心血管专家常说，治疗心衰有个“黄金三角”，是哪三大类药物？
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">倘若</span>把人体比作一台<span style="color: black;">设备</span>，血管<span style="color: black;">便是</span>运输能量的通道，心脏<span style="color: black;">便是</span>抽水机，负责把血液泵送到各个器官，<span style="color: black;">倘若</span>心脏出了问题，人的生活质量肯定大受影响。心力衰竭（简<span style="color: black;">叫作</span>心衰）是<span style="color: black;">各样</span>心血管事件的<span style="color: black;">最后</span>结果和<span style="color: black;">各样</span>心脏<span style="color: black;">反常</span>的累积效应，<span style="color: black;">最后</span><span style="color: black;">引起</span>心脏泵功能下降。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">随着我国老龄化社会进程加速，高血压、糖尿病、冠状动脉<span style="color: black;">疾患</span>及<span style="color: black;">肥壮</span>等<span style="color: black;">出现</span>率的<span style="color: black;">增多</span>，心衰发病人数<span style="color: black;">快速</span>攀升，治疗心衰<span style="color: black;">亦</span><span style="color: black;">作为</span><span style="color: black;">非常多</span>人关心的<span style="color: black;">专题</span>。心力衰竭的治疗<span style="color: black;">发展</span>方面，前沿治疗<span style="color: black;">包含</span>血管扩张剂、激素、细胞疗法、基因疗法、免疫疗法、抗病毒疗法和机械疗法，尽管初步<span style="color: black;">科研</span><span style="color: black;">表示</span>其中部分<span style="color: black;">干涉</span><span style="color: black;">办法</span>有益，但<span style="color: black;">危害</span>获益比和真实效果有待证实。而医学界<span style="color: black;">针对</span>治疗心衰的<span style="color: black;">药品</span>组合，<span style="color: black;">始终</span>有经典的“黄金三角”的说法，认为<span style="color: black;">能够</span>有效遏制心衰<span style="color: black;">发展</span>，给<span style="color: black;">病人</span>带来重生的<span style="color: black;">期盼</span>，<span style="color: black;">详细</span>是<span style="color: black;">那些</span><span style="color: black;">药品</span>呢？</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（1）肾素-血管紧张素-醛固酮系统（RASS）<span style="color: black;">控制</span>剂</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">RASS即肾素-血管紧张素-醛固酮系统，其激活<span style="color: black;">状况</span>与心衰的严重程度<span style="color: black;">关联</span>。RASS<span style="color: black;">控制</span>剂可降低心脏负荷，逆转心脏重构，降低病死率，<span style="color: black;">重点</span>有血管紧张素转换酶<span style="color: black;">控制</span>剂（ACEI）、血管紧张素受体拮抗剂（ARB）和血管紧张素受体-脑啡肽酶<span style="color: black;">控制</span>剂（ARNI）三类。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">①普利类降压药</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">常以“普利”二字结尾，如卡托普利、依那普利、福辛普利、贝那普利等，被公认是治疗心衰的基石和首选<span style="color: black;">药品</span>，<span style="color: black;">做为</span>血管紧张素转换酶<span style="color: black;">控制</span>剂，它们抗心衰的原理是<span style="color: black;">控制</span>血管紧张素转换酶，减少血管紧张素Ⅱ产生，从而<span style="color: black;">控制</span>了心肌细胞重构的作用，防止心肌的结构和质量<span style="color: black;">出现</span>改变，就<span style="color: black;">守护</span>了心功能。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">此类<span style="color: black;">药品</span>，双侧肾动脉狭窄<span style="color: black;">病人</span>及妊娠女性禁用 ，血肌酐高、血钾高的<span style="color: black;">病人</span>慎用。<span style="color: black;">通常</span>从小剂量<span style="color: black;">起始</span><span style="color: black;">运用</span>，<span style="color: black;">逐步</span>递增，达到<span style="color: black;">目的</span>剂量后终生维持，避免<span style="color: black;">忽然</span>停药，<span style="color: black;">以避免</span>病情恶化。<span style="color: black;">起始</span>治疗后1-2周内<span style="color: black;">检测</span>血钾和肾功能，以后每隔1月到2个月复查。<span style="color: black;">平常</span>不良反应为干咳，如停药后咳嗽消失，再次<span style="color: black;">运用</span>干咳再现，应<span style="color: black;">思虑</span>为<span style="color: black;">药品</span>副<span style="color: black;">功效</span>。</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">②沙坦类降压药</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">常以“沙坦”二字结尾，如缬沙坦、氯沙坦、坎地沙坦等，其在降低心衰病死率和发病率方面的机制和普利类<span style="color: black;">药品</span>相同，都是<span style="color: black;">控制</span>心肌重构，常用于<span style="color: black;">不可</span>耐受ACEI的心衰<span style="color: black;">病人</span>。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">双侧肾动脉狭窄<span style="color: black;">病人</span>及妊娠女性禁用。从小剂量<span style="color: black;">起始</span><span style="color: black;">运用</span>，<span style="color: black;">起始</span>应用及<span style="color: black;">调节</span>剂量后1~2周内，应监测血压（<span style="color: black;">包含</span>不同体位血压）、肾功能及血钾。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">③沙库巴曲缬沙坦</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">以沙库巴曲缬沙坦钠片为<span style="color: black;">表率</span>，可对抗血管收缩，改善水钠潴留和心脏重构。除了双侧肾动脉狭窄<span style="color: black;">病人</span>及妊娠女性禁用外，重度肝损害、胆汁性肝硬化及胆汁淤积<span style="color: black;">病人</span><span style="color: black;">亦</span><span style="color: black;">不可</span><span style="color: black;">运用</span>，血肌酐高、血钾高的<span style="color: black;">病人</span>慎用。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">病人</span>由<span style="color: black;">吃下</span>ACEI/ARB转为ARNI前血压需稳定，并于停用ACEI 36小时后<span style="color: black;">才可</span>使ARNI。由小剂量<span style="color: black;">起始</span>，每2~4周剂量加倍，<span style="color: black;">逐步</span>达到<span style="color: black;">目的</span>剂量。<span style="color: black;">初始</span>治疗和剂量<span style="color: black;">调节</span>后应监测血压、肾功能及血钾。禁止与ACEI合用，<span style="color: black;">不该</span>与ARB联用。</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（2）β受体阻滞剂</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">多以“洛尔”二字结尾，如美托洛尔、比索洛尔、卡维地洛等，可降低心脏交感神经兴奋性，延缓或降低心脏重构，降低心脏耗氧量，从而改善心衰症状。病情稳定的心衰<span style="color: black;">病人</span>应尽早<span style="color: black;">运用</span>β受体阻滞剂，<span style="color: black;">一般</span>由小剂量<span style="color: black;">起始</span>，每2~4周剂量加倍，<span style="color: black;">逐步</span>达到<span style="color: black;">目的</span>剂量，安静状态心率降至60次/分钟<span style="color: black;">上下</span>的剂量即为<span style="color: black;">目的</span>剂量，<span style="color: black;">平常</span>不良反应为心动过缓、低血压等，故而心率＜50次/分钟或收缩压＜90毫米汞柱应<span style="color: black;">减少</span><span style="color: black;">乃至</span>停药。此类<span style="color: black;">药品</span><span style="color: black;">吃下</span><span style="color: black;">时期</span>特别要<span style="color: black;">重视</span>，不要<span style="color: black;">忽然</span>停药，应<span style="color: black;">逐步</span><span style="color: black;">减少</span>停药。</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</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>的醛固酮生成及活化<span style="color: black;">增多</span>，且与心衰严重程度成正比。<span style="color: black;">运用</span>ACEI<span style="color: black;">能够</span>降低醛固酮的水平，然而<span style="color: black;">运用</span>3个月以上ACEI后，醛固酮水平却<span style="color: black;">不可</span>保持稳定、<span style="color: black;">连续</span>地降低，即<span style="color: black;">显现</span>“醛固酮逃逸现象”。因而可联用醛固酮受体拮抗剂进一步<span style="color: black;">控制</span>醛固酮的有害<span style="color: black;">功效</span>，防止心肌纤维化与心室重塑，从而发挥心血管<span style="color: black;">守护</span><span style="color: black;">功效</span>，降低心衰病死率。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">日前</span>国内常用的醛固酮受体<span style="color: black;">控制</span>剂为螺内酯，除能治疗心衰外还有保钾利尿的<span style="color: black;">功效</span>，其<span style="color: black;">重点</span>不良反应为肾功能恶化、高血钾，还可<span style="color: black;">导致</span>男性乳房<span style="color: black;">病痛</span>或乳腺增生，为可逆性，停药后可消失。<span style="color: black;">运用</span>过程中应<span style="color: black;">定时</span>肾功能及血钾。</p>
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<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">总结</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">总之，心衰的治疗<span style="color: black;">药品</span>较多，在<span style="color: black;">无</span>禁忌症的<span style="color: black;">状况</span>下，RASS<span style="color: black;">控制</span>剂、β受体阻滞剂、醛固酮受体拮抗剂这三类心衰“金三角”<span style="color: black;">药品</span>可<span style="color: black;">做为</span>基本治疗，<span style="color: black;">运用</span>过程中<span style="color: black;">重视</span><span style="color: black;">定时</span>监测肾功能、血钾、血压，必要时在<span style="color: black;">大夫</span><span style="color: black;">指点</span>下<span style="color: black;">选择</span>辅酶Q10等等<span style="color: black;">药品</span>，<span style="color: black;">同期</span><span style="color: black;">重视</span><span style="color: black;">恰当</span><span style="color: black;">膳食</span>、健康生活方式，就能最大程度<span style="color: black;">得到</span>疗效。</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">参考文献</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"> 国家卫生计生委<span style="color: black;">恰当</span>用药专家委员会, 中国药师协会. 心力衰竭<span style="color: black;">恰当</span>用药指南（第2版）. 中国医学前沿杂志（电子版）,2019,11（07）:1-78.</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"> 王敏. 治疗心衰, 用好金三角<span style="color: black;">药品</span>. 健康生活,2018,08:44-45.</p>
<p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">（文中部分<span style="color: black;">照片</span><span style="color: black;">源自</span>网络，版权归原作者所有，<span style="color: black;">这里</span>对<span style="color: black;">照片</span>作者<span style="color: black;">暗示</span>感谢，如您<span style="color: black;">发掘</span>有任何侵犯您版权的<span style="color: black;">状况</span>，请联系我，我将删除。）</p>
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