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fny5jt9 发表于 2024-5-31 13:36:51

药学人员必学：心力衰尽

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_gif/Qbp48GiaoaDCgqabRaibrUyOgHicgn87d5Sk19HzoPS6Mxg3ibDJll9ibQSc5PaHwFnVBkicicNVHoMn2NDR9AuSEHcKQ/640?wx_fmt=gif&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1" style="width: 50%; margin-bottom: 20px;"></p>心力<span style="color: black;">衰尽</span>（HF）<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">各样</span>心脏结构或功能性<span style="color: black;">疾患</span><span style="color: black;">引起</span>心室充盈和（或）射血功能受损，心排血量<span style="color: black;">不可</span>满足机体组织代谢<span style="color: black;">必须</span>，以肺循环和（或）体循环淤血，器官、组织血液灌注不足为临床表现的一组<span style="color: black;">综合症</span>，<span style="color: black;">重点</span>表现为<span style="color: black;">呼气</span>困难、体力活动受限和体液潴留。心力<span style="color: black;">衰尽</span>可分为急性心力<span style="color: black;">衰尽</span>及慢性心力<span style="color: black;">衰尽</span>，<span style="color: black;">亦</span>可分为收缩性心力<span style="color: black;">衰尽</span>及舒张性心力<span style="color: black;">衰尽</span>。冠心病、高血压是慢性心力哀竭的最<span style="color: black;">重点</span>病因。本文<span style="color: black;">重点</span>介绍慢性收缩性心力<span style="color: black;">衰尽</span>。</span></p><span style="color: black;">临床表现与分级</span><img src="https://mmbiz.qpic.cn/mmbiz_jpg/Qbp48GiaoaDCgqabRaibrUyOgHicgn87d5SXZQ0qHafjduT1RPHLO9EUlmY3xBe66TP591BGO1zgfwId6LIeC1AqA/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><strong style="color: blue;"><span style="color: black;">左心<span style="color: black;">衰尽</span></span></strong></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">以肺循环淤血及心排血量降低为<span style="color: black;">重点</span>表现。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">1.不同程度的<span style="color: black;">呼气</span>困难</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①劳力性<span style="color: black;">呼气</span>困难：是左心<span style="color: black;">衰尽</span>最早<span style="color: black;">显现</span>的症状。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②端坐<span style="color: black;">呼气</span>：高枕卧位、半卧位<span style="color: black;">乃至</span>端坐肘方可好转。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③夜间阵发性<span style="color: black;">呼气</span>困难：<span style="color: black;">病人</span>入睡后<span style="color: black;">忽然</span>因憋气而惊醒，被迫取坐位，重者可有哮鸣音，<span style="color: black;">叫作</span>为“心源性哮喘”，多于端坐<span style="color: black;">休憩</span>后缓解。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">2.咳嗽、咳痰、咯血</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">起始</span>常于夜间<span style="color: black;">出现</span>，坐位或立位时咳嗽可减轻，白色浆液性<span style="color: black;">泡泡</span>状痰为其特点，偶可见痰中带血丝。急性左心衰<span style="color: black;">爆发</span>时可<span style="color: black;">显现</span>粉红色<span style="color: black;">泡泡</span>样痰。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">3.组织灌注不足及代偿性心率加快<span style="color: black;">导致</span>的症状</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">表现为乏力、疲倦、运动耐量减低、<span style="color: black;">头昏</span>、心慌。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">4.少尿及肾功能损害</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">慢性肾血流量减少可<span style="color: black;">显现</span>血尿素氮、肌酐<span style="color: black;">上升</span>。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">5.体征</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①肺部湿性啰音。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②心脏体征：除<span style="color: black;">基本</span>心脏病的固有体征外，<span style="color: black;">通常</span>均有心脏扩大及相对性二尖瓣关闭不全的反流性杂音、肺动脉瓣区第二心音亢进及舒张期奔马律。</p>
    <img src="https://mmbiz.qpic.cn/mmbiz_jpg/Qbp48GiaoaDCgqabRaibrUyOgHicgn87d5SXZQ0qHafjduT1RPHLO9EUlmY3xBe66TP591BGO1zgfwId6LIeC1AqA/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><strong style="color: blue;"><span style="color: black;">右心<span style="color: black;">衰尽</span></span></strong></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">以体循环淤血为<span style="color: black;">重点</span>表现。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">1.消化道症状</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">胃肠道及肝淤血<span style="color: black;">导致</span>腹胀、食欲不振、恶心、呕吐等是右心衰最<span style="color: black;">平常</span>的症状。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">2.劳力性<span style="color: black;">呼气</span>困难</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">继发于左心衰的右心衰存在<span style="color: black;">呼气</span>困难。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">3.体征</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①水肿；</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②肝颈静脉回流征阳性、颈静脉充盈、怒张；</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③心脏体征：除<span style="color: black;">基本</span>心脏病的相应体征外，可因右心室<span style="color: black;">明显</span>扩大而<span style="color: black;">显现</span>三尖瓣关闭不全的反流性杂音；</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">④肝淤血：肝脏肿大常伴压痛，慢性可致心源性肝硬化。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">全心<span style="color: black;">衰尽</span>右心<span style="color: black;">衰尽</span>继发于左心<span style="color: black;">衰尽</span>而形成全心<span style="color: black;">衰尽</span>。<span style="color: black;">同期</span><span style="color: black;">拥有</span>左心<span style="color: black;">衰尽</span>和右心<span style="color: black;">衰尽</span>的症状和体征，但右心<span style="color: black;">衰尽</span>时右心排血量减少，<span style="color: black;">因此呢</span>阵发性<span style="color: black;">呼气</span>困难等肺淤血症状反而有所减轻。</p>心力<span style="color: black;">衰尽</span>分级<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">美国纽约心脏病学会（New York Heart Association，NYHA）的心功能分级<span style="color: black;">办法</span>如下：</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Ⅰ级：心脏病<span style="color: black;">病人</span><span style="color: black;">平常</span>活动量不受限制，<span style="color: black;">通常</span>活动不<span style="color: black;">导致</span>乏力、<span style="color: black;">呼气</span>困难等心衰症状。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Ⅱ级：心脏病<span style="color: black;">病人</span>体力活动轻度受限，<span style="color: black;">休憩</span>时<span style="color: black;">没</span>自觉症状，<span style="color: black;">通常</span>活动下可<span style="color: black;">显现</span>心衰症状。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Ⅲ级：心脏病<span style="color: black;">病人</span>体力活动<span style="color: black;">显著</span>受限，<span style="color: black;">小于</span>平时<span style="color: black;">通常</span>活动即<span style="color: black;">导致</span>心衰症状。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">Ⅳ级：心脏病<span style="color: black;">病人</span><span style="color: black;">不可</span>从事任何体力活动，<span style="color: black;">休憩</span>状态下<span style="color: black;">亦</span>存在心衰症状，活动后加重。</p><span style="color: black;">治疗</span><span style="color: black;">通常</span>治疗<h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">1.病因治疗</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">对所有可能<span style="color: black;">引起</span>心脏功能受损的<span style="color: black;">平常</span><span style="color: black;">疾患</span>如高血压、冠心病、糖尿病、代谢<span style="color: black;">综合症</span>等，在尚未<span style="color: black;">导致</span>心脏器质性改变前即应<span style="color: black;">初期</span>进行有效治疗。<span style="color: black;">针对</span><span style="color: black;">少许</span>病因未明的<span style="color: black;">疾患</span>如原发性扩张型心肌病等<span style="color: black;">也</span>应<span style="color: black;">初期</span>积极<span style="color: black;">干涉</span>，延缓<span style="color: black;">疾患</span><span style="color: black;">发展</span>。</p>

    <h2 style="color: black; text-align: left; margin-bottom: 10px;"><span style="color: black;"><strong style="color: blue;">2.消除诱因</strong></span></h2>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">平常</span>的诱<span style="color: black;">由于</span>感染（<span style="color: black;">尤其</span>是<span style="color: black;">呼气</span>道感染）、<span style="color: black;">心率</span>失常（<span style="color: black;">尤其</span>是心房颤动）、甲状腺功能亢进、贫血等，应积极治疗。</p>
    <span style="color: black;">药品</span>治疗<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">包含</span>利尿剂、肾素血管紧张素醛固酮系统(RAAS)<span style="color: black;">控制</span>剂、β受体阻断剂及正性肌力<span style="color: black;">药品</span>，按<span style="color: black;">必须</span>联合用药。</p>
    1．利尿剂<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">是心力<span style="color: black;">衰尽</span>治疗中改善症状的基石，是心衰治疗中<span style="color: black;">独一</span>能够<span style="color: black;">掌控</span>体液潴留的<span style="color: black;">药品</span>。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(1)袢利尿剂静脉注射效果优于口服。但须<span style="color: black;">重视</span>低血钾的不良反应。用于急性心衰肺水肿。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2)噻嗪类利尿剂轻度心力<span style="color: black;">衰尽</span>可首选，常与保钾利尿剂合用。该药因<span style="color: black;">控制</span>尿酸排泄而<span style="color: black;">导致</span>高尿酸血症，<span style="color: black;">长时间</span>大剂量应用可影响糖、脂代谢。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(3)保钾利尿剂多与<span style="color: black;">以上</span>两类利尿剂联用以加强利尿效果并预防低血钾。常用的有螺内酯、氨苯蝶啶和阿米洛利。电解质<span style="color: black;">错乱</span>是利尿剂<span style="color: black;">长时间</span><span style="color: black;">运用</span>最<span style="color: black;">平常</span>的不良反应，<span style="color: black;">尤其</span>是低血钾或高血钾均可<span style="color: black;">引起</span>严重后果，应<span style="color: black;">重视</span>监测。</p>2．RAAS <span style="color: black;">控制</span>剂<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(1)血管紧张素转换酶<span style="color: black;">控制</span>剂(ACEI)改善心室重塑；<span style="color: black;">初期</span>足量应用除可缓解症状，还能延缓心衰<span style="color: black;">发展</span>，降低死亡率。常用<span style="color: black;">药品</span>：卡托普利、依那普利、培哚普利、雷米普利。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">ACEI的不良反应<span style="color: black;">重点</span><span style="color: black;">包含</span>低血压、肾功能一过性恶化、高血钾、干咳和血管性水肿等。有威胁生命的不良反应（血管性水肿和<span style="color: black;">没</span>尿性肾<span style="color: black;">衰尽</span>）、妊娠期<span style="color: black;">女性</span>及ACEI 过敏者应禁用；低血压、双侧肾动脉狭窄、血肌酐<span style="color: black;">显著</span><span style="color: black;">上升</span>(＞265umol/L)、高血钾(＞5.5mmol/L)者慎用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(2)当血管紧张素受体拮抗剂(ARB)ACEI <span style="color: black;">导致</span>干咳、血管性水肿<span style="color: black;">不可</span>耐受时，可改用ARB，已<span style="color: black;">运用</span>ARB且症状<span style="color: black;">掌控</span>良好者不需换为ACEI。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">日前</span><span style="color: black;">科研</span>证实对心衰治疗有效的ARB 制剂：坎地沙坦缬沙坦、奥美沙坦、氯沙坦、厄贝沙坦、替米沙坦。ACEI 与ARB 联用并<span style="color: black;">不可</span>使心衰<span style="color: black;">病人</span>获益<span style="color: black;">更加多</span>，反而<span style="color: black;">增多</span>不良反应，<span style="color: black;">尤其</span>是低血压和肾功能损害的<span style="color: black;">出现</span>，<span style="color: black;">因此呢</span><span style="color: black;">日前</span>不主张ACEI 与ARB 联合应用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(3)醛固酮受体拮抗剂<span style="color: black;">必要</span><span style="color: black;">重视</span>血钾的监测，近期有肾功能不全、血肌酐<span style="color: black;">上升</span>或高钾血症者不宜<span style="color: black;">运用</span>。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">依普利酮是一种新型<span style="color: black;">选取</span>性醛固酮受体拮抗剂，且尤适用于老年、糖尿病和肾功能不全<span style="color: black;">病人</span>。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">(4)肾素<span style="color: black;">控制</span>剂<span style="color: black;">血液</span>肾素活性是动脉粥样硬化、糖尿病和心力<span style="color: black;">衰尽</span>等<span style="color: black;">病人</span><span style="color: black;">出现</span>心血管事件和预测死亡率的独立危险<span style="color: black;">原因</span>。新一代口服肾素<span style="color: black;">控制</span>剂阿利吉仑能<span style="color: black;">经过</span>直接<span style="color: black;">控制</span>肾素，降低<span style="color: black;">血液</span>肾素活性。缺乏证据。</p>3．β受体阻断剂<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">可<span style="color: black;">控制</span>交感神经激活对心力<span style="color: black;">衰尽</span>代偿的<span style="color: black;">有害</span><span style="color: black;">功效</span>，<span style="color: black;">长时间</span>应用能减轻症状、改善预后、降低死亡率和住院率；常用药为<span style="color: black;">选取</span>性β1受体阻断剂（美托洛尔、比索洛尔）与非<span style="color: black;">选取</span>性肾上腺素能α1、β1和β2受体阻断剂（卡维地洛）。β受体阻断剂的禁忌症为支气管哮喘、严重心动过缓、Ⅱ度及Ⅱ度以上房室传导阻滞、严重<span style="color: black;">周边</span>血管<span style="color: black;">疾患</span>（如雷诺病）和重度急性心衰。 所有病情稳定并<span style="color: black;">没</span>禁忌症的心功能不全<span style="color: black;">病人</span>一经诊断均应立即以小剂量<span style="color: black;">初始</span>，滴定增至<span style="color: black;">目的</span>剂量并维持治疗。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">用药<span style="color: black;">重视</span>：</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①从极低剂量<span style="color: black;">起始</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②治疗前和治疗<span style="color: black;">时期</span><span style="color: black;">病人</span><span style="color: black;">必要</span>体重恒定，已<span style="color: black;">没</span><span style="color: black;">显著</span>液体潴留，利尿剂已维持在最合适剂量。如<span style="color: black;">病人</span>有体液不足，易产生低血压；如有液体潴留，则有心力<span style="color: black;">衰尽</span>恶化的<span style="color: black;">危害</span>。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③确定β受体阻断剂治疗心力<span style="color: black;">衰尽</span>的剂量，原则与ACE <span style="color: black;">控制</span>剂相同，并不按<span style="color: black;">病人</span>的治疗反应来定，清晨静息心率55～60次/分，为达到<span style="color: black;">目的</span>剂量或最大耐受，<span style="color: black;">通常</span>不宜<span style="color: black;">小于</span>55次/分，应避免过快或<span style="color: black;">忽然</span>撤药，以防<span style="color: black;">导致</span>病情恶化。<span style="color: black;">也</span>应避免<span style="color: black;">出现</span>低血压、心动过缓及房室传导阻滞。</p>4．正性肌力<span style="color: black;">药品</span>(1)洋地黄类<span style="color: black;">药品</span>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">地高辛常以每日0.125～0.25mg <span style="color: black;">初始</span>并维持，70岁以上、肾功能损害或体重低的<span style="color: black;">病人</span>应予更小剂量（0.125mg，qd或qod）<span style="color: black;">初始</span>。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">毛花苷C(西地兰)、毒毛花苷K均为快速<span style="color: black;">生效</span>的静脉注射用制剂，适用于急性心力<span style="color: black;">衰尽</span>或慢性心衰加重时。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">最佳适应症：伴有快速心房颤动/心房扑动的收缩性心力<span style="color: black;">衰尽</span>是应用洋地黄的，其他适应症。还<span style="color: black;">包含</span>扩张型心肌病、二尖瓣或主动脉瓣病变、陈旧性心肌梗死及高血压心脏病<span style="color: black;">导致</span>慢性心力<span style="color: black;">衰尽</span>。</p><span style="color: black;">不消</span>洋地黄的<span style="color: black;">状况</span>：<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">1.代谢<span style="color: black;">反常</span><span style="color: black;">导致</span>的高排血量心衰如贫血性心脏病、甲状腺功能亢进<span style="color: black;">导致</span>心衰，洋地黄治疗效果欠佳。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.肺心病常伴低氧血症，易<span style="color: black;">出现</span>洋地黄中毒，应慎用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.肥厚型心肌病<span style="color: black;">病人</span>可能使原有的血流动力学<span style="color: black;">阻碍</span>加重，禁用洋地黄。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.风湿性心脏病单纯二尖瓣狭窄伴窦性<span style="color: black;">心率</span>的肺水肿<span style="color: black;">病人</span>因<span style="color: black;">增多</span>右心室收缩功能可能加重肺水肿程度而禁用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">5.严重窦性心动过缓或房室传导阻滞<span style="color: black;">病人</span>禁用。</p>(2)非洋地黄类正性肌力药<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①β体激动剂：多巴胺与多巴酚丁胺是常用的静脉制剂，多巴胺是去甲肾上腺素前体，激动多巴胺受体，可降低外周阻力，扩张肾血管、冠脉和脑血管；两者均只能短期静脉应用，在慢性心衰加重时起到<span style="color: black;">帮忙</span><span style="color: black;">病人</span>渡过难关的<span style="color: black;">功效</span>，连续用药超过72h可能<span style="color: black;">显现</span>耐药，<span style="color: black;">长时间</span><span style="color: black;">运用</span>将<span style="color: black;">增多</span>死亡率。</p>

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②磷酸二酯酶<span style="color: black;">控制</span>剂：<span style="color: black;">包含</span>米力农、氨力农等，<span style="color: black;">经过</span><span style="color: black;">控制</span>磷酸二酯酶活性促进Ca2+通道膜蛋白磷酸化，Ca2+内流<span style="color: black;">增多</span>，从而<span style="color: black;">加强</span>心肌收缩力。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">磷酸二酯酶<span style="color: black;">控制</span>剂短期应用可改善心衰症状，但已有<span style="color: black;">科研</span>证明，<span style="color: black;">长时间</span>应用米力农治疗重症慢性心力<span style="color: black;">衰尽</span>，<span style="color: black;">病人</span>的死亡率<span style="color: black;">增多</span>。<span style="color: black;">因此呢</span>，该药已很少应用，仅对心脏术后急性收缩性心力<span style="color: black;">衰尽</span>、难治性心力<span style="color: black;">衰尽</span>及心脏移植前的终末期心力<span style="color: black;">衰尽</span>的<span style="color: black;">病人</span>短期应用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">用药<span style="color: black;">重视</span>1.治疗心力<span style="color: black;">衰尽</span>不仅要缓解症状，更<span style="color: black;">要紧</span>的是降低死亡率和再住院率，改善<span style="color: black;">长时间</span>预后。<span style="color: black;">因此呢</span>，应当<span style="color: black;">保持</span><span style="color: black;">长时间</span><span style="color: black;">运用</span>足够剂量的ACEI和β受体阻断剂，除非<span style="color: black;">病人</span><span style="color: black;">不可</span>耐受。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.<span style="color: black;">起始</span>治疗后数日，应监测血钾和肌酐，病情稳定后，可延长检测时间至<span style="color: black;">几周</span>或数月1次。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.洋地黄中毒及其处理&nbsp;</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">① 洋地黄中毒表现：最<span style="color: black;">要紧</span>的表现为各类<span style="color: black;">心率</span>失常，<span style="color: black;">平常</span>有室性期前收缩，多表现为二联律，非阵发性交界区心动过速，房性期前收缩，心房颤动及房室传导阻滞等。 快速房性<span style="color: black;">心率</span>失常伴传导阻滞是洋地黄中毒的特征性表现。胃肠道表现可有恶心、呕吐，神经系统症状可有视力模糊、黄视、绿视等。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②洋地黄中毒的<span style="color: black;">危害</span><span style="color: black;">原因</span>：地高辛血药浓度＞2.0mg/ml易<span style="color: black;">出现</span>洋地黄中毒，但在心肌缺血、缺氧及低血钾、低血镁、甲状腺功能<span style="color: black;">衰退</span>的<span style="color: black;">状况</span>下则中毒剂量更小。心血管病常用<span style="color: black;">药品</span>如胺碘酮、维拉帕米及奎尼丁等均可降低地高辛的经肾排泄率而<span style="color: black;">增多</span>中毒的可能性。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③ 洋地黄中毒的处理：<span style="color: black;">出现</span>洋地黄中毒后应立即停药。单发性室性期前收缩、I度房室传导阻滞等停药后常<span style="color: black;">自动</span>消失；对快速性<span style="color: black;">心率</span>失常者，如血钾浓度低则可用静脉补钾，如血钾不低可用利多卡因或苯妥英钠。电复律<span style="color: black;">通常</span>禁用，因易致心室颤动。有传导阻滞及缓慢性<span style="color: black;">心率</span>失常者可予阿托品静脉注射，此时异丙肾上腺素易诱发室 性<span style="color: black;">心率</span>失常，不宜应用。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">病人</span>教育1.<span style="color: black;">认识</span>心力<span style="color: black;">衰尽</span>知识</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">病人</span>及家属应得到准确的<span style="color: black;">相关</span><span style="color: black;">疾患</span>知识和管理的<span style="color: black;">指点</span>，内容<span style="color: black;">包含</span>健康的生活方式、<span style="color: black;">安稳</span>的<span style="color: black;">心情</span>、诱因的规避、规范的<span style="color: black;">药品</span><span style="color: black;">吃下</span>、<span style="color: black;">恰当</span>的随访计划等。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">2.<span style="color: black;">平常</span>体重监测</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">能简便直观地反映<span style="color: black;">病人</span>体液潴留<span style="color: black;">状况</span>及利尿剂疗效，<span style="color: black;">帮忙</span><span style="color: black;">指点</span><span style="color: black;">调节</span>治疗<span style="color: black;">方法</span>。体重改变<span style="color: black;">常常</span>出<span style="color: black;">此刻</span>临床体液潴留症状和征之前。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">3.<span style="color: black;">膳食</span>管理</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">心衰<span style="color: black;">病人</span><span style="color: black;">身体</span>水钠潴留，故<span style="color: black;">掌控</span>液体入量、减少钠盐摄入有利于改善<span style="color: black;">以上</span><span style="color: black;">状况</span>。</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">4.<span style="color: black;">休憩</span>与活动</p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">急性期或病情不稳定者应限制体力活动，卧床<span style="color: black;">休憩</span>，以降低心脏负荷，有利于心功能的恢复。但<span style="color: black;">长时间</span>卧床易<span style="color: black;">出现</span>深静脉血栓形成<span style="color: black;">乃至</span>肺栓塞，<span style="color: black;">同期</span><span style="color: black;">亦</span>可能<span style="color: black;">显现</span>消化功能减低、肌肉萎缩、坠积性肺炎、压疮等，适宜的活动能<span style="color: black;">加强</span>骨骼肌功能，改善活动耐量。<span style="color: black;">因此呢</span>，应鼓励病情稳定的心衰<span style="color: black;">病人</span>主动运动，<span style="color: black;">按照</span>病情轻重不同，在不诱发症状的前提下从床边小坐<span style="color: black;">起始</span>逐步<span style="color: black;">增多</span>有氧运动。</p>考考你<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">左心<span style="color: black;">衰尽</span>最早<span style="color: black;">显现</span>的症状是</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">A.</span><span style="color: black;">夜间阵发性<span style="color: black;">呼气</span>困难</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">B.</span><span style="color: black;">端坐<span style="color: black;">呼气</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">C.</span><span style="color: black;">劳力性<span style="color: black;">呼气</span>困难</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">D.</span><span style="color: black;">粉红色<span style="color: black;">泡泡</span>样痰</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">E.</span><span style="color: black;">乏力</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">右心<span style="color: black;">衰尽</span>最常见的症状是</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">A.</span><span style="color: black;">腹胀、食欲不振、恶心、呕吐</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">B.</span><span style="color: black;">夜间阵发性<span style="color: black;">呼气</span>困难</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">C.</span><span style="color: black;">端坐<span style="color: black;">呼气</span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">D.</span><span style="color: black;">劳力性<span style="color: black;">呼气</span>困难</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">E.</span><span style="color: black;">粉红色<span style="color: black;">泡泡</span>样痰</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">答案：</span><span style="color: black;">CA</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_png/Qbp48GiaoaDCgqabRaibrUyOgHicgn87d5SLIB2ib69yq8NJgDq5Rm1mVTg6lCQJaSIGtjrFO0ZUbt5wxDzmjf5hbQ/640?wx_fmt=png&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/mmbiz_jpg/Qbp48GiaoaDCgqabRaibrUyOgHicgn87d5SsicNMOib9kmsevjaRlgg4SprQSmBoiat2XrEnIGgcjRqyBqwIjdEeia9Ew/640?wx_fmt=jpeg&amp;tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>

流星的美 发表于 2024-9-5 15:24:22

论坛的成果是显著的，但我们不能因为成绩而沾沾自喜。

4zhvml8 发表于 2024-11-1 15:46:45

你的见解独到，让我受益匪浅，期待更多交流。

b1gc8v 发表于 2024-11-5 13:18:58

回顾历史，我们不难发现：无数先辈用鲜血和生命铺就了中华民族复兴的康庄大道。

b1gc8v 发表于 2024-11-8 05:48:54

你的话语真是温暖如春，让我心生感激。

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