Abraham W T, Wagoner L E
Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky College of Medicine, (WTA), Lexington 40536-0284, USA.
Am J Med. 2001 May 7;110 Suppl 7A:47S-62S. doi: 10.1016/s0002-9343(98)00386-6.
Clinical trials of beta blockers in heart failure have generally required that patients be receiving optimal drug therapy before randomization to the study medication. Therefore, because beta blockers are used in addition to conventional drug therapy, review of the standard drug therapy of mild-to-moderate heart failure before the advent of beta blockade is essential to understanding the role of beta blockers in the treatment of heart failure. The conventional medical management of systolic heart failure includes angiotensin-converting enzyme (ACE) inhibitors, which should be used as first-line therapy; diuretics, for the management of body fluid-volume excess; digoxin; and some other vasodilators. These therapies have been evaluated in large-scale, randomized, controlled trials. ACE inhibitors have been shown to significantly attenuate disease progression and improve outcome (ie, morbidity and mortality) in patients with mild-to-moderate systolic heart failure. Controversial or unproven therapies include nonglycoside inotropic agents, angiotensin II receptor antagonists, antiarrhythmic agents, anticoagulants, and calcium channel blockers. The pharmacologic management of diastolic heart failure is largely empirical and is directed at reducing symptoms. Symptoms caused by increased ventricular filling pressures may be treated with diuretics and long-acting nitrates. Some calcium channel blockers and most beta blockers prolong diastolic filling time by slowing heart rate, thereby potentially improving the symptoms of diastolic heart failure. Calcium antagonists, beta blockers, diuretics, and ACE inhibitors may also promote regression of left ventricular hypertrophy and thus improve ventricular compliance, possibly preventing the development of diastolic dysfunction. Because randomized controlled trials of diastolic heart failure are lacking, this review focuses on the conventional management of mild-to-moderate systolic heart failure before the advent of beta blockade.
β受体阻滞剂治疗心力衰竭的临床试验通常要求患者在随机分组接受研究药物治疗前已接受最佳药物治疗。因此，由于β受体阻滞剂是在传统药物治疗基础上使用的，在β受体阻滞剂出现之前回顾轻至中度心力衰竭的标准药物治疗对于理解β受体阻滞剂在心力衰竭治疗中的作用至关重要。收缩性心力衰竭的传统药物治疗包括血管紧张素转换酶（ACE）抑制剂，应作为一线治疗药物；利尿剂，用于管理体液容量过多；地高辛；以及其他一些血管扩张剂。这些治疗方法已在大规模、随机、对照试验中进行了评估。已证明ACE抑制剂可显著减缓轻至中度收缩性心力衰竭患者的疾病进展并改善预后（即发病率和死亡率）。有争议或未经证实的治疗方法包括非糖苷类正性肌力药物、血管紧张素II受体拮抗剂、抗心律失常药物、抗凝剂和钙通道阻滞剂。舒张性心力衰竭的药物治疗很大程度上是经验性的，旨在减轻症状。由心室充盈压升高引起的症状可用利尿剂和长效硝酸盐治疗。一些钙通道阻滞剂和大多数β受体阻滞剂通过减慢心率延长舒张期充盈时间，从而有可能改善舒张性心力衰竭的症状。钙拮抗剂、β受体阻滞剂、利尿剂和ACE抑制剂也可能促进左心室肥厚的消退，从而改善心室顺应性，可能预防舒张功能障碍的发生。由于缺乏舒张性心力衰竭的随机对照试验，本综述重点关注β受体阻滞剂出现之前轻至中度收缩性心力衰竭的传统治疗方法。
