Lichtlen P R
Division of Cardiology, Hannover Medical School, West Germany.
Cardiovasc Drugs Ther. 1988 May;2(1):47-60. doi: 10.1007/BF00054252.
Today, three classes of drugs, all acting differently on the myocardium, the coronary circulation, and the peripheral circulation, that is, on the determinants for myocardial oxygen consumption (heart rate, contractility, and wall tension), are at the physician's disposition for anti-ischemic medical treatment: nitrates, beta-receptor blocking agents and Ca antagonists. All three drugs have been proven to exhibit a marked antianginal effect when given alone, as demonstrated both by an improvement in exercise performance as well as in perfusion and a significant decrease in symptomatic and silent ischemic episodes. Treatment should cover the total ischemic burden, which can be assessed today more accurately by Holter monitoring than with exercise tests alone. It has been shown in patients with stable angina that the majority of ischemic episodes are silent (over 75%); therefore, the question arose as to whether medical anti-ischemic treatment should aim at the prevention not only of symptomatic, but also of silent episodes. Furthermore, ischemia was revealed to be not only a marker for the presence of high-grade life-threatening obstructions, but also to have prognostic implications, not only in symptomatic, but also in asymptomatic episodes. In addition, ischemia can lead to life-threatening arrhythmia and irreversible myocardial damage, especially localized fibrosis. To what extent this is prevented by vigorous anti-ischemic treatment is still unanswered; however, as pathophysiologically symptomatic and asymptomatic ischemic episodes behave similarly, the latter should be included in treatment. The combinations of drugs, especially of nitrates and beta blockers, Ca antagonists and beta blockers, and also nitrates and Ca antagonists result in a further improvement in exercise performance and a reduction in ischemic episodes, allow the dose to be reduced, and minimize side effects. In addition, as is indicated from their hemodynamics, in special clinical situations, combinations might be preferable. Whether treatment should primarily reduce sympathetic drive or, rather, be directed towards vasodilation depends on the type of angina and the individual need. Hence, combining drugs in treating angina pectoris represents a true therapeutic challenge for the physician.
如今，有三类药物可供医生用于抗缺血药物治疗，它们对心肌、冠状动脉循环和外周循环的作用各不相同，也就是说，对心肌耗氧量的决定因素（心率、心肌收缩力和心室壁张力）有不同作用：硝酸盐类、β受体阻滞剂和钙拮抗剂。单独使用时，这三类药物均已被证明具有显著的抗心绞痛作用，运动能力、灌注的改善以及有症状和无症状缺血发作次数的显著减少均证明了这一点。治疗应涵盖总的缺血负荷，如今通过动态心电图监测比仅通过运动试验能更准确地评估缺血负荷。在稳定型心绞痛患者中已表明，大多数缺血发作是无症状的（超过75%）；因此，出现了这样一个问题，即药物抗缺血治疗是否不仅应旨在预防有症状的发作，还应预防无症状的发作。此外，缺血不仅被发现是存在严重危及生命的阻塞的一个标志，而且还具有预后意义，不仅在有症状的发作中如此，在无症状的发作中也是如此。此外，缺血可导致危及生命的心律失常和不可逆的心肌损伤，尤其是局部纤维化。积极的抗缺血治疗在多大程度上能预防这种情况仍未得到解答；然而，由于从病理生理学角度来看，有症状和无症状的缺血发作表现相似，后者也应纳入治疗。药物组合，特别是硝酸盐类与β受体阻滞剂、钙拮抗剂与β受体阻滞剂以及硝酸盐类与钙拮抗剂的组合，可进一步改善运动能力并减少缺血发作次数，允许减少剂量，并将副作用降至最低。此外，从它们的血流动力学情况来看，在特殊临床情况下，组合可能更可取。治疗应主要降低交感神经驱动还是应更直接地针对血管舒张，这取决于心绞痛的类型和个体需求。因此，联合用药治疗心绞痛对医生来说是一项真正的治疗挑战。
