van Kraaij D J, Jansen R W, Gribnau F W, Hoefnagels W H
Department of Geriatric Medicine, University Hospital Nijmegen, The Netherlands.
Drugs Aging. 2000 Apr;16(4):289-300. doi: 10.2165/00002512-200016040-00005.
Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on diuretic withdrawal in elderly patients with heart failure are discussed, with emphasis on issues involved in decision making such as diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of diuretics in elderly patients with heart failure with normal and decreased left ventricular systolic function and in those with diastolic heart failure are also discussed. By reducing intravascular volume, diuretics may further impair ventricular diastolic filling in patients with diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.
尽管在无容量超负荷的情况下利尿剂并无指征，但在老年患者中，长期使用利尿剂治疗心力衰竭的情况却非常普遍，而且这种治疗策略的理论依据往往并不明确。老年舒张性心力衰竭的概念可能会特别改变利尿剂治疗的作用，因为利尿剂在这些患者中可能会产生额外的不良反应。本文综述了利尿剂治疗对老年心力衰竭患者的影响，重点强调了左心室收缩功能正常和降低的患者之间的差异。文中讨论了老年心力衰竭患者停用利尿剂的研究，重点关注决策过程中涉及的问题，如老年患者利尿剂剂量的减少和停用，以及已确定的预测成功停药的因素。文中还讨论了针对左心室收缩功能正常和降低的老年心力衰竭患者以及舒张性心力衰竭患者的现有利尿剂处方指南。通过减少血管内容量，利尿剂可能会进一步损害舒张性心力衰竭患者的心室舒张期充盈，从而减少心输出量。事实上，初步研究表明，利尿剂可能会引发或加重这些患者站立时和进食后的低血压。因此，建议左心室收缩功能正常的老年心力衰竭患者不应接受长期利尿剂治疗，除非证明治疗或预防充血性心力衰竭有必要。这意味着医生应仔细评估所有这些患者减少利尿剂剂量或停药的机会，而且谨慎指导的间歇性利尿剂治疗模式对于护理左心室收缩功能正常的老年心力衰竭患者可能至关重要。
