Wieser Monika, Rhyner Daniel, Martinelli Michele, Suter Thomas, Schnegg Bruno, Bösch Claudia, Wigger Olivier, Dobner Stephan, Hunziker Lukas
1 Zentrum für Herzinsuffizienz, Universitätsklinik für Kardiologie Inselspital Bern.
2 Geteilte Erstautorenschaft.
Ther Umsch. 2018 Sep;75(3):180-186. doi: 10.1024/0040-5930/a000986.
Pharmacological therapy of heart failure with reduced ejection fraction Abstract. Pharmacological therapy for heart failure has made great progress over the last three decades and evidence-based therapies have significantly improved survival and quality of life. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers are the cornerstone of the heart failure therapy; indicated in virtually every patient with heart failure and reduced ejection fraction. As soon as the left ventricular ejection fraction decreases below 35 % and / or symptoms are still present (NYHA II-IV), a mineralocorticoid receptor antagonist should be added. A rather recent addition to current heart failure therapy with convincing data is the substance combination sacubitril / valsartan. It is indicated for patients with persistent symptomatic heart failure despite optimal medical therapy with ACE inhibitors or ARBs, beta-blockers, and MRAs. Crucial for all mentioned substances is to aim for the maximal tolerated dose. Various additional therapies have no proven survival benefit but are important for symptom control in everyday life. Above all the diuretics, where loop diuretics show a better effect profile compared to thiazide diuretics. Furthermore, achieving an optimal iron status (the limit to start a substitution is significantly higher than in patients without heart failure), decreasing the heart frequency with Ivabradine (if heart rate persists above 70 / min despite fully dosed betablocker) and «lifestyle changes» can add to the success of the medical treatment. The importance of digoxin has been steadily decreasing. The previously advocated therapeutic anticoagulation in patients with severely reduced LVEF is not propagated anymore. Significant arrhythmias (especially atrial fibrillation and ventricular arrhythmias) are common in advanced diseases. In addition to beta-blockers, amiodarone is clearly the antiarrhythmic drug of choice. According to latest data, an early interventional treatment of atrial fibrillation by pulmonary vein ablation may be beneficial and has the potential to reduce mortality in special subgroups of patients. New developments in the field of antidiabetic drugs seem to be promising for reduction of mortality and hospitalization in patients with heart failure.
射血分数降低的心力衰竭的药物治疗 摘要。在过去三十年中，心力衰竭的药物治疗取得了巨大进展，循证疗法显著提高了生存率和生活质量。血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂以及β受体阻滞剂是心力衰竭治疗的基石；几乎适用于每一位射血分数降低的心力衰竭患者。一旦左心室射血分数降至35%以下和/或仍有症状（纽约心脏协会II-IV级），应加用盐皮质激素受体拮抗剂。目前心力衰竭治疗中较新加入且有令人信服数据的药物组合是沙库巴曲/缬沙坦。它适用于尽管使用了血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β受体阻滞剂和盐皮质激素受体拮抗剂进行了最佳药物治疗但仍有持续性症状性心力衰竭的患者。对于所有上述药物，关键是要达到最大耐受剂量。各种其他疗法虽未被证实有生存益处，但对日常生活中的症状控制很重要。尤其是利尿剂，与噻嗪类利尿剂相比，袢利尿剂显示出更好的疗效。此外，达到最佳铁状态（开始替代治疗的阈值显著高于无心力衰竭患者）、用伊伐布雷定降低心率（如果尽管β受体阻滞剂已足量使用但心率仍持续高于70次/分钟）以及“生活方式改变”可有助于药物治疗的成功。地高辛的重要性一直在稳步下降。以前主张对左心室射血分数严重降低的患者进行治疗性抗凝，现在不再提倡。严重心律失常（尤其是心房颤动和室性心律失常）在晚期疾病中很常见。除β受体阻滞剂外，胺碘酮显然是首选抗心律失常药物。根据最新数据，通过肺静脉消融对心房颤动进行早期介入治疗可能有益，并且有可能降低特定亚组患者的死亡率。抗糖尿病药物领域的新进展似乎有望降低心力衰竭患者的死亡率和住院率。
