《指南和共识》PPT课件

ESC 指南和共识,Haga clic para modificar el estilo de texto del patrn,Segundo nivel,Tercer nivel,Cuarto nivel,Quinto nivel,*,Clic para editar estilo ttulo patrn,Haga clic para modificar el estilo de texto del patrn,Segundo nivel,Tercer nivel,Cuarto nivel,Quinto nivel,*,ESC ACEI 共识,Clic para editar estilo ttulo patrn,ACEI和阻滞剂的恰当使用,Haga clic para modificar el estilo de texto del patrn,Segundo nivel,Tercer nivel,Cuarto nivel,Quinto nivel,Clic para editar estilo ttulo patrn,ACEI和阻滞剂的恰当使用,Haga clic para modificar el estilo de texto del patrn,Segundo nivel,Tercer nivel,Cuarto nivel,Quinto nivel,Clic para editar estilo ttulo patrn,欧洲心脏病学会（ESC）,血管紧张素转化酶抑制剂（ACEI）共识性文件,ESC,成员,: 49,个国家,方法：,5-出版物,药理学. 作用机理,临床使用指征,药物使用的指导原则,使用不足,如何进行贯彻,ACE,I,珠江医院心内科讲座,ACE-i,ARBs,血管紧张素原,血管紧张素 I,AT,2,受体,血管紧张素 II,一氧化氮,失活肽,缓激肽,肾素,缓激肽受体,AT,1,受体,扩血管,抗增殖,修复组织,ACEI(激肽酶II),收缩血管、增殖、纤维化,血管加压素,肾上腺素能系统,醛固酮,珠江医院心内科讲座,不同ACEI的药代动力学特性,药物,药物的清除半衰期,肾脏清除率(%),标准治疗方案的给药剂量(毫克),肾脏功能衰竭（CrCl1030毫升/分钟）患者的给药剂量(毫克),含巯基的抑制剂,贝那普利*,11,85,2.520每日两次,2.510每日两次,卡托普利,2,95,25100 每日三次,6.2512.5每日三次,佐芬普利,4.5,60*,7.530每日二次,7.530每日二次,含羧基抑制剂,西拉普利,10,80,1.255 每日,0.52.5每日,依那普利,*,11,88,2.520每日二次,2.520每日二次,赖诺普利*,12,70,2.510每日,2.55每日,培哚普利,*,24,75,48每日,2每日,喹那普利*,24,75,1040每日,2.55每日,雷米普利*,814,85,2.510每日,1.255每日,螺普利,1.6,50*,36每日,36每日,群多普利,1624,15*,14每日,0.51每日,含膦酸基的抑制剂,福辛普利（蒙诺）*,12,50*,1040每日,1040每日,CrCl: 肌酐清除率。,* 药物前体。,* 显著的肝脏清除。,黄色,代表在中国常用,European Heart Journal (2004)25,1454-70,真正肝肾双通道,真正长效一天一次,真正安全肾功能不全患者无需调整剂量,贝那普利,依那普利,培哚普利,福辛普利（蒙诺）,珠江医院心内科讲座,蒙诺：真正安全的ACEI,真正肝肾双通道排泄的ACEI,Schoolwerth AC et al.Circulation,2001,104:1985-1991,珠江医院心内科讲座,蒙诺：真正安全的ACEI,肾功能不全患者不需改变剂量,Eurpean Heart Journal,2004,25:1454-1470,珠江医院心内科讲座,Zannad et al. Am J Hypertention 1996;9:633-643.,70%,60%,50%,40%,30%,20%,10%,0%,谷峰比,T/P,蒙诺 雷米普利 西拉普利 依那普利 赖诺普利 苯那普利,64%,51%,51%,48%,40%,56%,FDA,对,每日一次,降压药物的要求：谷峰比,50%,蒙诺：真正一天一次的ACEI权威期刊的谷峰比,珠江医院心内科讲座,药理学小结,ACEI具有类效应,但由于药物临床药理学特性不同，ESC官方批准的ACEI的用法也各不相同，如：,福辛普利一天一次，患者使用更方便，依从性也更高；此外，福辛普利是真正双通道排泄药物，因此肾衰患者无需调整剂量。,相反，贝那普利的推荐用法是一天两次，并且肾衰患者使用时需要降低剂量。,如果不按照官方批准的用法，就不能达到理想的疗效。,珠江医院心内科讲座,培哚普利,PROGRESS (ns)976,群多普利,PEACE (ns)534,培哚普利,EUROPA (ns)526,依那普利,SOLVD Prevention (ns)303,雷米普利,HOPE278,依那普利,SOLVD Treatment77,卡托普利,SAVE61,群多普利,TRACE54,雷米普利,AIRE43,依那普利,CONSENSUS3,心力衰竭,左室功能不全,二级预防,风险,获益,每年挽救1个生命所需治疗患者数（NNT）,珠江医院心内科讲座,ATLAS Circulation 1999;100:2312,ATLAS,心功能,II - IV,赖诺普利,2.5 -,5mg,32.5 -,35mg,全因性死亡,心血管性死亡,全因性死亡任何原因住院,全因性死亡心血管事件住院,全因性死亡心衰住院,心血管性死亡心血管事件住院,低剂量 高剂量 P,717(44.9) 666(42.5) 0.128,641(40.2) 588(37.2) 0.073,1338(83.8) 1250(79.7) 0.002,1182(74.1) 1115(71.1) 0.036,964(60.4) 864(55.1) 24h),高危,IA2,心梗后二级预防,IA2,高血压,IA3,1.,ESC chronic heart failure guidelines. Eur Heart J 2005 (in press),2.,Management of ST segment elevation AMI. Eur Heart J 2005,3.,Prevention of coronary heart disease in clinical practice. Eur Heart J 1998;19:1434,ESC,指南中,ACE-i,使用建议,珠江医院心内科讲座,Consensus,Solvd P & T,Save,Aire,Trace,Atlas,Network,VheFT,Elite -2,Optimaal,Overture,死亡率,住院事件,症状,急性心肌梗死,房颤,糖尿病,其它,心力衰竭,珠江医院心内科讲座,Lancet 2000;355:1575,ACE-i,对心衰患者存活率的影响,ACE-I,安慰剂,累计死亡率（）,随机分组后时间（年）,风险病例数,所有试验,安慰剂,珠江医院心内科讲座,长期生存率,CONSENSUS,珠江医院心内科讲座,ARB,ARB vs,其它 临床情况死亡住院,Vs,ACE-i,ELITE II,氯沙坦,/卡托普利充血性心力衰竭-,OPTIMAAL,氯沙坦,/卡托普利,心梗后心室功能不全,-,VALIANT,缬沙坦,/卡托普利,心梗后心室功能不全,-,-,或充血性心力衰竭,Vs,安慰剂,ValHeft,缬沙坦,/,安慰剂,充血性心力衰竭-+,CHARM added,坎沙坦,+ACEi /,安慰剂,充血性心力衰竭-+,CHARM altern.,坎地沙坦,/,安慰剂,充血性心力衰竭-/+,CHARM preser.,坎地沙坦,/,安慰剂,舒张性心力衰竭,-+,ACEIVSARB,珠江医院心内科讲座,急性心肌梗死,ns,Consensus 2,Gissi 3,ISIS 4,Smile,高危患者死亡率,再次心梗,房颤,糖尿病,急性心肌梗死后,ns,CCS1,Save,Trace,Aire,心肌梗死,珠江医院心内科讲座,AIRE,Lancet 1993; 342: 821,n = 1986,急性心肌梗死后,临床心衰,心功能,II - III,心梗后,3 - 10,天,随机分组,死亡率,%,相对危险度,: 0,73 ( 95% CI: 0,60 a 0,89),急性心肌梗死后时间（月）,30,24,12,18,0,6,5,15,10,35,30,25,20,0,安慰剂,雷米普利,p = 0.002,ACE-I.,急性心肌梗死患者临床获益,珠江医院心内科讲座,ISIS-4,天数,死亡率%,8,6,4,2,0,0,35,28,14,7,21,卡托普利,(6.87%),n=27382,安慰剂,(7.33%),n=27442,p = 0.04,Lancet 1995;345:669,急性心肌梗死 2.5 mg/dl , 220,mol/L,),高血钾 (K 5 mmol/L),肾动脉狭窄,过敏,咳嗽,妊娠,珠江医院心内科讲座,如何使用,低剂量起始,24-48 小时内增量到靶剂量,监测,血压,肌酐,血钾,珠江医院心内科讲座,使用ACEI的实践指南问题解决 (如有疑问，请寻求专家建议),症状性低血压,重新考虑是否有必要继续使用其它降压药,如无体液储留，减量或停用利尿剂,减少剂量,咳嗽,排除其它原因,:,肺部、支气管疾病,肺水肿,如症状严重或反复发作,停用ACEI，考虑换用,ARBs,肾功能恶化,开始治疗时常发生一过性的肌酐和血钾升高,重新考虑是否有必要继续使用非甾体类消炎药, K,补充剂,保,K,利尿剂,如无体液储留征象,利尿剂减量,如肌酐或血钾持续升高， 剂量减半,使用双通道清除的,ACE-I (,肾和胆汁途径,),珠江医院心内科讲座,药理学. 作用机理,临床使用指征,药物使用的指导原则,使用不足,如何进行贯彻,珠江医院心内科讲座,欧洲心衰,Survey-2,研究中ACEI剂量,0,20,40,60,80,100,%,卡托普利,依那普利,雷米普利,150mg,100% 剂量,福辛普利,赖诺普利,培哚普利,群多普利,20mg,10mg,20mg,4 mg,10 mg,4 mg,靶剂量,Euro Heart Failure Survey 2002,药理学. 作用机理,临床使用指征,药物使用的指导原则,使用不足,如何进行贯彻,珠江医院心内科讲座,0,50,100,ACEI,再次入院,治疗率 (%),1年死亡率,干预前 (n=11,038),干预后 (n=8,045),18*,23,65,95*,38*,46,Intermountain Health Care: 10 Hospitals Pre- 1/96-12/98 n=11,038 to 1/99-3/00 n=8,045.,Pearson. Circulation. 2001;104:II-838.,相对危险度 0.80,P,0.0001,相对危险度 0.77,P, 24h), 高危IA,MI后二级预防IA,高血压IA,1.,ESC chronic heart failure guidelines. Eur Heart J 2005 (in press),2.,Management of ST segment elevation AMI. Eur Heart J 2005,3.,Prevention of coronary heart disease in clinical practice. Eur Heart J 1998;19:1434,ESC,指南中ACEI 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