Majure David T, Teerlink John R
University of California, San Francisco, Box 0131, 505 Parnassus Ave., Room U127a, San Francisco, CA, 94143, USA,
Curr Treat Options Cardiovasc Med. 2011 Oct 6. doi: 10.1007/s11936-011-0149-2.
Treatment goals of acute decompensated heart failure are to decrease congestion, afterload, and neurohormonal activation in order to improve hemodynamics and symptoms and, perhaps, reduce in-hospital events, re-hospitalizations, and mortality while avoiding toxicities of therapy such as hypotension, arrhythmias, and renal dysfunction. Relief of congestion through intravenous loop diuretics is a mainstay of therapy. In cases where diuretics are not effective, ultrafiltration may be used to achieve euvolemia. Beta-blockers should be continued or reduced in dose at admission but should not typically be held. In patients with normotensive or hypertensive heart failure, afterload reduction with vasodilators should be instituted at presentation. Choice of a particular agent such as nitroglycerin, nitroprusside, or nesiritide depends on patient characteristics such as presence of ischemia, degree of congestion, and renal function. Nitroprusside may be preferable in patients with congestion and low cardiac output, but with caution in patients with significant hypotension. Intravenous inotropes/inodilators, such as dobutamine and milrinone, should be limited to hypotensive patients with evidence of poor tissue perfusion. Milrinone may be preferable in patients who have significant pulmonary venous hypertension. In patients who do not respond to initial medical therapy and who are candidates for either cardiac transplantation or destination left ventricular assist device, mechanical circulatory support should be considered early, prior to the development of end-organ damage.
急性失代偿性心力衰竭的治疗目标是减轻充血、降低后负荷和神经激素激活，以改善血流动力学和症状，并可能减少住院期间事件、再住院率和死亡率，同时避免治疗的毒性作用，如低血压、心律失常和肾功能不全。通过静脉注射袢利尿剂缓解充血是治疗的主要手段。在利尿剂无效的情况下，可采用超滤来实现血容量正常。β受体阻滞剂在入院时应继续使用或减量，但通常不应停用。对于血压正常或高血压性心力衰竭患者，应在就诊时开始使用血管扩张剂降低后负荷。选择特定药物，如硝酸甘油、硝普钠或奈西立肽，取决于患者特征，如是否存在缺血、充血程度和肾功能。硝普钠可能更适合充血且心输出量低的患者，但对于有明显低血压的患者需谨慎使用。静脉注射正性肌力药/血管扩张剂，如多巴酚丁胺和米力农，应仅限于有组织灌注不良证据的低血压患者。米力农可能更适合有明显肺静脉高压的患者。对于初始药物治疗无反应且适合心脏移植或植入左心室辅助装置作为终末期治疗的患者，应在发生终末器官损害之前尽早考虑机械循环支持。
