ACEI心衰治疗

1、心肌梗死 ef40%; nyha iiiv,906例死亡（记录事件）,缬沙坦40 mg bid， 上调至160 mg bid,安慰剂,随机分组,接受常规治疗包括ace抑制剂、利尿剂、地高辛、 -阻滞剂（分层随机）,val-heft 试验设计,val-heft：主要终点分析,val-heft试验：亚组分析,亚组 例数 相对危险,combined end point ace inhibitor+,beta-blocker- 3034 ace inhibitor+,beta-blocker+ 1610 ace inhibitor-, beta-blocker- 226 ace inhibitor-,

2、 beta-blocker+ 140 death ace inhibitor+,beta-blocker- 3034 ace inhibitor+,beta-blocker+ 1610 ace inhibitor-, beta-blocker- 226 ace inhibitor-, beta-blocker+ 140,0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9,arb在心力衰竭治疗中的应用要点（中华医学会心血管病学分会 中华心血管病杂志编辑委员会）,arb治疗心力衰竭有效，但未证实相当于或是优

3、于ace抑制剂 未应用过ace抑制剂的患者不应先用arb 能耐受ace抑制剂的患者不宜用arb取代 arb可用于不能耐受ace抑制剂的患者 arb与ace抑制剂相同，亦能引起低血压、高血钾及肾功能损害恶化,中华心血管病杂志 2002, 30(1):7-23,candesartan in heart failure assessment of reduction in mortality and morbidity,charm,pfeffer ma, et al. lancet 2003, 362(9386):759781,charm programme,charm 相加组,charm保留组,3

4、 component trials comparing candesartan to placebo in patients with symptomatic heart failure,charm替换组,n=2028 lvef 40%ace inhibitor intolerant,n=2548 lvef 40%ace inhibitor treated,n=3025 lvef 40%ace inhibitor treated/not treated,primary outcome for overall programme: all-cause death,primary outcome

5、for each trial: cv death or chf hospitalisation,charm-alternative trial,median follow-up of 33.7 months,candesartan n=1013,placebo n=1015,completed study n=1011,completed study n=1014,lost to follow-up n=2,lost to follow-up n=1,2028 patients randomised nyha iiiv, lvef 40%ace inhibitor intolerant,cha

6、rm-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,charm-added trial,median follow-up of 41 months,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 pa

7、tients randomised nyha iiiv, lvef 40%ace inhibitor treated,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 1272 1136 1013 906 422,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

8、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,standard post-ami care asa, bb, acei, statin, revascularization,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),fol

9、low-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,ephesus：主要终点事件,pitt b, et al. n engl j med 2003; 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

10、三类神经激素拮抗药,evidences from systematic overview of trials on early acei after myocardial infarction,ace inhibitor myocardial infarction collaborative group circulation 1998; 97: 22022212,effect of ace-inhibitor therapy on cumulative mortality during days 0 to 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）,

11、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

12、，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 (acute infarction ramipril efficacy),lancet 1993; 342(8875): 821-828,ramipril（n=1014） 2.55mg bid,evidence from early and late trials overviews early approach of an unselected population of ami patients 5 lives saved per 1000p=0.004 6 n

13、onfatal chf per 1000p=0.01 followed by a late treatment of the patients with lv dysfunction/heart failure 44 lives saved per 1000p0.0001 20 reami saved per 1000p=0.0004,心肌梗死后ace抑制剂效益汇总分析,ua p = 0.982,valsartan + captopril vs. captopril: hr = 0.98; p = 0.726,valiant: adverse experience leading to stu

14、dy drug discontinuation,valiant: conclusion,in ptients with mi complicated 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 reducti