Nicholls M G, Ikram H, Fitzpatrick M A, Crozier I G
Department of Cardiology, Princess Margaret Hospital, Christchurch, New Zealand.
Eur Heart J. 1988 Jun;9 Suppl H:77-83. doi: 10.1093/eurheartj/9.suppl_h.77.
The renin-angiotensin system is activated in heart failure in proportion to the severity of the haemodynamic derangement and to diuretic dose. Angiotensin converting enzyme (ACE) inhibitors reduce circulating levels of angiotensin II and aldosterone and, in some patients, plasma noradrenaline, vasopressin and cortisol. Typically there is potassium retention and a minor increase in plasma potassium, but cumulative sodium balance may increase or decrease depending on pretreatment fluid and haemodynamic status and on policy regarding diuretic dose. Circulatory dynamics usually improve and blood flow to the brain, myocardium and kidneys is preserved. Changes in glomerular filtration rate are dictated by haemodynamic characteristics and, again, by diuretic dose and dietary sodium. There are potential hazards with ACE inhibitor therapy but most problems can be anticipated and avoided. Future trends may include the introduction of ACE inhibitors with or without concomitant diuretic therapy in early cardiac failure, and intravenous ACE inhibition immediately after acute myocardial infartion. Whether the ACE inhibitors will prove more successful than alternative antihypertensive agents in preventing cardiac complications (including heart failure) of hypertension, is an intriguing question.
肾素 - 血管紧张素系统在心力衰竭中被激活，其激活程度与血流动力学紊乱的严重程度以及利尿剂剂量成正比。血管紧张素转换酶（ACE）抑制剂可降低循环中血管紧张素II和醛固酮的水平，在某些患者中还可降低血浆去甲肾上腺素、血管加压素和皮质醇的水平。通常会出现钾潴留，血浆钾轻度升高，但累积钠平衡可能会增加或减少，这取决于治疗前的液体和血流动力学状态以及利尿剂剂量策略。循环动力学通常会改善，脑、心肌和肾脏的血流得以维持。肾小球滤过率的变化取决于血流动力学特征，同样也取决于利尿剂剂量和饮食中的钠含量。ACE抑制剂治疗存在潜在风险，但大多数问题是可以预见并避免的。未来的趋势可能包括在早期心力衰竭中引入ACE抑制剂，可联合或不联合利尿剂治疗，以及在急性心肌梗死后立即进行静脉内ACE抑制治疗。ACE抑制剂在预防高血压的心脏并发症（包括心力衰竭）方面是否比其他抗高血压药物更成功，是一个引人关注的问题。
