Momma Kazuo
Department of Pediatric Cardiology, Heart Institute, Tokyo Women's Medical University, Tokyo, Japan.
Paediatr Drugs. 2006;8(1):55-69. doi: 10.2165/00148581-200608010-00005.
This article reviews reports of ACE inhibitor use in pediatric heart failure and summarizes the present implications for clinical practice. Captopril, enalapril, and cilazapril are orally active ACE inhibitors, and widely used in pediatric cardiology, although more than ten other ACE inhibitors have been applied clinically in adults. Effects of ACE inhibitors on the renin-angiotensin-aldosterone system in pediatric patients are similar to those in adults. ACE inhibitors lower aortic pressure and systemic vascular resistance, do not affect pulmonary vascular resistance significantly, and lower left atrial and right atrial pressures in pediatric patients with heart failure. In infants with a large ventricular septal defect and pulmonary hypertension, ACE inhibitors decrease left-to-right shunt in those infants with elevated systemic vascular resistance. ACE inhibitors induce a small increase in left ventricular ejection fraction, left ventricular fractional shortening, and systemic blood flow in children with left ventricular dysfunction, mitral regurgitation, and aortic regurgitation. These beneficial effects usually persist long term without the development of tolerance. Therapeutic trials of ACE inhibitors have been reported in children with heart failure and divergent hemodynamics, including myocardial dysfunction, left-to-right shunt, such as large ventricular septal defect and pulmonary hypertension, aortic or mitral regurgitation, and Fontan circulation. Hypotension and renal failure usually occur within 5 days after starting ACE inhibition or increasing the dose and, in most cases, recovery is seen after reduction or cessation of the drug. With all ACE inhibitors, smaller doses are administered initially to prevent excessive hypotension, and doses are increased gradually to the target dose. Captopril is administered orally, usually every 8 hours. Daily doses range from 0.3 to 1.5 mg/kg in children. Enalapril is administered orally, once or twice a day, and daily doses range from 0.1 to 0.5 mg/kg. Enalaprilat is administered intravenously, one to three times a day, in doses ranging from 0.01 to 0.05 mg/kg/dose. For the treatment of chronic heart failure in children, ACE inhibitors are essential along with other medications including diuretics, digoxin, and beta-blockers (beta-adrenoceptor antagonists).
本文回顾了关于血管紧张素转换酶（ACE）抑制剂在小儿心力衰竭中应用的报告，并总结了其目前对临床实践的启示。卡托普利、依那普利和西拉普利是口服活性ACE抑制剂，在儿科心脏病学中广泛应用，尽管另有十多种ACE抑制剂已在成人中临床应用。ACE抑制剂对小儿患者肾素-血管紧张素-醛固酮系统的作用与成人相似。ACE抑制剂可降低主动脉压和全身血管阻力，对肺血管阻力影响不大，并可降低小儿心力衰竭患者的左心房和右心房压力。在患有大型室间隔缺损和肺动脉高压的婴儿中，ACE抑制剂可减少那些全身血管阻力升高婴儿的左向右分流。ACE抑制剂可使左心室功能障碍、二尖瓣反流和主动脉反流患儿的左心室射血分数、左心室缩短分数和全身血流量略有增加。这些有益作用通常长期持续，不会产生耐受性。已有关于ACE抑制剂在心力衰竭和血流动力学不同的小儿患者中的治疗试验报告，这些患者包括心肌功能障碍、左向右分流（如大型室间隔缺损和肺动脉高压）、主动脉或二尖瓣反流以及Fontan循环。低血压和肾衰竭通常在开始ACE抑制或增加剂量后5天内发生，且在大多数情况下，减少或停用药物后可恢复。使用所有ACE抑制剂时，最初给予较小剂量以防止过度低血压，然后逐渐增加剂量至目标剂量。卡托普利口服给药，通常每8小时一次。儿童每日剂量范围为0.3至1.5mg/kg。依那普利口服给药，每日一次或两次，每日剂量范围为0.1至0.5mg/kg。依那普利拉静脉给药，每日一至三次，剂量范围为0.01至0.05mg/kg/剂量。对于小儿慢性心力衰竭的治疗，ACE抑制剂与包括利尿剂、地高辛和β受体阻滞剂（β肾上腺素能拮抗剂）在内的其他药物一样必不可少。
