Jardim Sofia Isabel, Ramos Dos Santos Luís, Araújo Inês, Marques Filipa, Branco Patrícia, Gaspar Augusta, Fonseca Cândida
Unidade Funcional Medicina 1.2, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
Serviço de Medicina Interna, Hospital Central do Funchal, Funchal, Portugal.
Rev Port Cardiol (Engl Ed). 2018 Nov;37(11):935-945. doi: 10.1016/j.repc.2018.03.014. Epub 2018 Nov 20.
Heart failure is a disease with high direct and indirect costs. Current treatment includes drugs that alter disease progression and drugs that to improve symptoms. Loop diuretics are the cornerstone of congestion relief for acute management, as well as for chronic stabilization. In heart failure patients, maximal diuretic response is reduced by many individual factors. Diuretic resistance is defined as failure to achieve effective congestion relief despite appropriate or escalating diuretic doses. Its causes include impaired delivery of the diuretic to its luminal site of action, neurohormonal activation, tubular compensatory adaptation and drug interactions. Several strategies can be employed to aid decongestion of patients with impaired diuretic response. These include salt restriction, a higher effective single dose or higher dose frequency of loop diuretics, continuous infusion of diuretics and/or sequential nephron blockade through a synergistic combination of two or more diuretics from different classes. Ultrafiltration has also been found to be another effective and safe therapeutic option and should be considered in patients with refractory diuretic resistance. Overall, there is a lack of high-quality clinical data to guide the choice of treatment strategy and therapy should be tailored on a case-by-case basis.
心力衰竭是一种直接和间接成本都很高的疾病。目前的治疗方法包括改变疾病进展的药物和改善症状的药物。袢利尿剂是急性处理以及慢性病情稳定时缓解充血的基石。在心力衰竭患者中，多种个体因素会降低利尿剂的最大反应。利尿剂抵抗的定义是尽管使用了适当或递增的利尿剂剂量，但仍未能实现有效的充血缓解。其原因包括利尿剂输送到其管腔作用部位受损、神经激素激活、肾小管代偿性适应和药物相互作用。可以采用几种策略来帮助利尿剂反应受损的患者消除充血。这些策略包括限制盐摄入、使用更高的有效单剂量或更高的袢利尿剂给药频率、持续输注利尿剂和/或通过联合使用两种或更多不同类别的利尿剂进行顺序肾单位阻断。超滤也被发现是另一种有效且安全的治疗选择，对于难治性利尿剂抵抗患者应予以考虑。总体而言，缺乏高质量的临床数据来指导治疗策略的选择，治疗应根据具体情况量身定制。
