急性心衰治疗若干进展PPT课件

急性心力衰竭药物治疗的若干进展 2011 4 内容 ASCEND HFDOSE 急性失代偿性心衰的预后 Medianlengthofhospitalstay 6daysHospitalreadmissionsHospitalreadmissions 20 at30days20 at30days 50 at6months50 at6monthsMortalityMortality 11 6 at30days11 6 at30days 33 1 at12months 50 at5years50 at5years RevCardiovascMed 2002 3 suppl4 ArchInternMed 2002 162InternMed 2002 162 Acuteheartfailurewithsystolicdysfunction Furosemide Vasodilator SBP 100mmHg SBP85 100mmHg SBP 85mmHg Vasodilator NTG SPN BNP Vasodilatorand orinotropic dobutamine PDEIorlevosimendan inotropicand orDopamine 5ug kg min Noresponse Reconsidermechanistictherapyinotropicagents Goodresponse OraltherapyACEI ESC2005急性心衰诊断和治疗指南 ADHF的药物治疗终于取得了一些进展 在过去30年中 急性失代偿性心衰 ADHF 的药物治疗几乎没有进展ADHF治疗新药乏善可陈在不同医院和不同医生之间利尿剂的应用剂量和应用方式均大相径庭 缺乏安全性和有效性的高质量研究终于有些进展ASCEND HF AHA2010 DOSE最新结果 NEnglJMed3月3号在线 奈西立肽 Nesiritide 人类BNP 一种激素样物质 除扩张动脉和静脉外 还可促进利钠利尿降低患者左室充盈压和呼吸困难程度 缓解症状FDAapproved2001 TheEffectsofNesiritideonNeurohormones Inpatientswithevidenceofseverelysymptomaticfluidoverloadintheabsenceofsystemichypotension vasodilatorssuchasintravenousnitroglycerin nitroprussideorneseritidecanbebeneficialwhenaddedtodiureticsand orinthosewhodonotrespondtodiureticsalone TheHospitalizedPatient SevereSymptomaticFluidOverload New AReportoftheACCF AHATaskForceonPracticeGuidelines BNP可用于治疗急性心衰 患者的体征为肺充血 水肿 BP 90mmHg静注BNP时 其输注速率从0 015到0 03ug kg min均可 无论开始是否进行负荷推注 2ug kg 不推荐和其他静注血管扩张剂联用 ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure2008 5个研究的荟萃分析 奈西立肽对肾功能影响 Control n N Nesiritide n N study 肾功能恶化的定义 SCr 0 5mg dL Circulation 2005 111 1487 1491 MortalityWithin30DaysofTreatmentAssociatedWithNesiritideorControlTherapyWithOverallRiskRatioCalculatedbyMantel HaenszelTestUsingaFixed EffectsModel Sackner Bernstein J D etal JAMA2005 293 1900 1905 Copyrightrestrictionsmayapply 荟萃3个小规模试验 NSGETVMACPROACTION ASCEND HF奈西立肽治疗失代偿性心衰患者临床疗效的短期研究 DukeHeartFailureResearchPager 970 0736 NHLBIHeartFailureClinicalResearchNetwork BaylorDukeHarvardMayoClinicMinnesotaMontrealMorehouseUtahVermont Purpose 在常规治疗基础上 通过双盲安慰剂对照研究评价奈西立肽对于急性代偿性心衰患者的疗效和安全性 Doubleblindedstudymeaningsubjects MD andresearchteamareunawareofwhattreatmentisbeingreceived 入选标准 静息时呼吸困难肺淤血 入院24小时内存在心衰的症状和体征 Interventions USEOFOPENLABELNESIRITIDEISNOTALLOWEDATANYTIME Whyisthisstudybeingdone DoesNesiritidedecreasere hospitalizationordeathin30days DoesNesiritidedecreasesymptomsofdyspneaat6and24hrsafterdruginitiated 复合主要终点 NursingRoles 在治疗6小时和24小时填写问卷表 和VAS量表问卷表和VAS量表内容包括 自我评价呼吸困难程度健康状态 一般情况 自我护理能力 疼痛 抑郁 体力7级评定 Foundinpatient schartbox 30天复合终点 30天复合终点的亚组分析 肾脏安全性 对ASCEND HF评价 ASCEND HF研究澄清了既往质疑 证实奈西立肽安全ASCEND HF研究在给药方案上可能存在问题 由于奈西利肽的有效半衰期比硝酸甘油和硝普钠长 因此其副作用的持续时间可能较长 低血压的发生率相对高采用保守 即无负荷量 和推荐剂量治疗可减少并发症 内容 ASCEND HFDOSE DiureticsandHeartFailure Diureticsaremainstayoftherapyforacuteheartfailure givento 90 ofptsinADHERE RelievesymptomsofdyspneaandedemainmostpatientsAssociatedwithvarietyofproblems ElectrolyteabnormalitiesActivationofRAASandSNSDiureticresistanceIncreasedmortality DiureticsandPCWP Circulation 1986 74 1303 1306 速尿静推40 100mg 强心 Ifpatientsarealreadyreceivingloopdiuretictherapy theinitialintravenousdoseshouldequalorexceedtheirchronicoraldailydose LevelofEvidence C TheHospitalizedPatient TreatmentWithIntravenousLoopDiuretics New AReportoftheACCF AHATaskForceonPracticeGuidelines TheHospitalizedPatient IntensifyingtheDiureticRegimen New Whendiuresisisinadequatetorelievecongestion asevidencebyclinicalevaluation thediureticregimenshouldbeintensifiedusingeither a higherdosesofloopdiuretics b additionofaseconddiuretic suchasmetolazone spironolactoneorintravenouschlorthiazide orc Continuousinfusionofaloopdiuretic AReportoftheACCF AHATaskForceonPracticeGuidelines 急性心衰患者利尿剂使用的指征及剂量 DiureticOptimizationStrategiesEvaluationinAcuteHeartFailure DOSE G MichaelFelker MD MHS FACCChristopherM O Connor MD FACConbehalfoftheNHLBIHeartFailureClinicalResearchNetwork 利尿剂优化策略治疗急性心衰评价 ACC2010NEnglJMed2011 364 797 805 Aims ToevaluatethesafetyandefficacyofvariousinitialstrategiesoffurosemidetherapyinpatientswithADHFRouteofadministration Q12hoursbolusContinuousinfusionDosingLowintensification 过去日剂量 Highintensification 过去日剂量的2 5倍 ACC2010NEnglJMed2011 364 797 805 允许48hr后根据患者临床反应调整治疗方案 AcuteHeartFailure 1symptomAND1sign 24hoursafteradmission308例 2x2factorialrandomization LowDose 1xoral Q12IVbolus 48hours 1 Changetooraldiuretics2 continuecurrentstrategy3 50 increaseindose Co primaryendpoints HighDose 2 5xoral Q12IVbolus LowDose 1xoral Continuousinfusion HighDose 2 5xoral Continuousinfusion 72hours StudyDesign Clinicalendpoints 60days 主要终点 主要疗效终点 基线至72h内患者对症状的总体自评次要疗效终点呼吸困难 体重变化 体液净损失 受充血影响的患者比例 肾功能恶化 心力衰竭恶化 PatientGlobalAssessmentVASAUC Q12vs Continuous PtGlobalAssessmentbyVAS Q12VASAUC mean SD 4236 1440 ContinuousVASAUC mean SD 4373 1404 P 0 47 Q12 Continuous Hours ACC2010NEnglJMed2011 364 797 805 PatientGlobalAssessmentVASAUC Lowvs HighIntensification Hours PtGlobalAssessmentbyVAS Low High LowVASAUC mean SD 4171 1436 HighVASAUC mean SD 4430 1401 P 0 06 ACC2010NEnglJMed2011 364 797 805 SecondaryEndpoints Lowvs HighIntensification ACC2010NEnglJMed2011 364 797 805 死亡 心衰再住院或再进急诊室的复合终点两种给药方式 两种剂量的比较 NEnglJMed2011 364 797 805 ChangeinCreatinineat72hours Q12Continuous p 0 45 p 0 21 0 05 0 07 0 04 0 08 0 0 05 0 1 0 15 ChangeinCreatinine mg dL LowHigh ACC2010NEnglJMed2011 364 797 805 对D