心力衰竭患者的 安全用药心力衰竭患者的 安全用药刘凡刘凡 河北医科大学第二医院河北医科大学第二医院河北省心血管病论坛2008 暨心血管安全用药?药物种类药物种类 ?使用剂量使用剂量 ?选择途径选择途径 ?相互作用相互作用安全用药是临床工作最重要安全用药是临床工作最重要的主题的主题河北省心血管病论坛2008 暨心血管安全用药心力衰竭患者的安全用药心力衰竭患者的安全用药心力衰竭有关问题心力衰竭有关问题 利尿剂的安全应用利尿剂的安全应用 洋地黄的安全应用洋地黄的安全应用河北省心血管病论坛2008 暨心血管安全用药Prevalence of HF by Age and Gender0246810Percent of Population20-2425-3435-4445-5455-6465-7475+Males FemalesUnited States: 1988-94Source: NHANES III (1988Source: NHANES III (1988- -94), CDC/NCHS and the American Heart Association94), CDC/NCHS and the American Heart Association河北省心血管病论坛2008 暨心血管安全用药OtherOtherDeathDeathn = 103n = 10312%12%24%24%64%64%CHFCHFOtherOtherSuddenSudden DeathDeathn = 103n = 103NYHA IINYHA II26%26%15%15%59%59%CHFCHFNYHA IIINYHA III56%56%11%11%33%33%CHFCHFOtherOtherSuddenSudden DeathDeathn = 27n = 27NYHA IVNYHA IVSuddenSuddenSeverity of Heart FailureSeverity of Heart Failure Modes of DeathModes of DeathMERITMERIT- -HF Study Group. Effect of HF Study Group. Effect of MetoprololMetoprolol CR/XL in chronic heart CR/XL in chronic heart failure: failure: MetoprololMetoprolol CR/XL randomized intervention trial in congestive CR/XL randomized intervention trial in congestive heart failure (MERITheart failure (MERIT- -HF). HF). LANCET. LANCET. 1999;353:20011999;353:2001- -07.07.河北省心血管病论坛2008 暨心血管安全用药成人慢性心力衰竭诊断与治疗指南 （成人慢性心力衰竭诊断与治疗指南 （ ACC/AHA 2001）定义：心脏器质性或功能性损害心室充盈和 射血能力引发的一组临床综合征。定义：心脏器质性或功能性损害心室充盈和 射血能力引发的一组临床综合征。 特征表现：症状（呼吸困难和疲乏）特征表现：症状（呼吸困难和疲乏）+体征 （液体潴留）。体征 （液体潴留）。 诊断依据：病史诊断依据：病史+物理检查。物理检查。 新主张：新主张：“心力衰竭心力衰竭”替代替代“充血性心力衰竭充血性心力衰竭”河北省心血管病论坛2008 暨心血管安全用药Class I:No symptoms with ordinary activity Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina Class III:Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain Class IV:Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency may be present even at restNew York Heart Association Functional Classification河北省心血管病论坛2008 暨心血管安全用药HF Classification: Evolution HF Classification: Evolution and Disease Progressionand Disease Progression?Four Stages of HF (ACC/AHA Guidelines): Stage A: Patient at high risk for developing HF with no structural disorder of the heart Stage B: Patient with structural disorder without symptoms of HF Stage C: Patient with past or current symptoms of HF associated with underlying structural heart disease Stage D: Patient with end-stage disease who requires specialized treatment strategies河北省心血管病论坛2008 暨心血管安全用药Treatment Approach for the Patient with Heart FailureTherapyTherapy All measures All measures under stages A,B, under stages A,B, and Cand C Mechanical assist Mechanical assist devicesdevices Heart Heart transplantationtransplantation Continuous (not Continuous (not intermittent) IV intermittent) IV inotropicinotropic infusions for infusions for palliationpalliation Hospice careHospice careStage AStage AAt high risk, no At high risk, no structural structural diseasediseaseStage BStage BStructural heart Structural heart disease, disease, asymptomaticasymptomaticStage DStage DRefractory HF Refractory HF requiring requiring specialized specialized interventionsinterventionsTherapyTherapy All measures All measures under stage Aunder stage A ACE inhibitors ACE inhibitors in appropriate in appropriate patientspatients BetaBeta- -blockers in blockers in appropriate appropriate patientspatientsTherapyTherapy All measures All measures under stage Aunder stage ADrugs:Drugs: DiureticsDiuretics ACE inhibitorsACE inhibitors BetaBeta- -blockersblockers DigitalisDigitalis Dietary salt Dietary salt restrictionrestrictionStage CStage CStructural heart Structural heart disease with disease with prior/current prior/current symptoms of HFsymptoms of HFTherapyTherapy Treat Treat HypertensionHypertension Treat lipid Treat lipid disordersdisorders Encourage Encourage regular exerciseregular exercise Discourage Discourage alcohol intakealcohol intake ACE inhibitionACE inhibition河北省心血管病论坛2008 暨心血管安全用药Treatment Approach for the Patient with Heart Failure河北省心血管病论坛2008 暨心血管安全用药诊治流程诊治流程河北省心血管病论坛2008 暨心血管安全用药The Donkey AnalogyLets compare our heart to this donkey, and our body to the wagon that this donkey has to pull every day.Ventricular dysfunction limits a patients ability to performVentricular dysfunction limits a patients ability to performthe routine activities of daily livingthe routine activities of daily living河北省心血管病论坛2008 暨心血管安全用药Diuretics, ACE InhibitorsReduce the number of sacks on the wagonReduce the number of sacks on the wagon河北省心血管病论坛2008 暨心血管安全用药Digitalis CompoundsLike the carrot placed in front of the donkeyLike the carrot placed in front of the donkey河北省心血管病论坛2008 暨心血管安全用药-BlockersLimit the donkeyLimit the donkey s spe