慢性心力衰竭的心脏再同步化治疗

随着血管紧张素转化酶抑制剂(或血管紧张素受体拮抗剂)、β受体阻滞剂、醛固酮拮抗剂在临床上广泛应用,慢性心力衰竭(CHF)治疗取得了很大的进展,然而有相当数量的患者药物治疗仍不能阻止心力衰竭的进行性加重.     

心律失常上游药物的治疗研究进展

心律失常是临床上最常见的疾病之一,是当今心脏疾病领域中的一大难题.无论是药物治疗还是非药物治疗,都有很多问题需要解决.近年来研究显示血管紧张素转换酶抑制剂(ACEI)、血管紧张素受体阻滞剂(ARB)、醛固酮受体拮抗剂、他汀类药物、不饱和脂肪酸等心律失常上游药物(upstream medical agents)均具有抗心律失常作用.     

慢性心力衰竭药物治疗进展

心力衰竭是一种复杂的临床症候群,其发病率高,预后不良。常规治疗药物包括神经内分泌抑制剂、血管紧张素转化酶抑制剂(ACEI)、血管紧张素受体阻滞剂(ARB)、β受体阻滞剂、醛固酮受体拮抗剂、利尿剂和洋地黄制剂,可有效治疗慢性心力衰竭(CHF),改善其预后,降低其死亡率。     

药物联合使用治疗慢性心力衰竭新进展

慢性心力衰竭(CHF)治疗可恢复已受损的心肌细胞,从而从根本上治疗CHF,改善其预后,降低其死亡率。血管紧张素转换酶抑制剂(ACEI)、血管紧张素受体拮抗剂(ARB)、β受体阻滞剂、醛固酮受体拮抗剂可改善心室重构,有效延缓和阻止心脏的重塑、改善临床症状,是目前治疗CHF的主要药物,可联合利尿剂、强心剂等进行综合治疗。     

抗神经内分泌治疗慢性心力衰竭进展

根据循证医学对近年来血管紧张素转换酶抑制剂、β受体阻滞剂、血管紧张素Ⅱ受体拮抗剂、醛固酮拮抗剂和利钠肽等神经内分泌拮抗剂的临床应用作一综述。     

利尿剂在心衰患者中的合理应用

<正>心力衰竭是指心脏结构或功能性疾病导致心室充盈及(或)射血能力受损而引起的一组综合征。目前能够改善心衰患者预后的药物主要包括血管紧张素转换酶抑制剂(ACEI)、血管紧张素Ⅱ受体拮抗剂(ARB)、β-受体阻滞剂和醛固酮受体拮抗剂等。但是,利尿剂从20世纪40年代开始应用于心衰的治疗,至今仍是有效控制及充分消除液体潴留的首选药物,临床上合理的使用利尿剂是联合其他治疗心衰药物取得成功的关键因素之一。     

高血压治疗新药研究进展

药物治疗是高血压防控的重要手段, 文章介绍了近些年在新药研制方面出现的几种新药, 包括: 新一代选择 性醛固酮受体拮抗剂、直接肾素抑制剂、血管紧张素受体- 脑啡肽酶双重阻滞剂、新型血管紧张素受体拮抗剂类药 物和第三代β 受体阻滞剂。     

神经内分泌拮抗剂在慢性心力衰竭的应用进展

随着许多大规模临床试验结果的不断问世,神经内分泌拮抗剂在慢性心力衰竭治疗中已取得令人鼓舞的结果。现将近年来血管紧张素转换酶抑制剂、β受体阻滞剂、血管紧张素Ⅱ受体拮抗剂及醛固酮拮抗剂4种神经内分泌拮抗剂的临床研究及应用进展作一综述。     

心力衰竭心脏再同步治疗

慢性心力衰竭的传统治疗为药物治疗，随着血管紧张素转化酶抑制剂、血管紧张素受体拮抗剂、β受体阻滞剂和醛固酮受体拮抗剂的广泛应用，心力衰竭患者的心功能有所改善，但其病死率仍居高不下。有文献报道，心力衰竭患者5年存活率与恶性肿瘤相似。近年来心力衰竭的非药物治疗，尤其是心脏再同步治疗（CRT）应用于中至重度患者，     

心脏再同步化起搏治疗心力衰竭

几十年来,随着血管紧张素转化酶抑制剂或血管紧张素拮抗剂、醛固酮拮抗剂、β受体阻滞剂的推广应用,心力衰竭(CHF)的治疗取得了巨大的进展。     

Resistant hypertension and hyperaldosteronism

Resistant hypertension is defined as blood pressure that remains uncontrolled in spite of ≥ 3 antihypertensive medications at effective doses, ideally including a diuretic. Although exact prevalence is unknown, clinical trials suggest that 20% to 30% of study participants are resistant. Hyperaldosteronism, obesity, refractory volume expansion, and obstructive sleep apnea are common findings in resistant hypertension patients. Multiple studies indicate that primary aldosteronism (PA) is common (∼ 20%) in patients with resistant hypertension. Screening for PA is recommended for most patients with resistant hypertension, ideally by measurement of 24-hour urinary aldosterone excretion, or by the plasma aldosterone/plasma renin activity ratio. Successful treatment of resistant hypertension is predicated on improvement of lifestyle factors; accurate diagnosis and treatment of secondary causes of hypertension; and use of effective multidrug regimens. A long-acting diuretic, specifically chlorthalidone, is recommended as part of the treatment regimen. Recent studies demonstrate that mineralocorticoid receptor antagonists provide substantial antihypertensive benefit when added to multidrug regimens, even in patients without demonstrable aldosterone excess.     

Aldosterone Excess and Resistant Hypertension: Investigation and Treatment

Among patients with resistant hypertension, primary aldosteronism (PA) is worth detecting as it appears to be particularly common in this cohort. It is associated with excessive cardiovascular morbidity in relation to the degree of hypertension and reduced quality of life, both of which can be abrogated with specific surgical or medical treatment. Knowledge concerning factors (including medications) which can influence the results of screening by aldosterone/renin ratio (ARR) testing is expanding, and is important to appreciate, particularly in patients with resistant hypertension, in whom the need for multiple medications can render interpretation challenging. Advances in approaches to confirmatory testing, subtype differentiation and assay methodology are helping to improve feasibility and reliability of the diagnostic workup for PA and new treatment approaches are emerging. Major developments in understanding the genetic bases for PA hold promise towards further improvements and options in diagnosis and therapy.     

Resistant hypertension and aldosterone: an update

Resistant hypertension (RHTN) is defined as a blood pressure remaining above goal despite the concurrent use of 3 antihypertensive medications of different classes, including, ideally a diuretic. RHTN is an important health problem with a prevalence rate expected to increase as populations become older, more obese, and at higher risk of having diabetes and chronic kidney disease, all of which are important risk factors for development of RHTN. The role of aldosterone has gained increasing recognition as a significant contributor to antihypertensive treatment resistance. In prospective studies, the prevalence of primary aldosteronism (PA) has ranged from 14%-21% in patients with RHTN, which is considerably higher than in the general hypertensive population. Furthermore, marked antihypertensive effects are seen when mineralocorticoid antagonists are added to the treatment regimen of patients with RHTN, further supporting aldosterone excess as an important cause of RHTN. A close association exists between hyperaldosteronism, RHTN, and obstructive sleep apnea (OSA) based upon recent studies which indicate that OSA is worsened by aldosterone-mediated fluid retention. This interaction is supported by preliminary data which demonstrates improvement in OSA severity after treatment with spironolactone.     

Spontaneous remission of idiopathic aldosteronism after long-term treatment with spironolactone: results from the German Conn's Registry

Context Primary aldosteronism (PA) is mainly caused by aldosterone‐producing adenoma and idiopathic bilateral adrenal hyperplasia (IHA). Recently, spontaneous resolution of IHA has been described. Objective We aimed to determine the frequency of spontaneous remission of PA during long‐term treatment with mineralocorticoid receptor (MR) antagonists. Design, setting and patients Thirty‐seven patients of the Munich PA registry with IHA treated by MR antagonists were investigated. The patients were identified retrospectively by chart review and prospectively assessed by clinical and biochemical means. Main outcome measures Complete remission of IHA was defined as normal aldosterone to renin ratio (ARR), normal suppression test and normalization of hypokalaemia in the presence of normal blood pressure. Partial remission was defined as normalization of normal ARR, normal suppression test and normalization of hypokalaemia in the presence of persistent hypertension. Results The mean period of MR antagonist treatment was 5·8 ± 0·7 years in the patients. We identified two of 37 (5·4%) patients with spontaneous remission: one with complete remission and one with partial remission. Conclusion Remission of IHA in PA may occur in some patients after long‐term mineralocorticoid antagonist treatment.     

Primary Aldosteronism with Parathyroid Hormone Elevation: A Single-center Retrospective Study

Objective Primary aldosteronism (PA) is a major cause of secondary hypertension. The association between PA and other hormone disorders is unclear. The present study aimed to evaluate whether the parathyroid hormone (PTH) value is associated with PA subtypes or specific treatments. Methods We enrolled 135 patients with PA who had their PTH value measured before undergoing a specific treatment. We evaluated whether PTH value is associated with PA subtypes or with specific treatments. The present study is a single-center retrospective study (2011-2018). Results Our study showed that, among the patients with PA, the proportion of those with PTH elevation was >30%. The PTH value was significantly correlated with both the basal plasma aldosterone concentration (PAC) and PAC after a captopril challenge test. However, the PTH value was not significantly different between the patients with unilateral and bilateral PA. We observed that the serum PTH value decreased after treatment of PA with unilateral adrenalectomy or mineralocorticoid receptor antagonists. Conclusion Our findings suggest that the PTH value in PA patients might be associated with the autonomous production of aldosterone. However, there was no correlation between the PTH value and PA subtypes in our study. Additionally, our study showed that targeted treatment for PA may lead to a decrease in the serum PTH levels. Hence, the PTH value could potentially be used as an index for measuring the suitability for PA treatment.     

Primary aldosteronism: diagnosis and treatment

Recent studies have indicated a higher prevalence of primary aldosteronism (PA) than reported historically. Aldosterone excess induces sodium and fluid retention with consequential increases in blood pressure. Patients with PA are at an increased risk of developing left ventricular hypertrophy, chronic kidney disease, and endothelial dysfunction. Measurement of the plasma aldosterone/plasma renin activity ratio is an effective screening test for PA. The majority of patients with PA do not have a discernable aldosterone-producing adenoma (APA), and the aldosterone excess is considered idiopathic in etiology and/or attributed to adrenal hyperplasia. Treatment of PA includes medical therapy with mineralocorticoid receptor antagonists and adrenalectomy for patients with a unilateral APA. A reasonable treatment strategy is to attempt medical therapy in all patients with a high plasma aldosterone/PRA ratio and reserve the extensive workup needed to identify an APA for those patients whose hypertension or hypokalemia cannot be controlled medically.     

Cost‐Effectiveness of Therapeutic Drug Monitoring in Diagnosing Primary Aldosteronism in Patients With Resistant Hypertension

Primary aldosteronism (PA) is present in up to 20% of patients with treatment‐resistant hypertension (TRH). Investigation for PA in patients with TRH is recommended by current guidelines after medication nonadherence is excluded. Studies using therapeutic drug monitoring (TDM) have shown that >50% of patients with TRH are nonadherent to their prescribed antihypertensive medications. However, the relationship between the prevalence of PA and medication adherence as confirmed by TDM has not been previously assessed. A retrospective analysis from a hypertension referral clinic showed that prevalence of PA in adherent patients with TRH by TDM was significantly higher than in nonadherent patients (28% vs 8%, P<.05). Furthermore, cost analysis showed that TDM‐guided PA screening was $590.69 less expensive per patient, with minimal impact on the diagnostic accuracy. These data support a TDM‐guided PA screening approach as a cost‐saving strategy compared with routine PA screening for TRH.     

Diagnosis of primary aldosteronism: from screening to subtype differentiation.

Numerous studies conducted in recent years have reported an increase in the prevalence of primary aldosteronism (PA). This increase has arisen because of changes in our screening methods used to detect PA, notably the widespread use of the ratio of plasma aldosterone concentration to plasma renin activity. A positive screening result, however, is not diagnostic and requires a confirmatory test. Strategies for screening and confirmation of PA and the techniques to identify the two main subtypes of PA--aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH)--are particularly important because hypertension in APA can be cured by adrenalectomy, whereas individuals affected with BAH can receive targeted medical treatment with mineralocorticoid receptor antagonists.     

Management and treatment of pediatric asthma: update.

Much of what we know about the pathogenesis and treatment of asthma has been learned from adult studies. Recently, a dramatic shift toward the pediatric age group has occurred in both of these areas. Such studies in children have overall supported similarities with the adult population with regard to pathogenesis (airway inflammation) and treatment (anti-inflammatory controller medications). However, the onset of asthma symptoms in less than 5 years is 80% of the time, yet controller medications approved for children under 4 years of age have generally not been available. This treatment gap was recently filled by the FDA approval of two important asthma controller medications. This review will focus on the use of leukotriene receptor antagonists and inhaled corticosteroids, which were recently approved for use in asthmatic children under 4 years of age.     

Medication dosing in outpatients with heart failure after implementation of a practice-based performance improvement intervention: findings from IMPROVE HF

Eligible outpatients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF) frequently do not receive target doses of HF medications. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) evaluated the effect of a practice-based performance improvement intervention on treatment of outpatients with LVEF ≤35%. Specific agent and dose were collected at baseline and 24?months for angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, and aldosterone antagonists. Changes in dosing over time were analyzed for each medication class. Data were available for 7605 patients. At baseline, target dose treatment rates were 36.1%, 20.5%, and 74.4%, respectively. Absolute and relative improvements of 9.8% and 47.7% (?P<.001) were achieved for β-blocker dosing at 24?months. The IMPROVE HF intervention was associated with significantly increased treatment of eligible patients with target doses of β-blockers but not ACE inhibitors/ARBs or aldosterone antagonists. Additional research to determine barriers to use of target doses of HF medications may be necessary.