Decompensated Heart Failure Fluid overload Organ hypoperfusion (low cardiac output) Maximize afterload reduction with Symptomatic IV Boluses of Loop Diuretic ACE inhibitors, hydralazine pulmonary congestion Addition of Metolazone Low /Normal Elevated SVR SVR Continuous Iv Infusion of Venodilator Loop Diuretic and/or Low-Dose Dopamine Dobutamine Nitroprusside or Milrinone Hemodialysis General approach to the treatment of patients hospitalized with decompensated heart failure
B Angiotensin converting enzyine inhibitors (ACEI) and angiotensin receptor blockerS(ARB ACEI captopril卡托普利 enalapril依那普利 ARB losartan氯沙坦 irbesartan厄贝沙坦
ACEI: captopril 卡托普利 enalapril 依那普利 ARB: losartan 氯沙坦 irbesartan 厄贝沙坦 B.Angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers(ARB)
Angiotensinogen Renin Bradykinin Angiotensin I Non-ACE-dependent pathways, ACE inhibitors e. g. chymase ACE Kininase Il) Inactive Angiotensin‖l Peptides I Bradykinin AT1 receptors AT2 receptors receptors AT 1 receptor antagonists Vasoconstriction Sympathetic stimulation Nitric oxide Cellular hypertrophy Prostacyclin Aldosterone Renovascular effects
inhibitors ( ACEl and angiotensin receptor antagonists ACEl 1. Pharmacological effects a Inhibiting the production of Ang ll vasoconstriction sodium retention V cardiac remodeling(myocardial hypertrophy )l Inhibiting the degradation of bradykinin vasodilatation个 Increasing ANP and scavenge free radicals
ACEI 1. Pharmacological effects ◼ Inhibiting the production of Ang II ◼ vasoconstriction ; sodium retention ; ◼ cardiac remodeling (myocardial hypertrophy) ◼ Inhibiting the degradation of bradykinin ◼ vasodilatation ◼ Increasing ANP and scavenge free radicals B. Angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor antagonists
Actions faCET Angiotensin li Inactive peptide bradykinin Angiotensin I ACEI ACEI B2receptor ACE Circulation and local ACE tissues Circulation and local PGI NO tissues Vasodilatation Anti-proliferation, anti-hypertrophy
Angiotensin II Angiotensin I ACE Circulation and local tissues ACEI ACE Circulation and local tissues (—) B2 receptor PGI2 NO ACEI (—) brandykinin Inactive peptide Vasodilatation Anti-proliferation, anti-hypertrophy Actions of ACEI