Klein W, Eber B, Dusleag J, Rotman B, Gasser R, Weinrauch V, Brussee H
Department of Internal Medicine, Karl Franzens University, Graz, Austria.
J Cardiovasc Pharmacol. 1991;18 Suppl 9:S7-14.
Transient myocardial ischemia may result from obstruction to flow in the large epicardial coronary arteries or diminished flow reserve due to small vessel disease or left ventricular hypertrophy. In patients with coronary heart disease, calcium blockers have proven to reduce stress induced ischemia in patients with normal left ventricular function and in those with ischemic cardiomyopathy. However, recent studies indicate a need for caution when giving calcium antagonists to patients with postinfarction left ventricular systolic dysfunction. Moreover, calcium antagonists that reduce heart rate (diltiazem) are able as a monotherapy to reduce total ischemic burden. Calcium antagonists that may increase rate (dihydropiridines) have to be combined with beta-blockers to achieve this goal. For 24-h control of ischemia the ischemic threshold should be determined for a differentiated therapy in the individual patient. Is the ischemic threshold of the majority of episodes lower than the exercise threshold, a calcium blocker should work. Angiotensin-converting enzyme (ACE) inhibitors are not effective in stress-induced ischemia, but may reduce total ischemic burden, although this effect is not significant. In patients with left ventricular hypertrophy and/or small vessel disease, calcium blockers and ACE inhibitors are probably effective in regression of left ventricular hypertrophy and vascular hypertrophy. However, it remains to be shown that ischemia is reduced by these drugs.
短暂性心肌缺血可能源于大的心外膜冠状动脉血流受阻，或因小血管疾病或左心室肥厚导致血流储备减少。在冠心病患者中，钙通道阻滞剂已被证明可减轻左心室功能正常患者及缺血性心肌病患者的应激性缺血。然而，最近的研究表明，给心肌梗死后左心室收缩功能不全的患者使用钙拮抗剂时需谨慎。此外，降低心率的钙拮抗剂（地尔硫䓬）可作为单一疗法减轻总的缺血负荷。可能增加心率的钙拮抗剂（二氢吡啶类）必须与β受体阻滞剂联合使用才能达到这一目的。为实现24小时缺血控制，应确定缺血阈值，以便对个体患者进行个体化治疗。如果大多数发作的缺血阈值低于运动阈值，钙通道阻滞剂可能有效。血管紧张素转换酶（ACE）抑制剂对应激性缺血无效，但可能减轻总的缺血负荷，尽管这种作用并不显著。在左心室肥厚和/或小血管疾病患者中，钙通道阻滞剂和ACE抑制剂可能对左心室肥厚和血管肥厚的消退有效。然而，这些药物是否能减轻缺血仍有待证实。
