Baker D W, Konstam M A, Bottorff M, Pitt B
Health Sciences Program, RAND, Santa Monica, Calif.
JAMA. 1994 Nov 2;272(17):1361-6.
This review of the pharmacologic treatment of heart failure due to left ventricular systolic dysfunction summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. It provides specific advice to help guide practitioners through clinical decision making.
Data were obtained from English-language studies and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific treatments. Where data were lacking, we relied on opinions of panel members and peer reviewers.
Only large prospective trials were used to estimate treatment efficacy. Smaller trials, case series, and case reports were reviewed for the incidence of adverse effects.
Randomized clinical trials were reviewed for inclusion and exclusion criteria, patient outcomes, adverse effects, and eight categories of study quality using a defined list of study flaws.
Angiotensin-converting enzyme (ACE) inhibitors should be given to all patients unless specific contraindications exist. Diuretics should be used judiciously early in treatment to prevent excessive diuresis that could prevent titration of ACE inhibitors to target doses. Digoxin has not been shown to affect the natural history of heart failure and should be reserved for patients who remain symptomatic after treatment with ACE inhibitors and diuretics. Isosorbide dinitrate and hydralazine hydrochloride should be tried in patients who cannot tolerate ACE inhibitors or who have refractory symptoms.
本综述总结了医疗保健政策与研究机构心力衰竭指南专家小组对左心室收缩功能障碍所致心力衰竭药物治疗的建议。它提供了具体建议，以帮助指导从业者进行临床决策。
数据取自1966年至1993年间发表在英文研究中且被MEDLINE或EMBASE收录的文献。我们使用了心力衰竭、充血性；充血性心力衰竭；心力衰竭；心功能不全；以及扩张型心肌病等检索词，并结合具体治疗方法的检索词。在缺乏数据时，我们依据专家小组成员和同行评审员的意见。
仅采用大型前瞻性试验来评估治疗效果。对小型试验、病例系列和病例报告进行了不良反应发生率的审查。
使用已定义的研究缺陷列表，对随机临床试验的纳入和排除标准、患者结局、不良反应以及八类研究质量进行了审查。
除非存在特定禁忌证，所有患者均应使用血管紧张素转换酶（ACE）抑制剂。利尿剂应在治疗早期谨慎使用，以防止过度利尿，从而避免妨碍将ACE抑制剂滴定至目标剂量。尚未证明地高辛会影响心力衰竭的自然病程，应仅用于在接受ACE抑制剂和利尿剂治疗后仍有症状的患者。对于不能耐受ACE抑制剂或有难治性症状的患者，应尝试使用硝酸异山梨酯和盐酸肼屈嗪。
