ACEI心衰治疗.ppt

1、a,1,心肌梗死 EF40% ACE inhibitor treated/not treated,Primary outcome for Overall Programme: All-cause death,Primary outcome for each trial: CV death or CHF hospitalisation,a,18,CHARM-Alternative Trial,Median follow-up of 33.7 months,Candesartan n=1013,Placebo n=1015,Completed Study n=1011,Completed Stud

2、y n=1014,Lost to follow-up n=2,Lost to follow-up n=1,2028 patients randomised NYHA IIIV, LVEF 40% ACE inhibitor intolerant,a,19,CHARM-Alternative: Primary outcome 心血管死亡和心衰住院率,Number at risk Candesartan 1013 929 831 434 122 Placebo 1015 887 798 427 126,a,20,CHARM-Added Trial,Median follow-up of 41 mo

3、nths,Candesartan n=1276,Placebo n=1272,Completed Study n=1273,Completed Study n=1271,Lost to follow-up n=3,Lost to follow-up n=1,2548 patients randomised NYHA IIIV, LVEF 40% ACE inhibitor treated,a,21,CHARM-Added: Primary outcome 心血管死亡和心衰住院率,Number at risk Candesartan 1276 1176 1063 948 457 Placebo

4、1272 1136 1013 906 422,a,22,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,a,23,Standard post-AMI care ASA, BB, ACEI, statin, revascula

5、rization,急性心肌梗死后(314 d), LVEF 40, rales or S3,Randomization (n=6642),Eplerenone initiation (n=3319) 25 mg qd, 50 mg at 4 wk,Matching placebo (n=3313),Follow-up (16 month),依普利酮急性心肌梗死后心力衰竭的效益和生存研究（EPHESUS）,Pitt B, et al. N Engl J med 2003;348(14):13091321,a,24,EPHESUS：主要终点事件,Pitt B, et al. N Engl J me

6、d 2003; 348(14):13091321,a,25,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,a,26,Evidences from systematic overview of trials on early ACEI after Myocardial Infarction,ACE Inhibitor Myocardial Infarction

7、 Collaborative Group Circulation 1998; 97: 22022212,a,27,a,28,a,29,Effect of ACE-inhibitor therapy on cumulative mortality during days 0 to 30,a,30,AMI早期ACE抑制剂降低死亡率的绝对效益 （非选择性患者，n=98 496）,a,31,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.

8、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）,a,32,CCS-1：早期与远期病死率（%）,与安慰剂组比较，* p=0.05, * p=0.02,a,33,AIRE (Acute Infarction Ramipril Effic

9、acy),Lancet 1993; 342(8875): 821-828,Ramipril（n=1014） 2.55mg bid,a,34,Evidence from early and late trials overviews Early approach of an unselected population of AMI patients 5 lives saved per 1000 p=0.004 6 nonfatal CHF per 1000 p=0.01 followed by a Late treatment of the patients with LV dysfunctio

10、n/heart failure 44 lives saved per 1000 p0.0001 20 reAMI saved per 1000 p=0.0004,心肌梗死后ACE抑制剂效益汇总分析,a,35,UA P = 0.982,Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726,a,48,VALIANT: Adverse Experience Leading to Study Drug Discontinuation,a,49,VALIANT: Conclusion,In ptients with MI complicate

11、d by heart failure, left ventricular dysfunction or both: Valsartan is as effective as a proven dose of captopril in reducing the risk of: Death CV death or nonfatal MI or heart failure admission In these patients, valsartan is a clinically effective alternative to an ACE inhibitor Combining valsartan with captopril produced no further reduction in mortalityand more adverse