浅谈急性心梗并室性心律失常中β～受体阻滞剂的使用

本文通过β～受体阻滞剂在临床上治疗急性心梗并室性心律失常,其在扩张冠状动脉、抗血小板聚集及胺碘酮抗心律失常方面取得了显著疗效.

Inappropriate use of digoxin in patients presenting with digoxin toxicity

Background Digoxin remains widely used today despite its narrow therapeutic index and toxicity. The objective of this study was to investigate the percentage of inappropriate use of digoxin and long-term outcomes of elderly patients hospitalized for digoxin toxicity. Methods The study included 99 consecutive patients hospitalized for digoxin toxicity. The other study criteria for the inappropriate use of digoxin was regarded if participants having depressed left ventricular systolic function （ejection fraction 〈 45%） who were not on optimal medical therapy including beta-blocker and angiotensin-converting-enzyme inhibitor therapy or if participants having permanent AF who were not on optimal beta-blocker therapy. Results Appropriate digoxin usage was confirmed in 33 of patients in spite of its narrow therapeutic index. A total of 16 of 99 patients died, with a mean follow-up time of 22.1 ± 10.3 months. Conclusions Contrary to popular belief, the rate of inappropriate digoxin usage remains high. On account of its narrow therapeutic index and toxicity, digoxin should be used more carefully according to the current evidence and guidelines.

Hypertension in the elderly： insights from recent research

Hypertension is a leading cause of mortality and morbidity around the world and,prevalence of hypertension is increasing with aging.Hypertension in the elderly is associated with increased occurrence rates of sodium sensitivity,isolated systolic hypertension,and ＇white coat effect＇.Arterial stiffness and endothelial dysfunction also increase with age.These factors should be considered in selecting antihypertensive therapy.The prime objective of this therapy is to prevent stroke.The fmdings of controlled trials show that there should be no cut-off age for treatment.A holistic program for controlling cardiovascular risks should be fully discussed with the patient,including evaluation to exclude underlying causes of secondary hypertension,and implementation of lifestyle measures.The choice of antihypertensive drug therapy is influenced by concomitant disease and previous medication history,but will typically include a thiazide diuretic as the first-line agent;to this will be added an angiotensin inhibitor and/or a calcium channel blocker.Beta blockers are not generally recommended,in part because they do not combat the effects of increased arterial stiffness.The hypertension-hypoten-sion syndrome requires case-specific management.Drug-resistant hypertension is important to differentiate from faulty compliance with medication.Patients resistant to the third-line drug therapy may benefit from treatment with extended-release isosorbide mononitrate.A trial of spironolactone may also be worthwhile.

Recent advances in the management of variceal bleeding

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients.It represents a medical emergency and is associated with a high morbidity and mortality.In those who survive the initial bleeding event,the risks of further bleeding and other decompensated events remain high.The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage.Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach.Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients.This approach seeks to risk stratify patients according to their disease stage.The exact type and timing of treatment offered can then be varied to suit individual patients.At the same time,the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies.In this review,we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding.We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.

Novel treatment options for portal hypertension

Portal hypertension is most frequently associated with cirrhosis and is a major driver for associated complications,such as variceal bleeding,ascites or hepatic encephalopathy.As such,clinically significant portal hypertension forms the prelude to decompensation and impacts significantly on the prognosis of patients with liver cirrhosis.At present,non-selective bblockers,vasopressin analogues and somatostatin analogues are the mainstay of treatment but these strategies are far from satisfactory and only target splanchnic hyperemia.In contrast,safe and reliable strategies to reduce the increased intrahepatic resistance in cirrhotic patients still represent a pending issue.In recent years,several preclinical and clinical trials have focused on this latter component and other therapeutic avenues.In this review,we highlight novel data in this context and address potentially interesting therapeutic options for the future.

Variceal bleeding in cirrhotic patients

Variceal bleeding is one of the major causes of death in cirrhotic patients.The management during the acute phase and the secondary prophylaxis is well defined.Recent recommendations(2015 Baveno VI expert consensus)are available and should be followed for an optimal management,which must be performed as an emergency in a liver or general intensive-care unit.It is based on the early administration of a vasoactive drug(before endoscopy),an antibiotic prophylaxis and a restrictive transfusion strategy(hemoglobin target of 7 g/dL).The endoscopic treatment is based on band ligations.Sclerotherapy should be abandoned.In the most severe patients(Child Pugh C or B with active bleeding during initial endoscopy),transjugular intrahepatic portosystemic shunt(TIPS)should be performed within 72 hours after admission to minimize the risk of rebleeding.Secondary prophylaxis is based on the association of non-selective beta-blockers(NSBBs)and repeated band ligations.TIPS should be considered when bleeding reoccurs in spite of a well-conducted secondary prophylaxis or when NSBBs are poorly tolerated.It should also be considered when bleeding is refractory.Liver transplantation should be discussed when bleeding is not controlled after TIPS insertion and in all cases when liver function is deteriorated.