水电解质平衡在心力衰竭中的重要作用

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,*,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,水电解质平衡在心力衰竭中的重要作用,心力衰竭治疗中的难点,钠水潴留,水电解质紊乱,利尿剂,稀释性低钠难治性心衰,恶性心律失常,2,主要内容,心力衰竭,-,钠水潴留的原因,利尿剂应用与电解质紊乱,纠正低钠血症,与,电解质紊乱策略,3,主要参考文献,2021 ACCF/AHA Guideline for the Management of Heart Failure,ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021,4,心力衰竭,-,钠水潴留的原因,心衰早期，,RAAS,系统,激活,:,1.,循环血液重新分配，,2.,维持重要器官动脉血压和血流灌注。,心衰晚期,RAAS,持续,与,过度激活,:,1.,水钠过度潴留,电解质紊乱,及心律失常,.,2.,外周血管痉挛,使心脏前后负荷增加,3.,导致心功能进一步恶化，最终形成难治性心力衰竭。,5,心力衰竭,-,钠水潴留的原因,低钠血症,-,AVP,系统,(,精氨酸加压素,arginine vasopressin,，,AVP) :,刺激垂体后叶分泌,AVP,使肾远曲小管和髓质集合管对水的重吸收增加；,2.Ag,增加近曲小管钠转运，至远曲小管和集合管钠转运减少。,总的效应是体内水和钠的含量均增加，但水的含量增加更明显，造成高容量性稀释性低钠血症。,6,心力衰竭,-,钠水潴留的原因,心衰晚期低钠血症,-,BNP,系统,:,1.,心力衰竭时,RAAS,持续恶化，心室容量超负荷,与,室壁张力改变的刺激，使,BNP,的表达、分泌和活性增加。,直接作用于肾小球和集合管，抑制肾素的释放和醛固酮的分泌，增加尿钠和尿液的排泌，使血钠下降，能诱导血容量减少性低钠血症。,7,心力衰竭,-,电解质紊乱原因,心力衰竭患者因胃肠瘀血，恶心、呕吐，使血清钠、钾排泄过多，造成低钾、低钠血症。,心力衰竭时强调限盐，是血钠、钾等电解质摄人缺乏的重要因素。,老年人肾脏储藏功能下降，肾小管对钠、钾的重吸收减少。,摄人缺乏与排泄过多,8,主要内容,心力衰竭,-,钠水潴留的原因,利尿剂应用与电解质紊乱,纠正低钠血症的策略与方法,9,心力衰竭的治疗,-,利尿剂的应用,10,利 尿 剂,起 始 剂 量,(mg),每日常用剂量,(mg),袢 利 尿 剂,a,呋塞米,2040,40240,布美他尼,0.51.0,15,托拉噻米,510,1020,噻嗪类,b,苄氟噻嗪,2.5,2.510,氢氯噻嗪,25,12.5100,美托拉宗,2.5,2.510,吲哒帕胺,c,2.5,2.55,保钾利尿剂,d,+ACEi/ ARB,-ACEi/ARB,+ACEi/ARB,-ACEi/ARB,螺内酯,/,依普利酮,12.525,50,50,100200,阿米洛利,2.5,5,510,1020,氨苯喋啶,25,50,100,200,A：口服或静脉注射，根据容量状态/体重，剂量可能需要调整，过量可引起肾损害或耳毒性；,B：如果估算的肾小球滤过率1.52.0 kg持续2 天，那么增加利尿剂剂量。,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,利尿剂的选择,12,Stages, Phenotypes and Treatment of HF,13,Pharmacologic Treatment for Stage C HF,r,EF,14,Pharmacological Treatment for Stage C HF,r,EF,(cont.),Diuretics,are recommended in patients with HF,r,EF who have evidence of fluid retention, unless contraindicated, to improve symptoms.,ACE inhibitors are recommended in patients with HF,r,EF and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality.,ARBs are recommended in patients with HF,r,EF with current or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity and mortality.,I,IIa,IIb,III,I,IIa,IIb,III,A,I,IIa,IIb,III,A,15,Pharmacological Treatment for Stage C HF,r,EF (cont.),1.Aldosterone receptor antagonists or mineralocorticoid receptor antagonists (MRA),are recommended in patients with NYHA class II-IV and who have LVEF of 35% or less,2.,Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate 30 mL/min/1.73m2) and potassium should be less than 5.0 mEq/L,.,3.Careful monitoring of potassium, renal function, to minimize risk of hyperkalemia and renal insufficiency.,I,IIa,IIb,III,A,16,Pharmacological Treatment for Stage C HF,r,EF (cont.),Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of 40% or less who develop symptoms of HF or who have a history of diabetes mellitus, unless contraindicated.,1.Inappropriate use of aldosterone receptor antagonists,is potentially harmful,2.,serum creatinine greater than 2.5 mg/dL in men or greater than 2.0 mg/dL in women (or estimated glomerular filtration rate 30 mL/min/1.73m2), and/or potassium above 5.0 mEq/L.,I,IIa,IIb,III,B,I,IIa,IIb,III,B,Harm,17,Pharmacological Treatment for Stage C HF,p,EF,Systolic and diastolic blood pressure should be controlled in patients with HF,p,EF in accordance with published clinical practice guidelines to prevent morbidity.,Diuretics,should be used for relief of symptoms due to volume overload in patients with HF,p,EF.,Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HF,p,EF despite GDMT.,I,IIa,IIb,III,B,I,IIa,IIb,III,I,IIa,IIb,III,18,利尿剂应用与电解质紊乱,利尿剂：利尿药是心力衰竭的根底用药。但无论是噻嗪类利尿剂还是袢利尿剂，长期或大剂量使用均能增加血清钠、钾排出，导致低钠、低钾血症。而且还能使有效血容量减少，也可进一步刺激AVP分泌增加。,螺内酯等保钾利尿剂单独或与ACEI类药物联合应用那么易致高钾血症。,药物对电解质的影响,19,主要内容,心力衰竭,-,钠水潴留的原因,利尿剂应用与电解质紊乱,纠正低钠血症,与,电解质紊乱策略,20,纠正低钠血症,与,电解质紊乱策略,异常,原因,临床意义,低钠血症,(150 mmol/L),水丢失,/,水摄入不足,评估水摄入、诊断性检查,低钾血症,(5.5 mmol/L),肾衰、补钾、,RAS,抑制剂,停止补钾,/,保钾利尿剂、减量,/,停止,ACEI/ARB,、,MRA,、评估肾功和尿,pH,、心动过缓和严重心律失常的危险,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,21,纠正低钠血症,与,电解质紊乱策略,AVP受体拮抗药,1.常用的AVP受体拮抗剂有托伐普坦、利希普坦、考尼伐坦等，其问世是伴有低钠血症的心力衰竭治疗的最重大的进展。,受体拮抗药可抑制AVP的过量分泌，在不改变钠、钾排泄的情况下产生利尿作用，促进自由水的排泄，维持钠和其他电解质的浓度，被称为排水利尿剂。,3.该药增加液体丧失，降低尿渗透压，它们不激活RAAS，因此不引起低渗性低钠血症或血压升高。,22,Arginine Vasopressin Antagonists,In patients hospitalized with volume overload, including HF, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT,vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor selective or a nonselective vasopressin antagonist.,I,IIa,IIb,III,B,23,纠正低钠血症,与,电解质紊乱策略,老年CHF患者常为稀释性低钠血症，发生机制多为钠摄入低于钠排出和(或)水潴留大于钠潴留，与长期严格限盐而未限水有关，多见于心功能进展性恶化者。,过度限盐不仅无助于心力衰竭的纠正，反而会因低钠血症的发生加快心力衰竭的开展。,不需大量、长期利尿治疗(多为病史短的心功能I级)者，可以适当限盐，以利水钠潴留的防治；,对需要长期、大量利尿治疗(多为病史长的心功能级)者，那么不限制经饮食途径摄入的盐的量，并根据血钠水平检测，适时适当地补盐，以防止低钠血症的发生。,24,Water Restriction,Fluid restriction,(1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms.,I,IIa,IIb,III,25,纠正低钠血症的策略与方法,低钠血症,容量耗竭：停用噻嗪类或转换到袢利尿剂；如果可能减量/停用 袢利尿剂。,容量负荷过重：限制液体；袢利尿剂加量；考虑AVP剂如能得到用托伐普坦；静脉正性肌力药支持；考虑超滤。,Hyponatraemia,Volume depleted:stop thiazide or switch to loop diuretic, if possible; reduce dose/stop loop diuretics if possible; volume overloaded:fluid restriction;,increase dose of loop diuretic; consider AVP antagonist (e.g. tolvaptan if available); i.v. inotropic support; consider ultrafiltration,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,26,纠正低钾血症的策略与方法,保钾利尿剂的使用和补钾 如果排钾利尿剂与ACEI和MRA或ARB联用，通常不需要补钾。 除了ACEIARB与MRA联用外，或补钾可能不需要。 不推荐ACEI、MRA和ARB 三类药物全用,Use of potassium-sparing diuretics and potassium supplements,If a potassium-losing diuretic is used with the combination of an ACE inhibitor and an MRA (or ARB), potassium replacement is usually not required.,Serious hyperkalaemia may occur if potassium-sparing diuretics or supplements are taken in addition to the combination of an ACE inhibitor (or ARB) and MRA.,The use of all three of an ACE inhibitor, MRA and ARB is not recommended.,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,27,纠正低钾血症的策略与方法,Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis,serum electrolytes (including calcium and magnesium),blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone.,Serial monitoring, when indicated, should include serum electrolytes and renal function.,I,IIa,IIb,III,I,IIa,IIb,III,28,利尿剂应用的适应症,与,禁忌症,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,适应症,1. 充血病症和体征的患者，无论EF如何；,2. EF降低者，与ACEI或ARB、-阻滞剂和MRA联用；最小剂以维持正常血容量“干重即保持无充血的病症和体征的重量)；剂量根据患者的容量状态增减；,禁忌症,1. 如果患者没有充血的病症或体征就没有适应症;,2. 的过敏反响。其它不良反响药物-特异的,29,利尿剂应用的本卷须知,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,1.明显的低钾血症(K+3.5 mmol/L)利尿剂可能会雪上加霜;,2.肾损害(肌酐 150 mol/L/1.7 mg/dL, eGFR 221 mol/L (2.5 mg/dL)或eGFR30 mL/min/1.73 m2)噻嗪类利尿剂可加重肾功能损害或患者可能对利尿剂无效;,4.病症性或重度无病症性低血压收缩压150 mol/L/1.7 mg/dL, eGFR 221 mol/L (2.5 mg/dL)或eGFR30 mL/min/1.73 m2)噻嗪类利尿剂可加重肾功能损害;,4.病症性或重度无病症性低血压收缩压90 mmHg)可因利尿剂所致加重低血容量;,5.螺内酯和依普利酮可引起高钾血症和肾功能恶化，如果用了二者之一，需要连续监测血电解质和肾功能,30,利尿剂应用本卷须知,检查肾功能和电解质:,1.以小剂量开场；,2.在启动治疗和任何加量后1-2周复查血液生化BUN、肌酐、K+,3.当停顿加量、减量、停顿治疗时要复查；,4.一个专科心衰护士可协助患者教育、随访当面或 、生化监测和剂量调整包括训练患者调整剂量。,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,31,利尿剂与药物的相互反响,注意药物相互反响,1.与ACEI或ARB或肾素抑制剂联用低血压危险,2.与其它利尿剂如袢利尿剂加噻嗪类低血容量、低血压、低血钾和肾损害的危险,3.NSAIDs 可减弱利尿作用。,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,32,纠正电解质紊乱,低钾血症,ACEI/ARB加量、加用MRA、补钾,低钠血症,容量缺乏：停用噻嗪类或转换到袢利尿剂；或减量/停用袢利尿剂；,容量负荷过重：限制液体；袢利尿剂加量；考虑AVP剂如能得到用托伐普坦；静脉正性肌力药支持；考虑超滤。,McMurray JJ, Adamopoulos S, Anker SD,et al.ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2021. European Heart Journal (2021)33, 17871847,33,小结,1.,心力衰竭时神经内分泌系统激活与钠水潴留电解质紊乱密切相关,.,2.,利尿剂是,GDMT,重要的治疗药物,3.,水电解质平衡在心力衰竭管理重要,34,谢谢,35,谢谢欣赏,36,谢谢观赏！,37,2020/11/5,