拡張期心不全の治療についてですね。毎度ながら、Up To Date (本日) を再度確認。
In patients with diastolic heart failure (DHF), certain types of hemodynamic stress including atrial fibrillation; tachycardia; abrupt, severe, or refractory elevations in systemic blood pressure, and myocardial ischemia are associated with worsening of diastolic dysfunction.
The treatment of DHF remains empiric since trial data are limited. The general principles for treatment of DHF are control of systolic and diastolic hypertension, control of heart rate, particularly in patients with atrial fibrillation, control of pulmonary congestion and peripheral edema with diuretics, and coronary revascularization in patients with coronary heart disease with ischemia judged to impair diastolic function.
An important caveat is that the patient who has left ventricular (LV) diastolic dysfunction with a small, stiff LV chamber is particularly susceptible to excessive preload reduction, which can lead sequentially to underfilling of the LV, a fall in cardiac output, and hypotension. In patients with severe LV hypertrophy due to hypertension or hypertrophic cardiomyopathy, excessive preload reduction can also create subaortic outflow obstruction. For these reasons, the diuretics or venodilators such as nitrates and dihydropyridine calcium channel blockers must be administered with caution.
Restoration and maintenance of sinus rhythm is preferred when atrial fibrillation occurs in patients with DHF. When this cannot be achieved, rate control becomes important.
Direct evidence to support a specific drug regimen to treat DHF is lacking.
Asymptomatic LV diastolic dysfunction is a predictor of future cardiovascular morbidity. Symptomatic patients with DHF experience morbidities (eg, hospitalization for HF) at a rate that is virtually the same as that seen in patients with systolic HF. Mortality rates in both DHF and systolic HF are high; published data on differences in mortality rates are conflicting.
2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension.
Eighty trials with 146 active treatment arms (n = 3767 patients) and 17 placebo arms (n = 346 patients)
left ventricular mass index decreased
13% with angiotensin II receptor antagonists (95% confidence interval [CI]: 8% to 18%),
11% with calcium antagonists (95% CI: 9% to 13%)
10% with ACE inhibitors (95% CI: 8% to 12%)
8% with diuretics (95% CI: 5% to 10%)
6% with beta-blockers (95% CI: 3% to 8%)
In pairwise comparisons, angiotensin II receptor antagonists, calcium antagonists, and ACE inhibitors were more effective at reducing left ventricular mass than were beta-blockers (all P <0.05 with Bonferroni correction).
N Engl J Med. 1997 Feb 20;336(8):525-33.という、有名な論文があります。
Circulation. 2006 Aug 1;114(5):397-403. こちらも押さえる論文ですね。