Guyatt Gordon H, Devereaux P J
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Mt Sinai J Med. 2004 Jan;71(1):47-54.
Heart failure is a common and costly medical condition. Ischemic heart disease and hypertension account for most cases of heart failure in developed countries. Estimates of the one-year mortality rates for patients with New York Heart Association (NYHA) Class II, III, and IV are 10%, 20%, and 40%, respectively. Angiotensin-converting enzyme (ACE) inhibitors reduce mortality of heart failure patients by approximately 25% (odds ratio 0.77, 95% CI 0.67 0.88). Larger doses of ACE inhibitors are more effective in preventing hospitalization than are lower doses. Angiotensin II receptor blockers (ARBs) are an alternative for patients who cannot tolerate ACE inhibitors because of their side effects (e.g., cough). Evidence for benefits of using combination of ACE inhibitors and ARBs is encouraging, but requires further study. For patients who cannot tolerate either ACE inhibitors or ARBs, vasodilator therapy with hydralazine and nitrates will probably provide benefit. (Diuretic therapy, while a mainstay of heart failure treatment, is primarily used for symptom relief.) There is also evidence that spironolactone reduces mortality (relative risk reduction 30%, 95% CI 18 40%) for patients with NYHA class III and IV heart failure. When administering spironolactone to heart failure patients, monitoring for hyperkalemia is essential. After two centuries of use, randomized controlled trials have finally demonstrated that digoxin is effective in preventing hospitalizations (relative risk reduction 28%, 95% CI 21 34%). There is now overwhelming evidence that beta-blockers are safe for heart failure patients but that they reduce the risk of death for these patients by approximately 30%. In addition to these medical interventions, heart failure patients may also benefit from a number of non-pharmacological interventions.
心力衰竭是一种常见且代价高昂的病症。在发达国家，缺血性心脏病和高血压是导致心力衰竭的主要病因。据估计，纽约心脏协会（NYHA）心功能II级、III级和IV级患者的一年死亡率分别为10%、20%和40%。血管紧张素转换酶（ACE）抑制剂可使心力衰竭患者的死亡率降低约25%（比值比0.77，95%可信区间0.67 - 0.88）。大剂量ACE抑制剂在预防住院方面比小剂量更有效。血管紧张素II受体阻滞剂（ARB）是因副作用（如咳嗽）而不能耐受ACE抑制剂的患者的替代药物。使用ACE抑制剂和ARB联合治疗的益处证据令人鼓舞，但仍需进一步研究。对于既不能耐受ACE抑制剂也不能耐受ARB的患者，肼屈嗪和硝酸盐类的血管扩张剂治疗可能会带来益处。（利尿剂治疗虽然是心力衰竭治疗的主要手段，但主要用于缓解症状。）也有证据表明，螺内酯可降低NYHA III级和IV级心力衰竭患者的死亡率（相对风险降低30%，95%可信区间18 - 40%）。给心力衰竭患者使用螺内酯时，监测高钾血症至关重要。经过两个世纪的使用，随机对照试验终于证明地高辛在预防住院方面有效（相对风险降低28%，95%可信区间2到34%）。现在有压倒性的证据表明，β受体阻滞剂对心力衰竭患者是安全的，而且可使这些患者的死亡风险降低约30%。除了这些药物干预措施外，心力衰竭患者还可能从一些非药物干预措施中获益。
