Application principles of vasodilators in the treatment of acute heart failure

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

Abstract

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

CLC Number:

R541.62

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

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URL: https://huicui.hebmu.edu.cn/EN/10.3969/j.issn.1004-583X.2023.09.001

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

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References 40

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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