【病例学习第6期】ACE Inhibitors and ARBs in Stable Ischemic Heart Disease

From Pharmacy Times(www.pharmacytimes.com)
Thanks to the author Craig I. Coleman, PharmD(Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.)

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ACE Inhibitors and ARBs in Stable Ischemic Heart Disease

EM, a 57-year-old Hispanic woman, comes for a follow-up visit at her primary care clinic. There she sees her primary care physician (PCP) and a consulting pharmacist. The PCP asks the pharmacist if EM could take any other medications that would improve her chances of a longer life. The pharmacist discerns that EM has a 10-year history of stable angina pectoris, has never had a myocardial infarction, and has a normal ejection fraction at 64%. Her chest pain is well-controlled on metoprolol 50 mg twice daily and amlodipine 10 mg once daily with nitroglycerin tablets for acute angina attacks. She receives aspirin 162.5 mg daily and pravastatin 40 mg daily (low-density lipoprotein cholesterol 72 mg/dL).

Given this information, should another therapy be added to EM’s medical regimen?

ANSWER：

Current evidence suggests that, in patients with stable ischemic heart disease and preserved left ventricular function already receiving standard medical therapy, the risk for death and nonfatal myocardial infarction can be further reduced by 13% and 17%, respectively, when angiotensin-converting enzyme (ACE) inhibitors are added. Furthermore, in one large evaluation, the OnTARGET trial (Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial), the combination of an ACE inhibitor and an angiotensin receptor blocker (ARB) was no better than an ACE inhibitor alone, and increased the risk of adverse effects. So EM would likely benefit from ACE inhibitor therapy, but not from combination therapy with an ACE inhibitor and an ARB.


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ACEI和ARBs治疗稳定缺血性心脏病

EM，57岁的西班牙裔女子来她的初级保健诊所进行一次后续访问。在那里，她看到她的初级保健医生（PCP）和咨询药剂师。PCP向药剂师咨询是否EM能够吃药来改善预后，延长生存期。药剂师分析：EM有10年的稳定型心绞痛的病史，没有心肌梗死， 64％射血分数正常。她的胸部疼痛通过服用美托洛尔50mg，日两次，和一次10毫克氨氯地平，急性发作时，用硝酸甘油片控制的很好。她每天服用阿司匹林162.5mg和她收到162.5毫克阿司匹林和普伐他汀40毫克（低密度脂蛋白胆固醇72毫克/分升）。
鉴于这一信息，治疗方案上还有补充吗？

答案：

   现有的证据表明，当稳定缺血性心脏病和左心室功能不全的病人已经开始接受标准的药物治疗后，加用ACEI可以使死亡和非致死性心肌梗死的风险可分别进一步减少13％和17％，减少了当血管紧张素转换酶（ ACE）抑制剂的补充。此外，在一个大规模试验中，目标试验组（单用替米沙坦与联用雷米普利），ACE抑制剂和血管紧张素受体阻滞剂（ARB）的联合并不比优于单独ACE抑制剂，并增加了不良反应的风险。因此，EM应该但单独使用ACEI，而不是ACEI联合ARB.

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Furthermore, in one large evaluation, the OnTARGET trial (Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial), ...
ONTARGET试验是针对ARB和ACEI的一项十分重要的临床试验。
So EM would likely benefit from ACE inhibitor therapy, but not from combination therapy with an ACE inhibitor and an ARB.
从上下文看，EM原来的处方中并没有ACEI,更没有ACEI+ARB，药师根据一些证据和ONTARGET试验结果，认为这个病人加用ACEI可能会受益，但强调，ACEI无须与ARB合用（作用差不多，ADR的风险增加）。
个人愚见，抛砖引玉

Good good study, Day day up

楼主幸苦了。。。  人们行走在“良相”与“良医”之间