지난 30년 동안 ACE/ARB, Beta-blockers, MRS, ARNI 약제는 누적적으로 HFrEF 환자의 사망률을 60% 이상 감소시켰습니다.
ADHF(acute decompensated heart failure)
HFrEF 환자에서 이환률과 사망률을 줄이는 증거 기반 약물 치료는 ACEI, ARB, ARNI, beta blocker, MRA입니다. 혈압이 감소되어 있는 acute decompensated heart failure 환자에서는 이 약제 투약을 보류하고(ie, the first 12 to 24 hours) 일단 환자가 안정화된 이후에(often within 48 hours after presentation) 투약합니다. 이전에 ACEI, ARB, ARNI를 복용하지 않았던 환자는 ADHF로 내원할 당시에 투약 시작을 하지 않습니다. 기존에 ACEI, ARB, ARNI를 복용 중인 환자는 주의하면서 지속하는 것을 제안하지만, 저혈압, 신기능 악화, 고칼륨혈증이 있다면 중단하거나 용량을 감량합니다. 즉 혈압이 저하된 환자에서는 시작하면 안되고, 복용 중이라면 중단하거나 감량합니다.
Approach to long-term therapy for heart failure with reduced ejection fraction
Evidence-based pharmacologic therapy to reduce morbidity and mortality for patients with chronic HFrEF includes an angiotensin converting enzyme (ACE) inhibitor, single-agent angiotensin receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNI); a beta blocker; and a mineralocorticoid receptor antagonist (MRA). During an acute HF episode, management of these agents depends upon whether the patient was already receiving these medications and whether the patient has contraindications to therapy such as hemodynamic instability or acute kidney injury. Once the patient is stable, evidence-based therapies are carefully initiated, re-initiated, or titrated with arrangements for appropriate outpatient follow-up. In stable patients, ACE inhibitor, ARNI (or ARB, if neither ACE inhibitor nor ARNI are tolerated) and beta blocker therapy should be initiated prior to hospital discharge and MRA as appropriate should be added prior to or soon after discharge (as needed to allow appropriate monitoring of serum potassium levels).
REF. UpToDate 2019.08.21
Heart Failure: A Companion to Braunwald's Heart Disease Fourth Edition
