ACEI心衰治疗

.,心肌梗死EF40%ACEinhibitortreated/nottreated,PrimaryoutcomeforOverallProgramme:All-causedeath,Primaryoutcomeforeachtrial:CVdeathorCHFhospitalisation,.,CHARM-AlternativeTrial,Medianfollow-upof33.7months,Candesartann=1013,Placebon=1015,CompletedStudyn=1011,CompletedStudyn=1014,Losttofollow-upn=2,Losttofollow-upn=1,2028patientsrandomisedNYHAIIIV,LVEF40%ACEinhibitorintolerant,.,CHARM-Alternative:Primaryoutcome心血管死亡和心衰住院率,NumberatriskCandesartan1013929831434122Placebo1015887798427126,.,CHARM-AddedTrial,Medianfollow-upof41months,Candesartann=1276,Placebon=1272,CompletedStudyn=1273,CompletedStudyn=1271,Losttofollow-upn=3,Losttofollow-upn=1,2548patientsrandomisedNYHAIIIV,LVEF40%ACEinhibitortreated,.,CHARM-Added:Primaryoutcome心血管死亡和心衰住院率,NumberatriskCandesartan127611761063948457Placebo127211361013906422,.,CHARM试验的临床意义,ARB用于慢性收缩性心力衰竭患者是有效的康得沙坦显著降低心血管病死亡和病残联合终点事件发生率总死亡率未能显著降低，提示疗效不如ACE抑制剂ARB作为心力衰竭治疗二线药物（替代）的地位得到确立ARB和ACE抑制剂合用有相加的效益康得沙坦显著降低心血管病死亡和病残联合终点事件发生率ARB、ACE抑制剂和-阻滞剂三药合用可能是安全的已用ACE抑制剂和-阻滞剂的患者是否加ARB，仍需研究,.,Standardpost-AMIcareASA,BB,ACEI,statin,revascularization,急性心肌梗死后(314d),LVEF40,ralesorS3,Randomization(n=6642),Eplerenoneinitiation(n=3319)25mgqd,50mgat4wk,Matchingplacebo(n=3313),Follow-up(16month),依普利酮急性心肌梗死后心力衰竭的效益和生存研究（EPHESUS）,PittB,etal.NEnglJmed2003;348(14):13091321,.,EPHESUS：主要终点事件,PittB,etal.NEnglJmed2003;348(14):13091321,.,ACE抑制剂治疗心力衰竭新动态,ACE抑制剂是治疗慢性心力衰竭的基石和首选药物慢性收缩性心力衰竭的标准治疗，就是ACE抑制剂单用或加用利尿剂，心功能级的患者加用-受体阻滞剂，地高辛可合用也可不用。能耐受ACE抑制剂的患者不宜用ARB取代醛固酮拮抗剂有望成为第三类神经激素拮抗药,.,EvidencesfromsystematicoverviewoftrialsonearlyACEIafterMyocardialInfarction,ACEInhibitorMyocardialInfarctionCollaborativeGroupCirculation1998;97:22022212,.,.,.,EffectofACE-inhibitortherapyoncumulativemortalityduringdays0to30,.,AMI早期ACE抑制剂降低死亡率的绝对效益（非选择性患者，n=98496）,.,卡托普利早期应用对心肌梗死患者远期病死率的影响：中国心脏研究-远期随访报告,CCS-1入选的AMI（发病36h内）患者卡托普利（12.5mg，3次/d）或安慰剂治疗4周随访7079例：平均随访23.316.9月（192个月）与安慰剂组（n=3525）相比，卡托普利组（n=3554）累计总死亡率降低10.6%（16.0%:17.9%,p=0.03）累计心血管病死亡率降低11.4%（14.7%:16.6%,p=0.03）累计心力衰竭死亡率降低25.0%（4.5%:6.0%,p=0.004）结论：AMI患者早期接受卡托普利治疗4周，能显著降低长期死亡率（每治疗1000例，2年中累计可救命19人）,.,CCS-1：早期与远期病死率（%）,与安慰剂组比较，*p=0.05,*p=0.02,.,AIRE(AcuteInfarctionRamiprilEfficacy),Lancet1993;342(8875):821-828,Ramipril（n=1014）2.55mgbid,.,EvidencefromearlyandlatetrialsoverviewsEarlyapproachofanunselectedpopulationofAMIpatients5livessavedper1000p=0.0046nonfatalCHFper1000p=0.01followedbyaLatetreatmentofthepatientswithLVdysfunction/heartfailure44livessavedper1000p0.000120reAMIsavedper1000p=0.0004,心肌梗死后ACE抑制剂效益汇总分析,.,UAP=0.982,Valsartan+Captoprilvs.Captopril:HR=0.98;P=0.726,.,VALIANT:AdverseExperienceLeadingtoStudyDrugDiscontinuation,.,VALIANT:Conclusion,InptientswithMIcomplicatedbyheartfailure,leftventriculardysfunctionorboth:Valsartanisaseffectiveasaprovendoseofcaptoprilinreducingtheriskof:DeathCVdeathornonfatalMIorheartfailureadmissionInthesepatients,valsartanisaclinicallyeffectivealternativetoanACEinhibitorCombiningvalsartanwithcaptoprilproducednofurtherreductioninmortalityandmoreadversedrugevents,.