AIM:新稳定型缺血性心脏病临床诊治指南更新

2012-11-26 欧柏青 编译 医学论坛网

  近日,美国多学会联合修订了《稳定型缺血性心脏病(IHD)的临床诊治指南》,该指南2012年11月19日在线发表于《内科学文献》(Arch Intern Med)。   该新指南由Amir Qaseem医师作为主撰稿人编写,由美国医师协会(ACP),美国心脏病学会基金会(ACCF),美国心脏学会(AHA),美国胸外科学会(AATS)心血管预防护理学会(PCNA)以

  近日,美国多学会联合修订了《稳定型缺血性心脏病(IHD)的临床诊治指南》,该指南2012年11月19日在线发表于《内科学文献》(Arch Intern Med)。

  该新指南由Amir Qaseem医师作为主撰稿人编写,由美国医师协会(ACP),美国心脏病学会基金会(ACCF),美国心脏学会(AHA),美国胸外科学会(AATS)心血管预防护理学会(PCNA)以及美国胸外科医师协会(STS)共同制定。

  新指南关于社区医疗健康教育的内容有48项推荐,涉及心血管危险因素管理,某些未经证实的危险因素控制策略的讨论,药物预防心梗和死亡以及缓解心绞痛症状,血运重建改善生存及症状以及患者随访。

  新指南首先强调了生活方式干预,包括戒烟,减肥,体力活动和健康饮食。该指南还提供了一份流程图,以循证为基础强调药物干预降低未来发生心血管事件的风险。也强烈支持药物作为IHD的一线治疗方法。 

  药物治疗包括抗血小板治疗,降脂治疗(尤其是是他汀类药物)和β受体阻滞剂治疗。新指南主要有如下推荐:

  1、血管紧张素转换酶抑制剂(ACEI)用于多数缺血性心脏病(IHD),如合并糖尿病或者左室功能不全的患者。

  2、β受体阻滞剂可用于稳定型IHD缓解症状的初始治疗;如果有β阻滞剂使用禁忌或因副作用不能继续使用或者初始治疗效果不好,推荐使用钙离子拮抗剂(CCB)或者长效硝酸酯类药物。

  3、舌下含服硝酸甘油片或者硝酸甘油喷雾剂推荐用于紧急缓解心绞痛发作。

  4、如果患者经药物治疗后症状持续不缓解,建议采用冠状动脉血运重建。

  5、推荐对一支或多支血管的明显病变(>70%)进行血运重建【冠状动脉旁路移植术(CABG) 或者经皮冠状动脉介入治疗(PCI)】治疗,以改善症状。但不推荐CABG 或者PCI用于冠脉狭窄未达到解剖学标准(左主干狭窄>50%,其他血管狭窄≥70%)或者生理学标准的患者。此外,如患者由于依从性或者其他因素不能坚持双联抗血小板治疗,则不能做PCI。

   6、不推荐螯合疗法用于稳定型IHD患者改善症状或者降低心血管风险,指南认为该药在这方面临床运用证据不足。不过最近有一项螯合疗法临床评估试验(TACT)结果显示该药能在一定程度改善急性心梗患者的预后。

  COURAGE研究首席研究员William Boden博士指出,应遵循生活方式干预和戒除不健康行为,随后进行二级预防和药物治疗的顺序管理IDH患者。他还指出,新指南期待已久并非常必要,因为自从2002年以来无论在血运重建还是药物治疗方面都已经发生了很大的变化,如何整合这些治疗至关重要。首先也是最重要的目标是预防死亡和IHD的并发症,以及心梗和心衰,然后才是改善生活质量和症状。

  指南全文:Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical Practice Guideline From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons

  

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