Forrester J S, Waters D D
Am J Med. 1978 Jul;65(1):173-80. doi: 10.1016/0002-9343(78)90707-6.
Selection of therapy for subjects with acute congestive dardiac failure usually involves a choice among a diuretic, a vasodilator and an inotropic agent. Three principal questions are involved in the decision: (1) Is cardiac out normal or depressed? (2) Is blood pressure normal or depressed? (3) is regional myocardial ischemia present? Diuretics are safe and easy to administer, but they do not increase cardiac output or relieve hypoperfusion. Inotropic agents increase cardiac output but differ widely in their effects on blood pressure: selection of specific agents is influenced by their blood pressure effect. All inotropic agents, however, potentially aggravate regional myocardial ischemia. In ischemic heart failure, therefore, vasodilators which also increase cardiac output, may be chosen. Vasodilator administration is in turn limited by the decrease in arterial pressure which accompanies increasing infusion rate. When these three questions are considered in combination, an effective therapeutic regimen can be identified. Thus, congestion without hypoperfusion requires a diuretic if blood pressure is normal; and a vasodilator when blood pressure is increased. In the presence of congestion with hypoperfusion, a vasodilator is employed if blood pressure is normal; and a positive inotropic drug when blood pressure is depressed.
急性充血性心力衰竭患者的治疗选择通常涉及在利尿剂、血管扩张剂和正性肌力药物之间做出抉择。决策过程涉及三个主要问题：（1）心输出量正常还是降低？（2）血压正常还是降低？（3）是否存在局部心肌缺血？利尿剂安全且易于给药，但它们不会增加心输出量或缓解灌注不足。正性肌力药物可增加心输出量，但它们对血压的影响差异很大：特定药物的选择受其血压效应的影响。然而，所有正性肌力药物都可能加重局部心肌缺血。因此，在缺血性心力衰竭中，也能增加心输出量的血管扩张剂可能是首选。血管扩张剂的使用又会受到随着输注速率增加而出现的动脉压降低的限制。综合考虑这三个问题时，就能确定一种有效的治疗方案。因此，无灌注不足的充血在血压正常时需要使用利尿剂；血压升高时则需要使用血管扩张剂。在存在充血并伴有灌注不足的情况下，血压正常时使用血管扩张剂；血压降低时则使用正性肌力药物。
