血管扩张剂在急性心力衰竭救治中的应用原则

doi:10.3969/j.issn.1004-583X.2023.09.001

摘要/Abstract

摘要：

急性心力衰竭是心血管内科常见疾病之一,其治疗原则包括减轻心脏前后负荷、改善心脏收缩与舒张功能等。目前,血管扩张剂尚无可行性的充分证据可以作为治疗急性心力衰竭的常用药物,故在临床使用中存争议。本文将静脉血管扩张剂应用于急性心力衰竭患者的病理生理学基础、使用人群、血压控制目标等重点介绍,以期为使用血管扩张剂提供参考。

关键词: 心力衰竭, 血管扩张药, 输注, 静脉内

Abstract:

Acute heart failure (AHF) is one of the common diseases in cardiovascular medicine. Its treatment principles include reducing cardiac preload and afterload, and improving cardiac systolic and diastolic function. Currently, evidences supporting the feasibility of vasodilators in the treatment of AHF are scant. The clinical application of vasodilators remains controversial. This review thoroughly described the pathophysiological basis, populations, and blood pressure control goals of intravenous vasodilators in the treatment of AHF, thus providing references for the clinical application.

Key words: heart failure, vasodilators, infusion, intravenous

中图分类号:

R541.62

段芳, 崔炜. 血管扩张剂在急性心力衰竭救治中的应用原则[J]. 临床荟萃, 2023, 38(9): 773-778.

Duan Fang, Cui Wei. Application principles of vasodilators in the treatment of acute heart failure[J]. Clinical Focus, 2023, 38(9): 773-778.

导出引用管理器 EndNote|Ris|BibTeX

链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.09.001

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I9/773

图/表 2

参考文献 40

[1]	Javaloyes P, Miró Ò, Gil V, et al. Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes[J]. Eur J Heart Fail, 2019, 21(11):1353-1365. doi: 10.1002/ejhf.1502 pmid: 31127677
[2]	Singh A, Laribi S, Teerlink JR, et al. Agents with vasodilator properties in acute heart failure[J]. Eur Heart J, 2017, 38(5):317-325. doi: 10.1093/eurheartj/ehv755 pmid: 28201723
[3]	Ezekowitz JA, O'Meara E, McDonald MA, et al. 2017 comprehensive update of the canadian cardiovascular society guidelines for the management of heart failure[J]. Can J Cardiol, 2017, 33(11):1342-1433. doi: 10.1016/j.cjca.2017.08.022 URL
[4]	Cotter G, Metra M, Davison BA, et al. Systolic blood pressure reduction during the first 24 h in acute heart failure admission: friend or foe?[J]. Eur J Heart Fail, 2018, 20(2):317-322. doi: 10.1002/ejhf.889 pmid: 28871621
[5]	Garatti L, Frea S, Bocchino PP, et al. Sodium nitroprusside in acute heart failure: A multicenter historic cohort study[J]. Int J Cardiol, 2022, 369:37-44. doi: 10.1016/j.ijcard.2022.08.009 pmid: 35944767
[6]	Chatterjee K, Swan HJ, Kaushik VS, et al. Effects of vasodilator therapy for severe pump failure in acute myocardial infarction on short-term and late prognosis[J]. Circulation, 1976, 53(5):797-802. pmid: 1260983
[7]	Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The task force for the diagnosis and treatment of acute and chronic heart failure of the European society of cardiology (ESC)developed with the special contribution of the heart failure association (HFA) of the ESC[J]. Eur Heart J, 2016, 37(27):2129-2200. doi: 10.1093/eurheartj/ehw128 URL
[8]	Vanhentenrijk S, Verbrugge FH, Tang W, et al. PRO: vasodilators remain an indispensable treatment for acute heart failure[J]. Eur Heart J Acute Cardiovasc Care, 2022, 11(11):850-857. doi: 10.1093/ehjacc/zuac128 pmid: 36208185
[9]	McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European society of cardiology. developed in collaboration with the heart failure association (HFA) of the ESC[J]. Eur J Heart Fail, 2012, 14(8):803-869. doi: 10.1093/eurjhf/hfs105 URL
[10]	Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology foundation/American heart association task force on practice guidelines[J]. J Am Coll Cardiol, 2013, 62(16):e147-239.
[11]	中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 急性心力衰竭诊断和治疗指南[J]. 中华心血管病杂志, 2010, 38(3):195-208.
[12]	中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 中国心力衰竭诊断和治疗指南2014[J]. 中华心血管病杂志, 2014, 42(2):98-122.
[13]	Mebazaa A, Yilmaz MB, Levy P, et al. Recommendations on pre-hospital & early hospital management of acute heart failure: A consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine[J]. Eur J Heart Fail, 2015, 17(6):544-558. doi: 10.1002/ejhf.2015.17.issue-6 URL
[14]	中华医学会心血管病学分会心力衰竭学组, 中国医师协会心力衰竭专业委员会, 中华心血管病杂志编辑委员会. 中国心力衰竭诊断和治疗指南2018[J]. 中华心血管病杂志, 2018, 46(10):760-789.
[15]	McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure[J]. Eur Heart J, 2021, 42(36):3599-3726. doi: 10.1093/eurheartj/ehab368 URL
[16]	Masip J, Frank Peacok W, Arrigo M, et al. A scientific statement from the association for acute cardio vascular care (ACVC) of the European society of cardiology[J]. Eur Heart J Acute Cardiovasc Care, 2022, 11(2):173-185. doi: 10.1093/ehjacc/zuab122 URL
[17]	Pang PS. Acute heart failure syndromes: initial management[J]. Emerg Med Clin North Am, 2011, 29(4):675-688. doi: 10.1016/j.emc.2011.08.004 URL
[18]	Bocchino PP, Angelini F, Frea S. Intravenous vasodilators in acute heart failure patients with low basic blood pressure: May the benefit come from targeting perfusion rather than pressure?[J]. Eur Heart J, 2020, 41(25):2409-2410. doi: 10.1093/eurheartj/ehaa372 pmid: 32556107
[19]	Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: A scientific statement from the American heart association council for high blood pressure research and the councils on clinical cardiology and epidemiology and prevention[J]. Circulation, 2007, 115(21):2761-2788. doi: 10.1161/CIRCULATIONAHA.107.183885 pmid: 17502569
[20]	中国高血压防治指南修订委员会. 中国高血压防治指南2010[J]. 中华心血管病杂志, 2011, 39(7): 579-615.
[21]	中国高血压防治指南修订委员会, 高血压联盟中国, 中华医学会心血管病学分会, 等. 中国高血压防治指南(2018年修订版)[J]. 中国心血管杂志, 2019, 24(1):1-46.
[22]	Stevenson LW. Management of acute decompensated heart failure[M]// Douglas LM. Heart failure: A companion to braunwald's heart disease. 2nd ed. Missouri:saunders, 2011:634-649.
[23]	Felker GM, Teerlink JR. Diagnosis and management of acute heart failur[M]//Libby P, Bonow RO, Mann DL, et al. Braunwald's heart disease: a textbook of cardiovascular medicine. 12th ed. Philadelphia: Elsevier, 2021:946-974.
[24]	Kitai T, Tang W, Xanthopoulos A, et al. Impact of early treatment with intravenous vasodilators and blood pressure reduction in acute heart failure[J]. Open Heart, 2018, 5(2):e000845.
[25]	Grand J, Miger K, Sajadieh A, et al. Blood pressure drops during hospitalization for acute heart failure treated with serelaxin: A patient-level analysis of 4 randomized controlled trials[J]. Circ Heart Fail, 2022, 15(4):e009199.
[26]	Harrison N, Pang P, Collins S, et al. Blood pressure reduction in hypertensive acute heart failure[J]. Curr Hypertens Rep, 2021, 23(2):11. doi: 10.1007/s11906-021-01127-8 pmid: 33611627
[27]	Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America[J]. Circulation, 2017, 136(6):e137-e161.
[28]	Putot S, Hacquin A, Manckoundia P, et al. Prognostic impact of systolic blood pressure in acute heart failure with preserved ejection fraction in older patients[J]. ESC Heart Fail, 2021, 8(6):5493-5500. doi: 10.1002/ehf2.13650 pmid: 34664426
[29]	Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the task force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European society of cardiology. developed in collaboration with the heart failure association of the ESC (HFA) and endorsed by the European society of intensive care medicine (ESICM)[J]. Eur J Heart Fail, 2008, 10(10):933-989. doi: 10.1016/j.ejheart.2008.08.005 URL
[30]	Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines[J]. Circulation, 2022, 145(18):e895-e1032.
[31]	Mebazaa A, Parissis J, Porcher R, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods[J]. Intensive Care Med, 2011, 37(2):290-301. doi: 10.1007/s00134-010-2073-4 pmid: 21086112
[32]	Shiraishi Y, Kohsaka S, Katsuki T, et al. Benefit and harm of intravenous vasodilators across the clinical profile spectrum in acute cardiogenic pulmonary oedema patients[J]. Eur Heart J Acute Cardiovasc Care, 2020, 9(5):448-458. doi: 10.1177/2048872619891075 URL
[33]	Gyory M, Abdallah S, Lagina A, et al. Ultra-high dose intravenous nitroglycerin in an ESRD patient with acutely decompensated heart failure[J]. J Am Coll Emerg Physicians Open, 2021, 2(2):e12387.
[34]	Miró Ò, Espinosa B, Gil V, et al. Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival[J]. Eur J Emerg Med, 2022, 29(6):437-449. doi: 10.1097/MEJ.0000000000000964 pmid: 35861663
[35]	Patrick C, Ward B, Anderson J, et al. Feasibility, effectiveness and safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema[J]. Prehosp Emerg Care, 2020, 24(6):844-850. doi: 10.1080/10903127.2020.1711834 URL
[36]	Kelly GS, Branstetter LA, Moran TP, et al. Low-versus high-dose nitroglycerin infusion in the management of acute pulmonary edema[J]. Am J Emerg Med, 2023, 65:71-75. doi: 10.1016/j.ajem.2022.12.022 URL
[37]	Mathew R, Kumar A, Sahu A, et al. High-dose nitroglycerin bolus for sympathetic crashing acute pulmonary edema: A prospective observational pilot study[J]. J Emerg Med, 2021, 61(3):271-277. doi: 10.1016/j.jemermed.2021.05.011 pmid: 34215472
[38]	Stemple K, DeWitt KM, Porter BA, et al. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series[J]. Am J Emerg Med, 2021, 44:262-266. doi: 10.1016/j.ajem.2020.03.062 pmid: 32278569
[39]	Kozhuharov N, Goudev A, Flores D, et al. Effect of a strategy of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization among patients with acute heart failure: The GALACTIC randomized clinical trial[J]. JAMA, 2019, 322(23):2292-2302. doi: 10.1001/jama.2019.18598 pmid: 31846016
[40]	Cotter G, Davison B. Intravenous therapies in acute heart failure-lack of effect or lack of well powered studies?[J]. Eur J Heart Fail, 2014, 16(4):355-357. pmid: 24578198

作者/指南	推荐/可以使用	谨慎使用	禁忌使用
《欧洲心脏病学会(European society of cardiology, ESC)急慢性心力衰竭的诊断与治疗指南2012》^[9]	SBP>110 mmHg且无严重二尖瓣或主动脉瓣狭窄	-	SBP<85 mmHg
《美国心脏病学会基金会(American college of cardiology foundation, ACCF)/美国心脏协会(American heart association,AHA)心力衰竭管理指南2013》^[10]	缓解血压正常AHF患者呼吸困难症状,或无症状性低血压^*患者利尿剂的辅助使用	-	-
《AHF诊断和治疗指南2010》^[11]	SBP>110 mmHg	SBP 90~110 mmHg	SBP<90 mmHg或持续低血压伴症状时(尤其是肾功能不全)
《中国心力衰竭诊断和治疗指南 2014》^[12]	SBP>110 mmHg	SBP 90~110 mmHg	SBP<90 mmHg或持续低血压伴症状时(尤其是肾功能不全)
《欧洲AHF院前和院内早期管理指南2015》^[13]	SBP正常或≥110 mmHg,静脉使用血管扩张剂或舌下含服硝酸盐	AHF前48小时内,SBP 85~100 mmHg,口服血管扩张剂应减量或停止服用	SBP<85 mmHg停止口服血管扩张剂
《ESC急性和慢性心力衰竭诊断和治疗指南2016》^[7]	>90 mmHg,且无症状性低血压	-	-
《加拿大心血管学会(Canadian cardiovascular society,CCS)心力衰竭管理指南2017》^[3]	SBP>100 mmHg	-	-
《中国心力衰竭诊断和治疗指南2018》^[14]	根据患者淤血和外周灌注情况个性化使用血管扩张剂	-	-
《ESC急性和慢性心力衰竭的诊断和治疗2021》^[15]	SBP>110 mmHg	-	-
《2022 ESC科学声明:2021年ESC心力衰竭指南中的急性心力衰竭》^[16]	院前SBP>160mmHg或出现胸痛;院内SBP>110 mmHg	-	-
Pang^[17]	高血压患者血压>160/100 mmHg;血压正常患者静脉使用利尿剂后,合并高风险,如尿量欠佳,肾功能欠佳,利尿剂抵抗,SBP升高或肌钙蛋白升高等;SBP<90 mmHg肺充血或尿量欠佳	-	-

作者/指南	推荐/可以使用	谨慎使用	禁忌使用
《欧洲心脏病学会(European society of cardiology, ESC)急慢性心力衰竭的诊断与治疗指南2012》^[9]	SBP>110 mmHg且无严重二尖瓣或主动脉瓣狭窄	-	SBP<85 mmHg
《美国心脏病学会基金会(American college of cardiology foundation, ACCF)/美国心脏协会(American heart association,AHA)心力衰竭管理指南2013》^[10]	缓解血压正常AHF患者呼吸困难症状,或无症状性低血压^*患者利尿剂的辅助使用	-	-
《AHF诊断和治疗指南2010》^[11]	SBP>110 mmHg	SBP 90~110 mmHg	SBP<90 mmHg或持续低血压伴症状时(尤其是肾功能不全)
《中国心力衰竭诊断和治疗指南 2014》^[12]	SBP>110 mmHg	SBP 90~110 mmHg	SBP<90 mmHg或持续低血压伴症状时(尤其是肾功能不全)
《欧洲AHF院前和院内早期管理指南2015》^[13]	SBP正常或≥110 mmHg,静脉使用血管扩张剂或舌下含服硝酸盐	AHF前48小时内,SBP 85~100 mmHg,口服血管扩张剂应减量或停止服用	SBP<85 mmHg停止口服血管扩张剂
《ESC急性和慢性心力衰竭诊断和治疗指南2016》^[7]	>90 mmHg,且无症状性低血压	-	-
《加拿大心血管学会(Canadian cardiovascular society,CCS)心力衰竭管理指南2017》^[3]	SBP>100 mmHg	-	-
《中国心力衰竭诊断和治疗指南2018》^[14]	根据患者淤血和外周灌注情况个性化使用血管扩张剂	-	-
《ESC急性和慢性心力衰竭的诊断和治疗2021》^[15]	SBP>110 mmHg	-	-
《2022 ESC科学声明:2021年ESC心力衰竭指南中的急性心力衰竭》^[16]	院前SBP>160mmHg或出现胸痛;院内SBP>110 mmHg	-	-
Pang^[17]	高血压患者血压>160/100 mmHg;血压正常患者静脉使用利尿剂后,合并高风险,如尿量欠佳,肾功能欠佳,利尿剂抵抗,SBP升高或肌钙蛋白升高等;SBP<90 mmHg肺充血或尿量欠佳	-	-

药物	剂量	剂量调整与疗程
硝酸甘油	初始剂量5~10μg/min,最大剂量200μg/min(ESC推荐起始 10~20 μg/min)	每5~10 min增加5~10 μg/min
硝酸异山梨酯	初始剂量1 mg/h,最大剂量5~10 mg/h	逐渐增加剂量
硝普钠	初始剂量0.2~0.3 μg/(kg·min),最大剂量5 μg/(kg·min)	每5~10 min增加5 μg/min,疗程≤72 h
重组人利钠肽(奈西立肽)	负荷量1.5~2.0 μg/kg静脉缓推或不用负荷量,继以0.0075~0.0100 μg/(kg·min)维持[ESC推荐维持剂量0.015~0.030 μg/(kg·min)]	根据血压调整剂量
乌拉地尔	100~400 μg/min,严重高血压者可缓慢静脉注射12.5~25.0 mg	根据血压调整剂量

药物	剂量	剂量调整与疗程
硝酸甘油	初始剂量5~10μg/min,最大剂量200μg/min(ESC推荐起始 10~20 μg/min)	每5~10 min增加5~10 μg/min
硝酸异山梨酯	初始剂量1 mg/h,最大剂量5~10 mg/h	逐渐增加剂量
硝普钠	初始剂量0.2~0.3 μg/(kg·min),最大剂量5 μg/(kg·min)	每5~10 min增加5 μg/min,疗程≤72 h
重组人利钠肽(奈西立肽)	负荷量1.5~2.0 μg/kg静脉缓推或不用负荷量,继以0.0075~0.0100 μg/(kg·min)维持[ESC推荐维持剂量0.015~0.030 μg/(kg·min)]	根据血压调整剂量
乌拉地尔	100~400 μg/min,严重高血压者可缓慢静脉注射12.5~25.0 mg	根据血压调整剂量