT1）受体拮抗剂4、受体阻断剂5、其他治疗CHF的药物：（1）钙拮抗剂（2）磷酸二酯酶抑制剂（3）其他血管扩张剂：长效硝酸酯类，肼苯哒嗪DIG研究50403020100Placebon=3403Digoxinn=3397480122436Mortality%NEnglJMed1997;336:525Monthsp=0.8DigitalisN=6800NYHAII-III0.6Proba

2、bilityofDeath0Placebo(273)Prazosin(183)Hz+ISDN(186)Months0.70.50.30.40.20.1NEnglJMed1986;314:1547Nitrates06121824303642V-HeFT-I研究combinationofhydralazine(300mg/day)andisosorbidedinitrate(160mg/day23%reductioninmortalityPlaceboEnalapril12111098765ProbabiilityofDeathMonths0.

3、10.800.20.30.70.40.50.6p<0.001p<0.002NEnglJMed1987;316:142943210CONSENSUS研究253patientswithclassIVheartfailureEnalapril：2.5-40mg/day31%reductioninmortality50403020100Months0612p=0.0036%Mortality241830364248Enalapriln=1285Placebon=1284NEnglJM1991;325:293n=2589CHF-NYHAII-III-

4、EF<35SOLVD(Treatment)研究11.3%reductioninmortality0,540,480122448600.750.500.2500.470.360.250.130.090.310.180.4236Monthsp=0.08NEnglJMed1991;325:303EnalaprilHZ+ISDNn=804p=0.016ProbabilityofdeathNitrate+HydralazineVsEnalaprilV-HeFTII研究YearsProbabilityofEvent00.050.10.150.20.25

5、0.301230.350.44ACE-IPlaceboACE-I299522501617892223Placebo297121841521853138FlatherMD,etal.Lancet.2000;355:1575–1581OR:0.74(0.66–0.83)ACE-I:702/2995(23.4%)Placebo:866/2971(29.1%)TRACEEchocardiographicEF£35%AIREClinicaland/orradiographicsignsofHFSAVERadionuclideEF£40%卡维地洛n

6、=696安慰剂n=398存活天050100150200250300350400危险度下降=65%p<0.001Packeretal(1996)CIBIS-IIInvestigators(1999)比索洛尔安慰剂接收后的时间(天)p<0.0001存活危险度下降=34%TheMERIT-HFStudyGroup(1999)美国卡维地洛计划CIBIS-II0.81.00.60随访月03691215182120151050安慰剂美托洛尔CRp=0.0062危险度下降=34%MERIT-HF月003691215182110090806070卡维地洛安

7、慰剂危险度下降=35%存活Packeretal(2001)哥白尼（COPERNICUS）研究p=0.000130.50.60.70.80.91.00200400600800死亡率(%)AldactonePlaceboSurvival1.00.90.80.70.60.5061218243036monthsp<0.0001AnnualMortalityAldactone18%;Placebo23%RR－21.7%N=1663NYHAIII-IVMeanfollow-up2yNEJM1999;341:709SpironolactoneRALES研

8、究心力衰竭药物治疗AsymptomaticMildtomoderateModerateLVdysfunctionCHFtosevereCHFACEinhibitorDigoxin