心臟衰竭治療之新進展

Advanced Therapy for Heart Failure

江碩儒(Shuo-Ju Chiang) ； 柯景塘(Jiing-Tang Ko)

《北市醫學雜誌》 4卷9_S期 (2007/12) Pp. 908-918

https://doi.org/10.6200/TCMJ.2007.4.9.15

摘要

心臟衰竭是指心臟肌肉受損或負荷過度，以致於無法輸送足夠的血液供給身體的需要，它是大多數心臟疾病的最終階段。心臟衰竭的死亡率依然很高，在嚴重的心臟衰竭病人(NYHA class Ⅳ)一年存活率是30%到50%；在中重度心臟衰竭的病人(NYHA class Ⅱ to Ⅲ)五年存活率是45% to 55%。這十年來，在心臟衰竭治療方面有重要的進展和突破，包括藥物治療，心臟移植治療，還有節律器治療進階應用的新進展，這些進展降低了心臟衰竭的死亡率，並且提高了存活率。心臟衰竭是一個動態疾病過程，起先是對心臟壁肌肉造成傷害，接著導致神經賀爾蒙系統－Adrenergic，Renin-Angiotensin-Aldosterone(RAA)及Vasopressin Systems的活化。這些神經賀爾蒙的活化(Neurohormonal Activation)可以維持血管內的血壓，因此一開始是好的影響，接著隨時間的進行，它不好的效果逐漸呈現，對心臟造成不可逆的結果。長期的目標來說，心臟衰竭的治療目標必須包括治療心臟衰竭的根本原因，同時還要降低神經賀爾蒙活化對心臟造成的不好影響。因此，某些藥物，例如Angiotensin-converting enzyme inhibitor、β-blocker、Angiotensin Ⅱ Receptor Antagonist及Aldosterone Antagonist可以調控及降低 Adrenergic及RAA系統，就成為近年來治療心臟衰竭的主流藥物。近幾年來，節律器治療在中至重度心臟衰竭病人進階應用的新進展，以雙心室同步調律器(Cardiac Resynchronization Therapy, CRT)為代表，雙心室同步調律器甚至可以結合體內電擊器(Intracardiac Defibrillator)用於需要的病人身上。目前各種大型研究顯示雙心室同步調律器可以降低心臟衰竭病人全原因死亡率及改善病人生活品質，這提供心臟衰竭病人治療的一個新的選擇。

關鍵字

心臟衰竭 ； 心臟衰竭的藥物治療 ； 神經賀爾蒙的活化 ； 節律器治療 ； 雙心室同步調律器

並列摘要

Heart failure is a pathologic state in which the myocardium is impaired and overloaded and the heart is unable to maintain an adequate cardiac output to meet the metabolic requirements of tissues. Heart failure is the final process of most heart diseases. Mortality from heart failure remains high, with a 30 to 50% one-year survival for advanced heart failure (NYHA class Ⅳ) and a 45 to 55% five-year survival in less severe cases (NYHA class Ⅱ to Ⅲ). In recent 10 years, there have been several important advances in the heart failure therapy. New breakthroughs in the treatment of heart failure include the development of drug therapy, successful transplantation programs and device therapy proven to improve mortality and morbidity. Heart failure is a process starting with an insult to the myocardium, which results in activation of the adrenergic, renin-angiotensin-aldosterone, and vasopressin systems. This neurohormonal activation maintains blood pressure and therefore is beneficial initially, but may become deleterious over time. The medication therapy, such as angiotensin-converting enzyme inhibitors and β blockers, angiotensin Ⅱ receptor antagonist, may adjust and decrease the activity of adrenergic and renin-angiotensin-aldosterone systems. The long-term goals for heart failure treatment include treating any underlying or causative factors and attenuating the deleterious effects of neurohormonal activation on myocardium. These years, new development of device therapy has progressed much, including the cardiac resynchronization therapy with or without intracardiac defibrillator. The large scale trials have proven that cardiac resynchronization therapy can decrease all-cause mortality, improve patient's quality of life. These provide new alternative ways in the treatment of heart failure.

並列關鍵字

heart failure ； drug therapy of heart failure ； neurohormonal activation ； device therapy ； cardiac resynchronization therapy