خانه / انواع بيماريهاي قلبي / نارسايي قلبي / درمان نارسایی مزمن قلبی

درمان نارسایی مزمن قلبی


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برای درمان نارسایی مزمن قلبی، در درمان نگهدارنده اغلب از ترکیبات دیگوکسین استفاده می‌شود. همچنین تنظیم الکترولیتها و مایعات بدن ( اجتناب از احتباس آب و سدیم ) و کاستن از فشار خون ( به خصوص عوامل موثر بر انقباض عروقی شریانها مانند بلوک کننده های کانال کلسیم ) نیز به درمان حال بیمار مبتلا به نارسایی مزمن قلبی کمک می کند . استفاده از قلب مصنوعی ، پیوند قلب و پیوند سلولهای بنیادی جدیدترین روشهای درمانی نارسایی مزمن قلبی هستند.

درمان با توجه به مرحله بیمار مبتلا به نارسایی مزمن قلبی بر اساس طبقه بندی زیر انجام می شود.

Class I از بیماران نارسایی مزمن قلبی: بدون علامت هستند، محدودیتی در فعالیت ندارند و فعالیت های معمول بدنی این نوع از بیماران نارسایی مزمن قلبی سبب خستگی، طپش قلب و تنگی نفس و درد در آنها نمی شود. (فعالیت های بیش از معمول (Overordinary) سبب ایجاد علائم در بیماران نارسایی مزمن قلبی می شوند)

درمان ç کم کردن سرعت پیشرفت HF با مهار سیستم نوروهورمونال که باعث Remodeling قلب می شوند

Class II از بیماران نارسایی مزمن قلبی: محدودیت خفیف در فعالیت فیزیکی، در هنگام استراحت بی علامت هستند ولی فعالیت های روزمره این نوع از بیماران نارسایی مزمن قلبی سبب تنگی نفس ، خستگی، تپش قلب و درد می­شود.

Class III از بیماران نارسایی مزمن قلبی: محدودیت شدید در فعالیت بدنی دارند ولی در طی استراحت بی علامت هستند و فعالیت های بیماراننارسایی مزمن قلبی سبب علامت دار شدن بیمار می شوند.

Class IV از بیماران نارسایی مزمن قلبی: علائم در طی استراحت هم وجود دارند و هر نوع فعالیتی سبب تشدید علائم می شود.

در مواردی که بیمار نارسایی مزمن قلبی علامت دار است هدف کاهش احتباس مایع، کم کردن علائم و کاهش سرعت پیشرفت و مرگ است ç  تجویز دیورتیک، محدودیت آب و نمک و مهار سیستم نوروهورمونال

درمان نارسایی مزمن قلبی

۱- درمان بیماری های نارسایی مزمن قلبی همزمان مانند HTN، آنمی، CAD، اختلالات خواب و عفونت.

۲- قطع سیگار یا مصرف الکل برای درمان بیماری نارسایی مزمن قلبی (حداکثر ۲ پیک در روز در مردان و ۱÷ در زنان ولی اگر کاردیومیوپاتی الکلی دارند باید الکل کاملاً قطع شود)

۳- کم کردن فعالیتهای ورزشی شدید و جلوگیری از بالا رفتن زیاد درجه حرارت در بیماران نارسایی مزمن قلبی.

۴- محدودیت مصرف داروهایی که نارسایی مزمن قلبی را تشدید می­کنند مثل NSAIDs ها و CSI ها (Cox II Specific Inhibitor). این دو دسته دارو در مواردی که Chronic HF وجود دارد سبب احتباس آب و نمک می­شوند خصوصاً در مواردی که عملکرد کلیه کم است و یا بیمار ACEI مصرف می­کند.

سایر داروها و عواملی که نارسایی مزمن قلبی را تشدید می­کنند عبارتند از: CCBها (وراپامیل، دیلتیازم)، بتابلوکرهای طولانی اثر مانند آتنولول، ضد آریتمی ها خصوصاً کلاس I و سوتالول (تمام داروهای آنتی آریتمی اینوتروپ منفی اند بجز Dofetilide و Amiodarone)، Ab ضد TNF، حاملگی و تشدید اختلال دریچه ای.

۵-     تجویز واکسن آنفلوآنزا و پنوموکوک در درمان نارسایی مزمن قلبی .

۶- یکی از موارد مهم در درمان نارسایی مزمن قلبی آموزش رژیم و فعالیت به بیمار و خانواده ی بیمار مبتلا به نارسایی مزمن قلبی می باشد .

۷- مراقبت سرپائی از بیمار نارسایی مزمن قلبی توسط تیم مجرب پرستاری و پزشکی.

میزان فعالیت در بیمار دچار نارسایی مزمن قلبی

در بیماران نارسایی مزمن قلبی فعالیت شدید توصیه نمی شود ولی فعالیت روتین و خفیف در کلاس I-III توصیه می شود. در بیمارانی که اضافه حجم ندارند ورزش های ایزوتونیک مثل پیاده روی، دویدن و دوچرخه سواری در حد تحمل مناسب است چون باعث افزایش کمپلیانس و کیفیت زندگی می شوند. کاهش وزن و کاهش دریافت کالری توصیه می­شود.

سنگ بنای درمان نارسایی مزمن قلبی عبارتست از بتابلوکرها + ACEI‌ و دیورتیک.  اگر به این داروها جواب ندهد به آن Refractory Heart Failure  می­گویند. داروهایی که اضافه می­شوند عبارتند از ARB، آلداکتون،‌ترکیب هیدرالازین+‌نیترات و دیگوکسین. نوع درمان اضافی بر اساس شرایط بیمار (داشتن RF، سطح K،فشار خون، نژاد...) فرق می­کند.

- ترکیب غلط: ARB+ACEI+آلداکتون <‌ هیپرکالمی شدید

- اندیکاسیون تجویز دیگوکسین عبارتند از:

۱- Refractory Hear Failure+ AF

۲- HF‌ مقاوم به درمان نارسایی مزمن قلبی

دوز اولیه ۰٫۱۲۵-۰٫۲۵ mg است. سطح سرمی آن باید ۰٫۱ ng/ml> باشد خصوصاً در موارد RF، سن بالا و لاغر اندام. دوزهای بالاتر موثر نیستند. برای شروع نیاز به Loading dose ندارد.

درمان ضد انعقادی و ضد پلاکت در نارسایی مزمن قلبی

خطر ترومبوز وریدی و شریانی در HF‌بالاتر است. خطر سکته مغزی در HF سالیانه ۱٫۳-۲٫۴% است.

اندیکاسیونهای تجویز ضد انعقاد عبارتند از:

۱- AF+HF‌ مزمن یا حمله­ای یا HF+سابقه TIA یا سکته مغزی یا PTE < ‌ وارفارین با ۲-۳: INR

۲- به بیماران با کاردیومیوپاتی ایکسمیک با یا بدون علامت+MI قدامی بزرگ و یا MI‌ اخیر به همراه ترومبوز ثابت شده،‌ باید تا سه ماه بعد از MI  وارفارین (۲-۳:INR) داد.

۳- در HF+IHD باید ASA  با دوز حداکثر ۷۵-۸۱ mg داد. دوز بالاتر سبب تشدید HF‌می شود.

برای مطالعه " تغذیه در بیماران نارسایی مزمن قلبی " کلیک کنید .

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