Packer M
Division of Circulatory Physiology, Columbia University, College of Physicians and Surgeons, New York, New York.
Am J Cardiol. 1993 Mar 25;71(9):3C-11C. doi: 10.1016/0002-9149(93)90081-m.
During the last 50 years, physicians have developed three distinct conceptual models of heart failure that have provided a rational basis for the treatment of the disease. In the 1940s through the 1960s, physicians regarded heart failure principally as an edematous disorder and formulated a cardiorenal model of the disease in an attempt to explain the sodium retention of these patients. This model led to the widespread use of digitalis and diuretics. In the 1970s and 1980s, physicians viewed heart failure principally as a hemodynamic disorder and formulated a cardiocirculatory model of the disease in an attempt to explain patients' symptoms and disability. This model led to the widespread use of peripheral vasodilators and the development of novel positive inotropic agents. Now, in the 1990s, physicians are beginning to think about heart failure as a neurohormonal disorder in an attempt to explain the progression of the disease and its poor long-term survival. This new conceptual framework has led to the widespread use of converting-enzyme inhibitors and the development of beta blockers for the treatment of heart failure. Which conceptual model most accurately describes the syndrome of heart failure and leads physicians to utilize the most effective treatment? This paper critically reviews the available evidence supporting and refuting the validity of all three models of heart failure. We conclude that, to varying degrees, all three approaches provide useful, but incomplete, insights into this physiologically complex and therapeutically challenging disease.
在过去的50年里,医生们已经形成了三种不同的心力衰竭概念模型,这些模型为该疾病的治疗提供了合理依据。在20世纪40年代至60年代,医生们主要将心力衰竭视为一种水肿性疾病,并构建了该疾病的心肾模型,试图解释这些患者的钠潴留现象。这种模型导致了洋地黄和利尿剂的广泛使用。在20世纪70年代和80年代,医生们主要将心力衰竭视为一种血流动力学疾病,并构建了该疾病的心脏循环模型,试图解释患者的症状和残疾情况。这种模型导致了外周血管扩张剂的广泛使用以及新型正性肌力药物的研发。如今,在20世纪90年代,医生们开始将心力衰竭视为一种神经激素紊乱疾病,试图解释该疾病的进展及其较差的长期生存率。这种新的概念框架导致了转化酶抑制剂的广泛使用以及β受体阻滞剂用于心力衰竭治疗的研发。哪种概念模型最准确地描述了心力衰竭综合征,并引导医生采用最有效的治疗方法?本文批判性地回顾了支持和反驳所有三种心力衰竭模型有效性的现有证据。我们得出结论,这三种方法在不同程度上都为这种生理上复杂且治疗上具有挑战性的疾病提供了有用但不完整的见解。