Fischer T A, Treese N
Brigham and Women's Hospital, Department of Medicine, Boston, USA.
Med Klin (Munich). 1997 Sep 15;92(9):546-51. doi: 10.1007/BF03044930.
Although supported by more than 200 years of experience and anecdotal clinical evidence, the efficacy of digitalis in the management of heart failure has been questioned until the past decade. The idea to improve contractility of the diseased myocardium with an inotropic agent is fundamental in the management of left ventricular dysfunction. The majority of clinical trials published since 1980, most of which examined patients with mild to moderate heart failure, indicate that digitalis alone or in combination with vasodilators may improve the clinical outcome particular in those patients with more advanced symptoms and poorer left ventricular function. Aside from its action as an inotropic drug the pharmacology and the mechanisms by which digitalis influence the diseased myocardium and peripheral circulation in heart failure has gained more complexity within the last years, raising the idea of other mechanisms that might be involved in its action. Particular for ACE inhibition multiple clinical trials have conclusively demonstrated its impact on survival and morbidity in congestive heart failure. Improvement of clinical outcome as measured in terms of fewer hospitalizations and improvement of symptoms in patients receiving digitalis seems to be comparable to patients receiving beta-blockers additional to diuretics and ACE inhibitors, an entirely different approach to the treatment of heart failure. Despite initial improvement of hemodynamics it now appears that there is no survival benefit found for digitalis in the management of heart failure.
尽管洋地黄在治疗心力衰竭方面有200多年的经验及临床轶事证据支持，但直到过去十年，其疗效一直受到质疑。使用正性肌力药物改善病变心肌的收缩力，这一理念是治疗左心室功能障碍的根本。自1980年以来发表的大多数临床试验，其中大部分研究的是轻至中度心力衰竭患者，表明洋地黄单独使用或与血管扩张剂联合使用，可能会改善临床结局，尤其是那些症状更严重、左心室功能更差的患者。除了作为一种正性肌力药物的作用外，近年来洋地黄影响心力衰竭时病变心肌和外周循环的药理学及机制变得更加复杂，这引发了关于其作用可能涉及其他机制的想法。特别是对于ACE抑制，多项临床试验已确凿地证明了其对充血性心力衰竭患者生存率和发病率的影响。以住院次数减少和症状改善来衡量，接受洋地黄治疗的患者临床结局的改善似乎与接受利尿剂和ACE抑制剂之外还加用β受体阻滞剂的患者相当，这是一种完全不同的心力衰竭治疗方法。尽管洋地黄最初能改善血流动力学，但现在看来，在心力衰竭治疗中使用洋地黄并没有生存获益。
