心力衰竭患者使用利尿剂可能增加了死亡危险[图]
![心力衰竭患者使用利尿剂可能增加了死亡危险[图]/DiureticsLinkedtoIncreasedMortalityinHeartFailure/](/Images/2004/6/16/22/18/26/81_1.GIF) |
2004年3月9日，世界上最大的心力衰竭登记处——美国国立急性失代偿性心力衰竭登记处(ADHERE)的研究人员说，在为心力衰竭病人特别是其中的肾功能不足者开予利尿剂时，一定要慎重。这些资料由科斯坦卓(Maria Rosa Costanzo)昨天在美国心脏病学院第53届科学年会上提交。
为追踪心衰病人的治疗、后果和资源使用情况，于2001年成立了ADHERE。如今，它已登记了10,500名失代偿性心衰病人的资料。科斯坦卓和同事把这些病人分成两组，即肌酐水平低于2.0mg/dl组或大于等于2.0mg/dl组。作者说，他们所用的肾功能不足的阈值相当低，所以70%的病人没有肾功能不足，而有肾功能不足者约72%长期使用利尿剂治疗。
结果发现，使用了利尿剂和肌酐水平高者死亡率更高，住院时间更长。用利尿剂的肾功能不足者死亡率为7.8%，不用者为5.5%。用利尿剂的肾功能正常者死亡率为3.3%，不用者为2.7%。死亡率最高的病人是肌酐水平最高且长期使用了利尿剂的。但不管最初的肾功能如何，长期利尿剂治疗者的死亡率都比没有长期治疗者高。利尿剂也直接与住院时间长有关：肌酐水平低没有长期利尿剂治疗者平均住院5.5天，而肌酐水平高用利尿剂者平均6.9天。
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“我们需要重新考虑心衰病人的治疗。对这种病人利尿剂可能不是最佳选择”，科斯坦卓告诉记者，“如果你完善了ACE和β受体阻滞剂的治疗，病人就会稳定，可能就不再需要使用利尿剂了”。她说，她就不赞成她的病人在不需要时还使用利尿剂。“我们制定了何时用利尿剂的严格标准，如体重快速增加、水肿等情况下可用，但症状消失后要停掉”。
德州大学西南医疗中心的杨西(Clyde Yancy)提醒，“这些结论并不意味着利尿剂治疗增加了死亡率”，“首先要确认的一点是，心衰和肌酐水平大于2mg/dl的病人危险较大”，他说，“随着肌酐变化，危险还会增加”。“我们不是要去说利尿剂本身增加了危险，而是要弄清用利尿剂的病人为什么危险最大”，“这些结论令人注目，但不是确定性的……目前我还不会反对使用剂尿剂”。
Diuretics Linked to Increased Mortality in Heart Failure
, 百拇医药
Mar. 9, 2004 (New Orleans) — Caution should be used when prescribing diuretics for patients with heart failure, especially those who show signs of renal insufficiency, according to investigators with the Acute Decompensated Heart Failure National Registry (ADHERE), the world's largest heart failure registry in the world.
Maria Rosa Costanzo, MD, from Midwest Heart Specialists in Naperville, Illinois, presented the data here yesterday at the American College of Cardiology's 53rd annual scientific session.
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ADHERE was launched in 2001 to track the management, outcomes, and resource utilization of patients with heart failure. It now holds data on 105,000 patients hospitalized with decompensated heart failure.
In this analysis, Dr. Costanzo and colleagues divided patients into two groups: those with creatinine levels less than 2.0 mg/dL and those with levels of 2.0 mg/dL or higher. Dr. Costanzo noted that the ADHERE investigators used a fairly low threshold to define renal insufficiency.
, 百拇医药
Dr. Costanzo reported that 70% of those without renal insufficiency and 72% of those with renal insufficiency received chronic diuretic therapy.
Elevated creatinine level and diuretics were associated with higher death rates and longer length of hospital stay, Dr. Costanzo reported. The mortality rate for patients with renal insufficiency who were receiving chronic diuretic therapy was 7.8% compared with 5.5% for those not receiving diuretics. For patients with normal renal function receiving diuretics, mortality was 3.3% compared with 2.7% for their counterparts.
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The highest mortality rates in ADHERE occurred in patients with the highest creatinine levels who were receiving chronic diuretic therapy. But regardless of baseline renal function, mortality was higher in patients receiving chronic diuretic therapy than in patients not receiving long-term therapy.
Increased length of hospital stay was also directly correlated to diuretic use. Patients with low creatinine levels not receiving chronic diuretic therapy had a mean length of stay of 5.5 days compared with 6.9 days for patients with elevated creatinine levels receiving chronic diuretic therapy.
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"We need to rethink treatment for patients with heart failure, that diuretics may not be the best idea for these patients," Dr. Costanzo told Medscape. "What we are seeing in clinical practice is a knee-jerk reaction for physicians to give patients with decompensated heart failure larger doses of diuretics and smaller doses of [angiotensin-converting enzyme] ACE inhibitors and beta-blockers. We would like to shift that paradigm. If you optimize ACE and beta-blocker therapy, patients will stabilize and may not need diuretic therapy at all."
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Dr. Costanzo said she discharges her patients with heart failure with orders to take diuretics on an as-needed basis only. "We set fairly specific parameters on when to take them: for rapid weight gain, edema, and so on — and to stop taking them when those symptoms resolve."
Dr. Costanzo noted that with the ADHERE database, investigators can track the medications that heart failure patients are given over time. The most common diuretic prescribed was furosemide and other loop diuretics. With long-term use of these drugs, Dr. Costanzo pointed out that the kidney tries to compensate by increasing sodium resorption in the distal tubules. She recommended sequential glomerular blockade with diuretics in this patient population.
, 百拇医药
"The next step is to draw attention to the fact that practice needs to change," Dr. Costanzo said.
"These findings do not mean that diuretic therapy is causing the increase in mortality," cautioned Clyde Yancy, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, and a member of the scientific advisory committee for ADHERE.
"The first thing to do is recognize what is incontrovertible: that patients with heart failure and creatinine levels above 2 mg/dL have an increasing rate of events," Dr. Yancy told Medscape. "As the creatinine changes, the risk goes up."
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"We need to refrain from saying that administration of diuretics per se is causing the increased risk, but to identify why the patient is on diuretics in the first place," Dr. Yancy said.
"These findings are compelling and provocative but not conclusive.... I would not impugn the use of diuretics at this time," Dr. Yancy added.
ACC 53rd Annual Scientific Session: Session 1069-114. Presented March 8, 2004., http://www.100md.com