さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

[復習]拡張期心不全の治療

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. 

 

Management of patients with diastolic heart failure
Control edema
  • Low salt diet (eg, <2 g sodium per day)
  • Diuretic (eg, furosemide or hydrochlorothiazide)
  • ACE inhibitor* (eg, enalapril or lisinopril)
  • Angiotensin II receptor blocker* (eg, candesartan, valsartan, or losartan)
  • Aldosterone antagonist* (eg, spironolactone)
Rate control
  • Calcium channel blocker (eg, diltiazem or verapamil)
  • Beta blocker (eg, atenolol, metoprolol)
  • Radiofrequency modification of atrioventricular node and pacing
Maintain and restore atrial contraction
  • Cardioversion
  • Radiofrequency ablation
  • Antiarrhythmic therapy
Manage myocardial ischemia
  • Medical management
    • Nitrates (eg, isosorbide dinitrate or isosorbide mononitrate)
    • Beta blocker (eg, atenolol or metoprolol)
    • Calcium channel blocker (eg, diltiazem or verapamil)
  • Percutaneons coronary intervention
  • Coronary artery bypass surgery
Control arterial hypertension
  • Diuretic (eg, chlorthalidone or hydrochlorothizide)
  • Beta blocker (eg, atenolol or metoprolol)
  • Calcium channel blocker (eg, amlodipine or felodipine)
  • Angiotensin converting enzyme inhibitor (eg, enalapril or lisinopril)
  • Angiotensin II receptor blocker (eg, candesartan, valsartan, or losartan)
* The renin-angiotensin-aldosterone system is inhibited by angiotensin converting enzyme inhibitor, angiotensin II receptor blocker, and aldosterone antagonist and thus these agents have a theoretical benefit in promoting regression of left ventricular hypertrophy and preventing myocardial fibrosis. However more data are required to demonstrate whether they improve outcomes in patients with diastolic heart failure. Two of these three agents may be combined in some patients with proper monitoring but use of all three is generally not recommended.
¶ The list of medications is not comprehensive but rather includes examples that are in common clinical use or have been included in studies of patients with diastolic dysfunction or heart failure. A more exhaustive list of antihypertensive agents can be found in the guidelines of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Courtesy of Dr. William H. Gaasch.       Graphic 51637 Version 6.0
 
重要なガイドライン (free) として、
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.
www.ncbi.nlm.nih.gov 
 
2003年の8試験メタアナ
A meta-analysis of the effects of treatment on left ventricular mass in essential hypertension.

www.ncbi.nlm.nih.gov

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).

 

ちなみに、ジゴシンは拡張期心不全に対して、一般的に使用しませんが

N Engl J Med. 1997 Feb 20;336(8):525-33.という、有名な論文があります。

ジゴシンも捨てたもんじゃないっと

www.ncbi.nlm.nih.gov

 

Circulation. 2006 Aug 1;114(5):397-403. こちらも押さえる論文ですね。

www.ncbi.nlm.nih.gov

 

 

心不全の疫学

拡張期心不全の病態生理

 

akinohanayuki.hatenablog.com