Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, 55455, USA.
VA Medical Center, One Veterans Dr., Minneapolis, MN, 55417, USA.
Am J Cardiovasc Drugs. 2018 Oct;18(5):333-345. doi: 10.1007/s40256-018-0277-0.
Primary care physicians play a significant role in managing heart failure (HF), with the goals of reducing mortality, avoiding hospitalization, and improving patients' quality of life. Most HF-related hospitalizations and deaths occur in patients with New York Heart Association functional class II or III, many of whom are perceived to have stable disease, which often progresses without clinical symptoms due to underlying deleterious effects of neurohormonal imbalance and endothelial dysfunction. Management includes lifestyle changes and stepped pharmacological therapy directed at the four stages of HF, with aggressive uptitration of therapies, including beta-blockers and inhibitors of the renin-angiotensin-aldosterone system. Recently, two new HF treatments have become available in clinical practice. Ivabradine was approved to reduce the risk of hospitalization for HF in patients with stable, symptomatic HF. Additionally, the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril/valsartan, was found to be significantly superior to enalapril in reducing risks of cardiovascular death and HF-related hospitalization. The respective 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America clinical practice guideline updates recommend that patients taking angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy be switched to ARNI therapy to further reduce morbidity and mortality. For HF management to be maximally effective, physicians must be knowledgeable about the risks and benefits of treatments and stay engaged with patients to identify signs of disease progression. This article provides an overview of the progressive nature of HF in apparently stable patients and describes areas for treatment improvement that may help to optimize patient care.
初级保健医生在心力衰竭（HF）的管理中发挥着重要作用，其目标是降低死亡率、避免住院治疗，并提高患者的生活质量。大多数与 HF 相关的住院和死亡发生在纽约心脏协会功能分级 II 或 III 的患者中，其中许多人被认为患有稳定的疾病，由于神经激素失衡和内皮功能障碍的潜在有害影响，疾病往往在没有临床症状的情况下进展。管理包括生活方式的改变和针对 HF 四个阶段的阶梯式药物治疗，包括积极滴定治疗，包括β受体阻滞剂和肾素-血管紧张素-醛固酮系统抑制剂。最近，两种新的 HF 治疗方法已在临床实践中应用。伊伐布雷定被批准用于降低稳定、有症状的 HF 患者的 HF 住院风险。此外，血管紧张素受体-脑啡肽酶抑制剂（ARNI）沙库巴曲缬沙坦在降低心血管死亡和 HF 相关住院风险方面明显优于依那普利。分别于 2016 年和 2017 年更新的美国心脏病学会/美国心脏协会/心力衰竭学会临床实践指南建议，正在接受血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂治疗的患者转换为 ARNI 治疗，以进一步降低发病率和死亡率。为了使 HF 管理达到最大效果，医生必须了解治疗的风险和益处，并与患者保持联系，以识别疾病进展的迹象。本文概述了看似稳定的患者中 HF 的进行性特征，并描述了可能有助于优化患者治疗的治疗改进领域。
