肺动脉高压该怎么用药?阜外医院经验

2021-06-04 罗勤,柳志红 中国循环杂志

肺动脉高压可源于肺血管自身病变,也可继发于其他疾病。肺动脉高压第一大类动脉性肺动脉高压晚期预后极差。

肺动脉高压可源于肺血管自身病变,也可继发于其他疾病。肺动脉高压第一大类动脉性肺动脉高压晚期预后极差。

怎样给予更好的治疗?

阜外医院柳志红、罗勤指出,肺动脉高压的治疗绝非简单的处方靶向药物,而是一个包括病情严重程度评估、急性肺血管反应性评价、一般措施、支持治疗、PAH 特异性治疗、疗效评价及介入和外科治疗的复杂过程。

两位学者指出,在初次接诊和每次随访肺动脉高压患者时,均应根据基线及随访指标准确进行危险分层,并采取积极措施使患者保持在低危状态。

建议病情稳定的患者每3~6个月随访1次。要注意的是,“稳定中危”的患者死亡风险高,因此稳定不代表好,还需稳定在低危状态。

对于危险分层,第六届世界肺动脉高压大会提出了一种简化的四项六参数危险分层法,并给出了低、中、高危的定义。这样分层的目的意在将风险评估与治疗无缝链接。

表1 第六届世界肺动脉高压大会简化的肺动脉高压风险评估

治疗方面,WHO功能Ⅱ~Ⅲ级患者,建议起始单药治疗或联合口服药物治疗;对高危患者,或病情恶化的功能Ⅲ级患者,或对治疗反应不佳的患者建议肠外给予前列环素类药物,若治疗效果不佳,可考虑序贯双联或三联治疗。

起始单药治疗的适宜患者包括:

(1)特发性肺动脉高压、遗传性肺动脉高压、疾病相关性肺动脉高压患者,若急性肺血管反应试验阳性,应接受最大耐受剂量的钙拮抗剂治疗,使患者临床症状,运动耐量,肺动脉压和肺血管阻力(PVR)达到并维持在接近正常;

(2)长期接受单药治疗(>5~10 年),症状稳定处于低危状态的患者;

(3)年龄>75 岁,存在射血分数保留心力衰竭的多个危险因素(高血压、糖尿病、冠心病、心房颤动、肥胖);

(4)怀疑或者高度可能是肺静脉闭塞症/肺毛细血管瘤的患者;

(5)HIV或门脉高压或者未矫正的先天性心脏病相关肺动脉高压(由于上述患者未被纳入起始联合的随机对照试验 );

(6)轻症肺动脉高压患者(即 WHO功能Ⅰ级、PVR<4 WU、平均肺动脉压<30 mmHg、超声心动图示右心室功能正常 );

(7)联合治疗无法获得或有禁忌证者(如严重肝脏疾病 )。

作为Ⅰ级推荐的序贯治疗方案有:西地那非 + 马昔滕坦、波生坦 + 利奥西呱片,内皮素受体阻滞剂或 5 型磷酸二酯酶抑制剂+Selexipag、依前列醇加西地那非。

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    2020-07-11 148ba1d5m35暂无昵称

    一楼打广告那个大家别信

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    2020-06-28 1de33e15m69(暂无匿称)

    必须吃燕窝,我妈吃一氧化氮保护动脉大血管和日本造的地龙补巡素后,肺动脉已经从比大拇指还粗恢复正常水平,肺正治甚难,喝西双版纳肾茶袋泡茶后血压明显被**下去了

    0

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  6. [GetPortalCommentsPageByObjectIdResponse(id=1925368, encodeId=b29d192536823, content=<a href='/topic/show?id=26d633354c9' target=_blank style='color:#2F92EE;'>#动脉高压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33354, encryptionId=26d633354c9, topicName=动脉高压)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=44a360, createdName=jklm09, createdTime=Wed Jan 13 07:22:02 CST 2021, time=2021-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1816173, encodeId=f1d718161e3fd, content=<a href='/topic/show?id=fc4e9e348b6' target=_blank style='color:#2F92EE;'>#阜外医#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97348, encryptionId=fc4e9e348b6, topicName=阜外医)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c97a2500111, createdName=thinkibmz_44722594, createdTime=Wed Jul 01 11:22:02 CST 2020, time=2020-07-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=802515, encodeId=418b80251585, content=一楼打广告那个大家别信, beContent=null, objectType=article, channel=null, level=null, likeNumber=149, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eb9f5325551, createdName=148ba1d5m35暂无昵称, createdTime=Sat Jul 11 16:31:23 CST 2020, time=2020-07-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=800061, encodeId=c2db80006199, content=必须吃燕窝,我妈吃一氧化氮保护动脉大血管和日本造的地龙补巡素后,肺动脉已经从比大拇指还粗恢复正常水平,肺正治甚难,喝西双版纳肾茶袋泡茶后血压明显被**下去了, beContent=null, objectType=article, channel=null, level=null, likeNumber=150, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c2531680715, createdName=1de33e15m69(暂无匿称), createdTime=Sun Jun 28 01:07:32 CST 2020, time=2020-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1293770, encodeId=aee91293e706a, content=<a href='/topic/show?id=4c6e9e34931' target=_blank style='color:#2F92EE;'>#阜外医院#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97349, encryptionId=4c6e9e34931, topicName=阜外医院)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8942242, createdName=jj000001, createdTime=Sat Jun 27 16:22:02 CST 2020, time=2020-06-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=799902, encodeId=6406e9990288, content=<a href='/topic/show?id=0bad820e112' target=_blank style='color:#2F92EE;'>#肺动脉高压#</a>不罕见的罕见病!🌴🌴🌴, beContent=null, objectType=article, channel=null, level=null, likeNumber=217, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82071, encryptionId=0bad820e112, topicName=肺动脉高压)], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/02/28/889a1910ded7780f3c049b354f1648b7.jpg, createdBy=2a791737770, createdName=mswert122, createdTime=Fri Jun 26 08:31:27 CST 2020, time=2020-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1050901, encodeId=b46d105090161, content=肺动脉高压表面是罕见病,事实上临床上并不少见,治疗药物虽然有一些,但是整体仍然不理解,可能未来需要采用综合治疗措施。, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=明天jing, createdTime=Fri Jun 26 04:22:02 CST 2020, time=2020-06-26, status=1, ipAttribution=)]
    2020-06-26 mswert122

    #肺动脉高压#不罕见的罕见病!🌴🌴🌴

    0

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    2020-06-26 明天jing

    肺动脉高压表面是罕见病,事实上临床上并不少见,治疗药物虽然有一些,但是整体仍然不理解,可能未来需要采用综合治疗措施。

    0

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