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題 名 | 實證醫學慢性心臟衰竭的治療指引=Evidence-Based Therapeutic Guidelines of Chronic Heart Failure |
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作 者 | 胡為雄; | 書刊名 | 中華民國重症醫學雜誌 |
卷 期 | 6:1 民93 |
頁 次 | 頁56-71 |
分類號 | 415.319 |
關鍵詞 | 實證醫學; 心臟衰竭; 治療; Evidence-based; Heart failure; Therapy; |
語 文 | 中文(Chinese) |
中文摘要 | 慢性心臟衰竭是工業國家人民健康的最大威脅之一。慢性心臟衰竭的形成及進展,現在已視為是血行力學及神經激素機轉共同導致的結果。 最近,經由一些設計良好的隨機臨床研究評估各種治療對發病及死亡的影響後,治療上確有重要進展。按照心機衰竭四個不同階段各有不同的治療策略;第一階段確認會形成心臟衰竭的高危險群,雖仍無器質性心疾患者,第二階段是已有器質性心疾但還未有心臟衰竭症狀者,第三階段是器質性心疾患者,曾有或現有心臟衰竭症狀,第四期是指心臟衰竭末期患者需要特殊的治療策略,如機械性的循環支撐,連續強心劑滴注,心臟移植或安寧療護。 藥物治療已有許多隨機抽樣並有對照組的研究報告。血管張力素轉換酶抑制劑已證實在充血性心臟衰竭而有收縮功能異常患者,當服用適當劑量皆有益處。β阻斷劑對生活品質及存活皆有益處。Spironolactone對嚴重充血性心臟衰竭患者可加入治療。對血管張力素轉換酶抑制劑無法耐受的患者,可以II型血管張力素接受體拮抗劑取代。已有很多證據顯示純強心劑的期給予是有害的,且無法降低死亡率,此類藥物現在只適用於急性發作的心臟衰竭失償時的短期給予。Digoxin是唯一不會增加死亡率的強心劑。至於血管張劑,只有併用hydralazine及isosorbide dinitrate經證實可有效地減輕症狀及增進存活。利尿劑適用於體液貯留及減輕充血徵候及症狀,然而仍無利尿劑用於充血性心臟衰竭的長期研究,因此尚無證實能降低死亡率的有利報告。 很明顯地並非所有充血性心臟衰竭藥物治療的推薦皆有堅強的實證依據。非藥物治療部份的推薦,如血管重建、二尖瓣膜手術、心肌成形術、心臟移植及心室轉助器皆是依專家及臨床經驗的協商陳述。 |
英文摘要 | Chronic heart failure (CHF) is one of the most important threats to health in industrialized countries. The development and progression of heart failure (HF) is now viewed as resulting from the interplay of hemodynamic and neurohormonal mechanisms. More recently, important advances in therapy have been made, based on the results of well-designed randomized clinical trial (RCTs) that assessed the effects of various treatment on morbidity and mortality. Different therapeutic strategies are recommended according to 4 different stage of CHF: Stage A identities the patient who is at high risk for developing HF but has no structural disorder of the heart. Stage B refers to a patient with a structural disorder of the heart but who has never developed symptoms of HF. Stage C denotes the patient with past or current symptoms of HF associated with underlying structural heart disease, and Stage D designates the patient with end-stage disease who requires specialized therapeutic strategies such as mechanical circulatory support, continuous inotropic infusion, cardiac transplantation or hospice care. Drug intervention has been subjected to numerous RCTs. Angiotensin-converting enzyme inhibitors (ACE-I) are of demonstrated benefit in all forms of CHF with systolic dysfunction when used at optimal doses. Beta-blockers confer additional quality of life and survival benefits. Spironolactone may be added in patients with severe CHF. In patients who are intolerant of ACE-O, angiotensin II receptor blockers may be useful as a substitute. There are several lines of evidence that long term prescription of agents that act purely as inotropes is probably deleterious, and dose not reduce mortality, this class of drugs should now be considered most suitable for short-term use in acute episodes of decompensated HF. Digoxin emerges as the only inotropic drug that dose not increase mortality. With regard to vasodilators, only the combination of hydralazine with isosorbide dinitrate has been shown to be effective in reducing symptoms and improving survival. Diuretics are indicated for fluid retention and relief of congestive signs and symptoms. However, there are no long term studies of siuretics in CHF, and there is therefore no proven mortality benefit. It is clear that not all recommendations for pharmacotherapy in CHF are based on strong evidence. The place of a number of treatment options remains to be firmly established. Recommendations for nonpharmacological approaches of CHf, such as the case with revascularization, mitral valve surgery, cardiomyoplsty, heart transplantation and ventricular assist devices are all based on consensus statements from experts and clinical experience. |
本系統中英文摘要資訊取自各篇刊載內容。