最新心力衰竭的现代药物治疗-药学医学精品资料.ppt

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1、最新心力衰竭的现代药物治疗-药学医学精品资料CHF-OutlineEpidemiologyPathophysiologyClinicalTrialsRAASblockersBetablockersHospitalizationRatesforCHFAge45-64and>65,U.S.,1971-1997Hospitalizations/100,000PopulationU.S.Population>65YearsOld02040608010060708090001020304016.625.63

2、1.134.975.6%oftotal9.211.312.512.720.7MillionsYear16.653.6CM876789-7CHFPathophysiologyCascadeMyocardialInjurySNSETRAASCardiacpeptidesHRContractilityVaso-constrictionNa,H20,retentionRAAS,ETNatriuresis,VasodilatationRA,PCW,CISVR,BPmyocytedea

3、th,cellproliferation&hypertrophyRA,PCWSVR,BPcellproliferationandhypertrophyCLINICALTRIALMETHODOLGYDouble-blind,placebo-controlledparallelcohortdesignClearendpoints:death,hospitalization,exercisecapacity,EFSamplesizeBaselinetherapyincludesproventhe

4、rapiesCHFPathophysiologyCascadeMyocardialInjurySNSETRAASCardiacpeptidesHRContractilityVaso-constrictionNa,H20,retentionRAAS,ETNatriuresis,VasodilatationRA,PCW,CISVR,BPmyocytedeath,cellproliferation&hypertrophyRA,PCWSVR,BPcellprolifera

5、tionandhypertrophyACEINHIBITIONACEIImpactonSurvivalSAVE*(n=1,115)ClassISOLVD*Prevention(n=2,111)ClassI-IISOLVD*Treatment(n=1,285)ClassII-IIICONSENSUS*(n=127)ClassIVPlaceboCaptoprilEnalapril*4-yearfollow-up**1-yearfollow-upPiefferetal:NEJM327:669-77,199

6、2CONSENSUSTrial:NEJM316:1429-35,1987SOLVDInvestigators:NEJM325:293-302,1991SOLVDInvestigators:NEJM327:685-91,1992ACEICrudeAnnualizedMortalityRates1-yrplacebo1-yrmortalityTrialAgentNYHAnmortality(%)decrease(%)CONSENSUSenal42535231SOLVD-Rxenal1-325691521

7、SOLVD-Penal1-2422850TOTAL1-470501116Bristow,Circ,2000ACEI-ClinicalPointsHighdose-nomortalitybenefitandsmallincrementalreductioninhospitalizationrateRECOMMENDATION:Use“Standard”proventargetdoseofACEI(eg,Enalapril10mgB.I.D.)andaddBetaBlockerACEIinCHF:Sum

8、maryReducedmortality/morbidityinallclassesofCHFExtensivelyandrigorouslystudiedinmultiplecontrolledtrialsusingdifferentACEI’sandshowingconsistentbenefitsANGIOTENSIN-IIRECEPTORBLOCKERSAngiotensinIAngiotensinogen(Liver)AT1AT2AngiotensinIIA