Management of acute left heart failure treated by western medicine in heart failure
1, sitting posture, legs drooping.
2, oxygen inhalation.
Oxygen should be given through 50% ethanol or 1% dimethyl silicone oil aerosol to remove lung foam, and oxygen can be given under pressure through a mask or tracheal intubation.
3, morphine 10mg subcutaneous injection or pethidine 50 ~ 100 mg intramuscular injection (deep and long breathing), if necessary, intravenous injection. Coma, shock, severe lung infection and respiratory depression are prohibited, and should be used with caution in elderly patients, which can be adjusted after half-dose observation.
4. Cardiotonic: At present, 0.2 ~ 0.4 mg of verbenolide C (Ceylon) is commonly used for intravenous slow injection with 20ml of 5% glucose solution (forbidden for patients with extremely fragile heart).
5, rapid diuresis: intravenous injection of furosemide) 20 ~ 40 mg, in order to quickly reduce the effective circulating blood volume, reduce the cardiac preload and pulmonary congestion and edema.
6. Vasodilator: If the heart failure is still not controlled after the above treatment, it can be treated with vasodilators such as phentolamine or sodium nitroprusside. The improvement of blood pressure, heart rate and clinical symptoms must be closely observed before and after medication. Sublingual administration of nitroglycerin or isosorbide dinitrate (isosorbide dinitrate) is also effective in the early stage of the disease.
7. Add 0.25g aminophylline into 20ml 10% glucose solution and inject it slowly intravenously.
8. Intravenous injection of dexamethasone 5 ~ 10 mg can enhance myocardial contraction, dilate peripheral blood vessels, relieve bronchospasm, induce diuresis, and reduce pulmonary capillary permeability.
9, pulmonary edema with severe cyanosis, or obvious microcirculation disturbance, can choose atropine, scopolamine, anisodamine (654-2) and other intravenous slow injection, to improve microcirculation perfusion.
10, treat the etiology, remove the inducement and prevent recurrence.
Treatment of congestive heart failure
1, according to the routine of heart care. Low-salt, digestible, high-vitamin diet, rest, oxygen inhalation, avoid emotional excitement, and keep the stool unobstructed.
2. Treat the cause and eliminate the inducement.
3, digitalis preparation:
The administration method is generally divided into two stages, that is, taking a loading dose in a short period of time and then giving a maintenance dose to maintain the curative effect. According to the condition and the accumulation of digitalis in the body, there are two ways of administration. ① rapid administration: for those who are in critical condition, have never used digitalis preparation or stopped using digitalis for more than 2 weeks, use digitalis l/2 load, namely lanatoside C 0.4mg for the first time, add 20ml 10% glucose solution for intravenous slow injection, and then inject 0.2 ~ 0.4 mg again after 2 ~ 4 hours, and then take digoxin orally for maintenance. Or toosendanin K 0. 1.25 ~ 0.25 mg, diluted with glucose solution and injected intravenously. If necessary, repeat 1 ~ 2 hours later 1 time (total dose 0.5mg), and then take digoxin orally for maintenance. Or take digoxin 0.5mg orally immediately, then 0.25 mg/6 ~ 8 h, * * * 2 ~ 3 times, and then use the maintenance amount. ② Slow administration method: suitable for patients with general heart failure. Digoxin can be taken orally 0.25mg/6 ~ 8h hours, or 3 times/d; Or use digitalis toxin 0. 1mg, 3 times a day, and change to maintenance dose after 2 days. For patients who are easily poisoned or whose condition is not very urgent, digoxin 0.25mg/d can be used, and the load can be reached after 2 ~ 6 days. The maintenance dose of digoxin is generally 0. 1.25 ~ 0.25mg/d, which should be reduced in elderly patients and patients with renal failure.
During the medication, we should closely observe the condition, pay attention to the heart rhythm, heart rate (70 ~ 80 beats/min), tight pulse, urine output, and whether there are any toxic reactions (such as vomiting, retinol, frequent premature beats, bipolar and bradycardia). Toxic reactions easily occur in myocarditis and myocardial hypoxia (such as myocardial hypertrophy, coronary artery stenosis, cor pulmonale and hypothyroidism). ) and electrolyte disorder, the dosage should be reduced as appropriate. For those who are suspected of toxic reaction, the serum digoxin concentration can be determined. In case of toxic reaction, besides stopping digitalis preparation and diuretic immediately, electrolyte disorder (especially hypokalemia and hypomagnesemia) should be corrected. For premature beats and tachyarrhythmia, potassium chloride can be used intravenously (patients with renal insufficiency, hyperkalemia and high atrioventricular block are prohibited), or phenytoin sodium 100 ~ 200mg diluted with normal saline can be injected intravenously. Or diluted with lidocaine 50mg and injected slowly intravenously, and then maintained at 1 ~ 4 mg/min. If the above drugs are ineffective, you can try to dilute 2g magnesium sulfate and inject it slowly intravenously, and then use 500ml 2% magnesium sulfate intravenously within 6 ~ 12 hours. If poisoning shows bradycardia, ventricular rate
4. Diuretics: hydrochlorothiazide, furosemide, phenylbutazone, diuretic sodium, aminopterin and spironolactone can be used interchangeably. Pay attention to toxic reactions and side effects (such as hyponatremia, hypochloremia and hypokalemia). ) when in use.
5. Vasodilator: isosorbide dinitrate (isosorbide dinitrate) 5mg, 3 times a day; Or nitroglycerin 0.3 ~ 0.6 mg, 3 times/d; Hydrazine (hydralazine) 10 ~ 50mg, 3/d. Intravenous injection of phentolamine10 ~ 20mg+500ml of 5% glucose solution, or intravenous drip of sodium nitroprusside 25mg+500ml of 5% glucose solution,1/d. Pay attention during medication.
6. Invertase inhibitor: commonly used captopril 6.25 ~ 25 mg, 3 times a day; Or enalapril 5 ~ 10 mg,1/d.
7, heart failure with heart rate increase or rapid arrhythmia, choose atenolol (aminoacylpropranolol) can reduce the heart rate, help to improve heart function. Usage: 12.5 ~ 25mg, 3 times a day.
Treatment of refractory heart failure
1, further careful observation and examination, looking for various factors affecting the curative effect, and giving correct treatment.
① Remove the causes, such as anemia, hyperthyroidism, rheumatism and hypertension. , must be actively treated. ② Various infections, such as respiratory infection, must be controlled; And be sure to look for hidden infection lesions, such as urinary tract infection; Patients with valve diseases should pay attention to whether there is infective endocarditis. ③ Improper application of digitalis (insufficient or excessive dose) should be adjusted. (4) Electrolyte disorder should be corrected. ⑤ Treatment complications: If there is arrhythmia, anti-arrhythmia treatment should be carried out.
2. Adrenal cortical hormone therapy: After general treatment, patients who are still in critical condition can take prednisone 10 ~ 20 mg/d in batches, and gradually reduce the dosage after the curative effect appears, and stop taking the medicine after reaching the treatment goal. The general drug is 1 ~ 2 months.
3. Short-term intravenous infusion of adrenergic inotropic drugs is helpful to control the symptoms of heart failure. For example, dobutamine 20~60mg+ 10% glucose solution 500ml, with 7.5~ 10? G/min intravenous drip, or with dopamine 20 ~ 40 mg+65438+500% glucose solution 500ml, with 2.5~5? G/min speed drops statically.
4. Vasodilators and invertase inhibitors can also be selected.
Management of pregnancy complicated with heart failure
1. Pregnancy-induced hypertension complicated with heart failure: it is mainly to dilate peripheral blood vessels, so phentolamine and sodium nitroprusside can be considered, but the former is easy to increase myocardial oxygen consumption, and the latter is too strong to control, so phentolamine should be used as appropriate. Receptor blocker. Note that cardiotonic agents, spasmolytics, diuretics, sedatives, diuretics and supplements are only adjuvant therapies.
2, other general treatment of pregnancy complicated with heart failure:
(1) Low sodium diet.
(2) Slow intravenous infusion.
(3) cardiotonic agents, diuretics and vasodilators.
(4) The delivery process should be carried out under the supervision of anesthesiologists and cardiologists.
3.ACEI and ARB are forbidden to pregnant women because they have teratogenic effects on the fetus.
Polizel's therapy
1, calm down. Comfort patients and relieve their tension and fear. At the same time, sedatives such as diazepam and lumina should be selected. If bronchospasm is complicated, drugs such as morphine and aminophylline can be used. However, morphine should be used with caution or reduced in the elderly, children and patients with poor respiratory function, and patients with cor pulmonale should be prohibited.
2, oxygen inhalation. Reasonable oxygen therapy is an important means to treat heart failure and correct dyspnea. Generally, oxygen is inhaled by nasal catheter with a flow rate of 3~5L. /minute. If the punishment of pulmonary edema is severe, 30~50% alcohol can be filtered to absorb oxygen, or defoamer can be used to facilitate the absorption of alveolar surface tension and improve pulmonary edema.
3. The application of cardiotonic drugs. Digitalis is the first choice for treating and rescuing heart failure. Digoxin 0. 125mg, twice a day, or diluted with glucose solution for intravenous injection, the first dose is 0.2~0.4mg, and then 0.2mg each time. The daily dose for adults should not exceed1.2mg.. Because the therapeutic dose of digitalis is very close to the toxic dose, it is easy to cause toxic reactions, especially for elderly patients. Because of the large heart, poor renal function, electrolyte disorder and repeated heart attacks, it is necessary to carefully select the preparation, dosage, administration method and route of digitalis according to the condition, and strengthen nursing observation and drug reaction. It is not suitable for patients with low blood external factors and ⅱ ~ ⅲ degree atrioventricular block. Nausea, vomiting, diarrhea, visual impairment, yellow vision, green vision, dizziness, headache, insomnia, especially various arrhythmia, such as ventricular premature beats? Biliary rhythm, triple rhythm, conduction block, ST-segment hook depression, heart rate slowdown, etc. Attention should be paid to digitalis poisoning. Serum digoxin concentration can be determined by radioimmunoassay, which is helpful for diagnosis. Normal adults are 1.3? 0.6m7890-g/ml, such as >: 2mg/ml, is regarded as digitalis poisoning, so it is necessary to stop taking medicine immediately, quickly eliminate the inducing factors and supplement potassium salt, because potassium can compete with digitalis for Na+? K+-ATPase receptor reduces the binding constant of cardiac glycoside and enzyme, and potassium itself can reduce myocardial autonomy, and can also hydrolyze the bound cardiac glycoside with Na+-K+ATP, thus reducing poisoning. Digoxin combined with specific antibody antigen is very effective in treating conduction block caused by digitalis poisoning.
Conventional drug therapy
1, ACE inhibitor: It is the basis of triple therapy. There have been 39 clinical trials to treat heart failure (8308 cases of heart failure, 136 1 death). All patients were systolic heart failure, LVEF.
2. Diuretics: Suitable for all patients with symptomatic heart failure. Patients with NYHAⅰ asymptomatic heart failure do not need to use it, so as to avoid the decrease of cardiac output caused by the decrease of blood volume and activate neuroendocrine. Diuretics must be combined with ACE inhibitors, because ACE inhibitors can inhibit neuroendocrine activation caused by diuretics. Diuretics can strengthen the effect of ACE inhibitor in relieving symptoms of heart failure. Diuretics are generally used indefinitely. Dose should be the minimum dose to relieve symptoms. The purpose of using diuretics is to control fluid retention in patients with heart failure. Once the edema subsides, the weight remains unchanged (the detection index of recessive edema), which can be maintained for a long time with the minimum effective amount. About the choice of preparation: thiazide drugs can be used for mild heart failure; Generally, loop diuretics should be used above the medium level, and can be used together when necessary. Because of their synergistic effect, truly refractory heart failure can be treated with furosemide (1 ~ 5 mg/h). In correcting hypokalemia, potassium-preserving diuretics are superior to potassium-supplementing agents. When combined with ACE inhibitor, it is necessary to monitor serum creatinine and potassium every 5 ~ 7 days until it is stable. Spironolactone is an aldosterone receptor antagonist, so it has a special position in the treatment of heart failure. Basil test showed that low dose spironolactone (
3. Digitalis is a traditional inotropic drug, and it also has neuroendocrine function, which can restore the inhibitory effect of cardiac baroreceptor on central sympathetic nerve impulse, thus reducing the activity of sympathetic nervous system (SN system) and RA system; Increase the tension of vagus nerve. Digitalis has a weak inotropic effect, but it does not produce tolerance. It is the only positive inotropic drug that can continuously increase LVEF. Some placebo-controlled clinical trials show that digoxin treatment 1 ~ 3 months can improve symptoms, quality of life and exercise tolerance. Whether the basic rhythm is sinus or atrial fibrillation, and the cause is ischemic or non-ischemic, it is effective. Discontinuation test of digoxin (Radiation) showed that the deterioration rate of heart failure was the lowest in the triple therapy of digoxin. 1997 DIG (Digitalisisinvestment Group) trial is the only long-term clinical trial with mortality as the main end point. The secondary end point was to observe whether digoxin would reduce the hospitalization rate due to the deterioration of heart failure. 68,065,438+0 patients with sinus heart failure were selected, with an average LVEF of 28%, 50% of patients with NYHA II and 2% of patients with NYHA IV. On the basis of standard treatment (ACE inhibitor and diuretic), digoxin was added for 28-58 months (average 37 months), and the standard dose was 0.25mg/d(70% patients). Results: The effect of digoxin on total mortality was neutral. During the 3.5-year follow-up, the cardiovascular mortality of both groups was 30%. The risk of death caused by worsening heart failure in digoxin group decreased. Digoxin significantly reduced the risk of hospitalization due to heart failure (28%, P
The FDA officially approved digoxin on 1997. This old medicine, which has been controversial for more than 200 years, has been used to treat heart failure, confirming the sustained and effective effect of digoxin. According to the international guidelines for the treatment of heart failure, digoxin can be applied to all patients with heart failure complicated with atrial fibrillation and symptomatic sinus rhythm heart failure. Patients with atrial fibrillation can adjust the dose according to the ventricular rate. There is not enough evidence whether patients with sinus rhythm are based on serum digoxin concentration. According to the digestion test, 0.25mg/day is recommended.
4、? -Receptor blockers: It has long been known that the continuous activation of SN system in chronic heart failure can promote the deterioration and sudden death of heart failure. Blood NE can be used as an index to reflect the prognosis of heart failure. ? Since 1970s, blockers have been used to treat heart failure. It can improve symptoms and LVEF, but the effect will not appear until 2 ~ 3 months after taking the medicine, which may aggravate heart failure in the early stage. This acute pharmacological effect is completely different from the long-term effect, and it is considered to be the effect of myocardium itself and the result of improving ventricular remodeling. More than 20 randomized controlled trials have been applied to nearly 10000 patients with heart failure. Blocker therapy. All patients were patients with systolic heart failure (LVEF)
5. Aldosterone receptor antagonist: Aldosterone plays an important role in myocardial extracellular matrix remodeling. When patients with heart failure use ACE inhibitors for a long time, they often appear? Aldosterone escaped? Phenomenon, that is, the level of aldosterone in blood can not keep stable and continuous decline. Therefore, some people think that ACE inhibitors and aldosterone receptor antagonists are a good combination. RALES test was published in 1999, and was selected into 1663 patients with severe heart failure (trial grade ⅳ). Etiology includes ischemic and non-ischemic cardiomyopathy. On the basis of routine treatment, spironolactone was added, the maximum dose was 25mg/d, and the average application period was 24 months. Results The total mortality decreased by 29%, the cardiogenic mortality decreased by 365,438 0%, and the nonfatal hospitalization rate aggravated by heart failure decreased by 36%(P
6. Myocardial energy optimizers: trimetazidine, coenzyme Q 10, 1, 6- fructose diphosphate (FDP), B vitamins, etc. Can improve and optimize myocardial metabolism and nourish myocardium. Among these drugs, Longdan Tongluo Capsule is very representative. The main component of its extract is 1, 6- fructose diphosphate (FDP). Heart failure is a chronic erosive disease, which seriously affects health. The energy supply of myocardial cells in all patients is insufficient. Zhou Yujie, director of the Department of Cardiology, anzhen hospital, Beijing, believes that all cardiovascular patients are involved in an obstacle of myocardial energy metabolism, and FDP, the extract of Longdan Tongluo Capsule, can promote the recovery of acute myocardial infarction and chronic myocardial energy metabolism (and failure). Clinical findings: whether in the rescue process or after the rescue, if an appropriate amount of Longdan Tongluo capsule is added to the treatment plan to quickly supply energy to myocardial cells, the activity state of myocardial cells can be fully improved, so that myocardial cells can avoid whipping injury caused by diuretics and cardiotonic agents, thus accelerating the speed and quality of rehabilitation. Clinicians also believe that even normal people should eat more substances that are conducive to enhancing the vitality of myocardial cells, which will keep them away from heart failure.
7. Angiotensin Ⅱ receptor blocker (ARB): ARB can block all the side effects of A Ⅱ, including A Ⅱ produced by ACE pathway and chymotrypsin pathway. However, the existing data are not enough to show that the efficacy of ARB exceeds or is equivalent to ACE inhibitors. ELITE test showed that the mortality rate of losartan group was 46% lower than that of captopril group (P = 0.035), but it was not the original endpoint. There was no significant difference between the two groups after applying composite endpoint correction. ELITEⅱⅱ test results showed that the mortality rate of the two groups was similar, and there was no statistical difference. The FDA has not approved ARB to treat heart failure. At present, it is suggested that people who have good tolerance to ACE inhibitors or have never used ACE inhibitors do not need ARBARB to replace those patients who have cough or angioedema and cannot tolerate ACE inhibitors. However, ARB and ACE inhibitors have similar effects on hypotension, renal function deterioration and hyperkalemia.
Treatment of heart failure with traditional Chinese medicine 1. Deficiency of heart yang and qi
The main symptoms are palpitation, shortness of breath, chest tightness, mental fatigue, dizziness, pale tongue with thin white fur and deep and thin pulse.
Tonifying yang and supplementing qi.
Baoyuan decoction is added with Atractylodis Rhizoma, Poria, Radix Polygalae, etc.
2. Heart-kidney yang deficiency syndrome
The main symptoms are palpitation, pale face, cold limbs, blue lips, or weak waist and knees, pale tongue, thin white fur and weak pulse.
Treatment method warms and tonifies heart and kidney.
Compound Shenfu decoction combined with Jingui Shenqi pill.
3. Yang deficiency and water-dampness syndrome
The main symptoms are palpitation, asthma, chest tightness and discomfort, short and red urine, edema of lower limbs, pale and fat tongue, white and slippery fur and heavy pulse.
Wenyangli water method.
Zhenwu decoction and Gui Ling Shugan decoction.
4. Deficiency of both heart qi and yin
The main symptoms are palpitation, shortness of breath, edema of lower limbs, vexation and insomnia, red or purple tongue, scanty body fluid and rapid pulse.
Treatment of invigorating qi and nourishing yin.
Add and subtract fried licorice soup.
5. Deficiency of Yin and Yang
The main symptoms are chest tightness, palpitation, difficulty in lying down, edema of lower limbs, aversion to cold limbs, upset and hot, preference for cold drinks, red tongue, less fur and rapid pulse.
Warming yang and nourishing yin.
Prescriptions Jisheng Shenqi Pill and Shengmai Powder.
6. Qi deficiency and blood stasis syndrome
The main symptoms are palpitation, shortness of breath, chest tightness and chest pain, mental fatigue, loss of appetite, abdominal distension, mild edema of lower limbs, purplish tongue and weak pulse.
Treatment of invigorating qi and removing blood stasis.
Buyang huanwu decoction
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