~Teachingcenter的醫學筆記~

藥物使用建議

Diuretics (利尿劑)
= IV loop diuretics are recommended for all patients with acute heart failure with signs/symptoms of fluid overload to improve symptoms. It is recommended to regularly monitor symptoms, urine output, renal function and electrolytes during use of IV diuretics.
--- 對於有明顯症狀、水分過多的急性心衰竭病人，應該給予靜脈注射(亨利氏)環利尿劑(如furosemide)，並且觀察症狀，確實記錄腎功能、尿量(計I/O更好)、電解質變化
= In patients with new-onset acute heart failure or those with chronic, decompensated heart failure not receiving oral diuretics the initial recommended dose should be 20~40mg IV furosemide (ore equivalent); for those on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose.
--- 對於第一次使用(亨利氏)環利尿劑的心衰竭成人，furosemide起始注射劑量建議為20~40mg，而對於已經長期有在使用口服furosemide的病人，注射劑量應至少等於口服劑量(通常會再多打一點，以促進作用效果)
= It is recommended to give diuretics either as intermittent boluses or as a continuous infusion, and the dose and duration should be adjusted according to symptoms and clinical status.
--- 間歇式給予和連續是給予的效果是差不多的，給予的劑量取決於病人的症狀和臨床狀態
~~~~可以一同參考”心衰竭和furosemide”~~~~
https://teachingcenter1.pixnet.net/blog/post/359235876
= Combination of loop diuretic with either thiazide-type diuretic or spironolactone may be considered in patients with resistant edema or insufficient symptomatic response.
--- 使用furosemide的同時，可以考慮合併使用噻嗪類利尿劑(thiazide)或螺內酯(spironolactone，又稱保鉀型利尿劑，使用時須注意高血鉀)

 

Vasodilator (血管擴張劑)
= IV vasodilators should be considered for symptomatic relief in acute heart failure with SBP > 90 mmHg (and without symptomatic hypotension).
--- 除了低血壓的病人，急性心衰竭的病人應給予血管擴張劑(例如nitroglycerin, isosorbide mononitrate and isosorbide dinitrate)
= In patients with hypertensive acute heart failure, IV vasodilators should be considered as initial therapy to improve symptoms and reduce congestion.
--- 對於高血壓的急性心衰竭病人，血管擴張劑應為首選用藥

 

Inotropic agents (強心劑)
= Dobutamine, dopamine, levosimendan, phosphodiesterase III (PDE III) inhibitors
= Short-term IV infusion of inotropic agents may be considered in patients with hypotension (SBP < 90 mmHg) and/or signs/symptoms of hypoperfusion despite adequate filling status, to increase cardiac output, increase blood pressure, improve peripheral perfusion and maintain end-organ function.
--- 休克的病人可以考慮給予強心藥物
= An intravenous infusion of levosimendan or a PDE III inhibitor may be considered to reverse the effect of beta-blockade if beta-blockade is thought to be contributing to hypotension with subsequent hypoperfusion.
--- 如果懷疑是beta-blocker造成的低血壓，可以使用levosimendan或磷酸二酯酶抑制劑如milrinone, tadalafil, or vardenafil
= Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused because of safety concern.
--- 安全起見，強心藥物僅建議使用於臨床上出現休克症狀的病人

 

Vasopressors (升壓劑)
= A vasopressor (norepinephrine preferably) may be considered in patients who have cardiogenic shock, despite treatment with another inotrope, to increase blood pressure and vital organ perfusion.
--- 心衰竭造成心因性休克時，應考慮使用Levophed (norepinephrine)
= It is recommended to monitor ECG and blood pressure when using inotropic agents and vasopressors, as they can cause arrhythmia, myocardial ischemia, and in the case of levosimendan and PDE III inhibitors also hypotension.
--- 由於可能造成心律不整、心肌缺血，應監測心電圖和密切測量血壓(或打A-line)

 

Thrombo-embolism prophylaxis (血栓預防)
= Thrombo-embolism prophylaxis (e.g. with LMWH) is recommended in patients not already anticoagulated and with no contra-indication to anticoagulation, to reduce the risk of deep venous thrombosis and pulmonary embolism.
--- 如果沒有禁忌症，建議給予預防血栓性用藥以預防深層靜脈栓塞或肺栓塞

 

其他
= For acute control of the ventricular rate in patients with atrial fibrillation:
--- digoxin and/or beta-blockers should be considered as the first-line therapy
--- amiodarone may be considered
Digoxin在心衰竭心房顫動的病人是首選，可以合併beta-blocker，其次才選擇amiodarone
= Opiates may be considered for cautions use to relieve dyspnea and anxiety in patients with severe dyspnea but nausea and hypopnea may occur.
--- 可以使用鴉片類藥物，但需要小心噁心嘔吐和呼吸抑制的副作用

 

增進心肌收縮的藥物

Agents	Mechanism
Incr. i Ca	PDEi	SV	Vasodilation
Inotropic agents
Dobutamine	++	X	+	X
Dopamine	++	X	+	X
Milrinone	++	++	+	++
Enoximone	++	++	+	++
Cardiac enhancers
Levosimendan	+-	+	+	++
Pimobendan	+-	+	+	+

Incr. i Ca: increasing of intracellular calcium
PDEi: phosphodiesterase inhibitors
SV: stroke volume

 

影響血管阻力之藥物

藥物	Alpha-1	Beta-1	Beta-2	Dopaminergic	效果
Phenylephrine	+++	0	0	0	SVR↑↑, CO↑/0
Norepinephrine	+++	++	0	0	SVR↑↑, CO↑/0
Epinephrine	+++	+++	++	0	CO↑↑, SVR↓(low dose), SVR↑(high dose)
Dobutamine	0/+	+++	++	0	CO↑, SVR↓
Isoproterenol	0	+++	+++	0	CO↑, SVR↓
Dopamine (mcg/kg/min)
0.5~2	0	+	0	++	CO↑
5~10	+	++	0	++	CO↑, SVR↑
10~20	++	++	0	++	SVR↑↑