【文章內(nèi)容簡介】 Functions and Effects of the RAAS 29/70 30/70 ㈠ 擴管降壓，增加動脈血管順應(yīng)性 ㈡ 抗心血管病理性重構(gòu) ㈢ 保護血管內(nèi)皮細胞 ㈣ 抗心肌缺血和保護心肌 ㈤ 保護腎臟 ㈥ 抗動脈粥樣硬化 ㈣ 抗氧化作用 ACEI降低血漿脂質(zhì)過氧化物濃度，對抗自由基對心臟和血管的損傷作用。 三、作用機理（機制） ㈠減少 Ang II的生成 因 Ang II量減少，削弱Ang II對心血管的 直接 和 間接 作用。 ㈡ 減少 BK的代謝 BK量增加，通過激活 PLC和PLA2，使 NO和 PGI2增加 → 舒張血管、抗血小板聚集、抗心血管細胞肥大增生。 31/70 ㈢ 抑制交感神經(jīng)遞質(zhì)的釋放 減弱 AngⅡ 對交感神經(jīng)沖動傳遞的易化作用 。 Hypertension 高血壓 (一線藥物 ) ACE inhibitors alone normalize blood pressure in approximately 50% of patients with mild to moderate hypertension. 90％ of patients with mild to moderate hypertension will be controlled by the bination of an ACE inhibitor and either a Calcium channel blocker, an adrenergic receptor blocker, or a diuretic. 32/70 Therapeutic Uses 在輕～中度高血壓，單用轉(zhuǎn)換酶抑制劑可使 50％患者的血壓得以控制，如與其他降壓藥合用，控制率可達 90％。 33/70 ACE inhibitors are superior to other antihypertensive drugs in hypertensive patients with diabetes, in whom they improve endothelial function and reduce cardiovascular events. 在伴有糖尿病的高血壓病人，轉(zhuǎn)換酶抑制藥能改善內(nèi)皮細胞功能，減少心血管事件，故優(yōu)于其他抗高血壓藥物。 Left Ventricular Systolic Dysfunction 34/70 ACE Inhibitors prevents or delays the progression of heart failure, decreases the incidence of sudden death and myocardial infarction, decreases hospitalization, and improves quality of life. ACE 抑制藥能預(yù)防或延緩心衰的進展，減少心梗和猝死事件，降低住院率，改善生活質(zhì)量。 （左室收縮功能不全） (一線藥物 ) 35/70 Several large prospective, randomized, placebocontrolled clinical studies support the usefulness of ACE inhibitors in patients with varying degrees of left ventricular systolic dysfunction. 大樣本、前瞻性、隨機、安慰劑對照的臨床試驗結(jié)果支持在各種程度的左室收縮性功能不全患者使用轉(zhuǎn)換酶抑制藥。 36/70 Unless contraindicated, ACE inhibitors should be given to all patients with impaired left ventricular systolic function whether or not they have symptoms of overt heart failure. 只要沒有禁忌癥，無論其有否心衰癥狀， 所有左室收縮功能受損者 ，都應(yīng)使用 ACE抑制藥。 The more severe the ventricular dysfunction, the greater is the benefit from ACE inhibition. 左室功能不全越嚴(yán)重，使用 ACE抑制藥的受益越大。 ACE inhibitors reduce overall mortality when treatment is begun during the periinfarction period. The beneficial effects of ACE inhibitors in acute myocardial infarction are particularly large in hypertensive and diabetic patients. 37/70 Acute Myocardial Infarction 急性心梗 在圍梗死期開始用轉(zhuǎn)換酶抑制藥，降低總死亡率。患有高血壓和糖尿病的急性心肌梗死患者獲益更甚。 38/70 Unless contraindicated (., cardiogenic shock or severe hypotension), ACE inhibitors should be started immediately during the acute phase of myocardial infarction. 如無禁忌 (心源性休克、嚴(yán)重的低血壓 )， 心梗的急性期應(yīng)立即使用轉(zhuǎn)換酶抑制藥。 39/70 In highrisk patients (., large infarct, systolic ventricular dysfunction), ACE inhibition should be continued long term. 在高危病人 (大面積梗死、左室收縮功能不全 )， 轉(zhuǎn)換酶抑制劑應(yīng)長期應(yīng)用。 Clinical Trials with ACE Inhibitors in Heart Disease 臨床試驗代碼 ISIS4 SMILE HOPE UROPA 資料發(fā)表時間 1995 1995 2022 2022 入選病種 MI MI CAD CAD 入選病人數(shù) 58050 1556 9297 12218 觀察時間 1 M 6 W 5 yr yr MI 心肌梗死 － － ↓ ↓ Stroke 中風(fēng) － ↓ ↓ － cardiac death － － ↓ ↓ overall mortality ↓ ↓ ↓ － －：未觀察 40/70 ACE inhibitors tilt the fibrinolytic balance toward a profibrinolytic state in patients with coronary artery disease. 在冠心病人， ACE抑制藥使纖溶系統(tǒng)向促纖溶方向傾斜。 Patients Who Are at High Risk of Cardiovascular Events 心血管事件高?；颊? Profibrinolytic state Antifibrinolytic state 41/70 Diabetes mellitus is the leading cause of renal disease. In patients with type 1 diabetes mellitus and diabetic nephropathy, captopril prevents or delays the progression of renal disease. 42/70 Chronic Renal Failure (慢性腎衰 ) 糖尿病是腎臟疾病的首因，在 I型糖尿病和糖尿病性腎病患者，卡托普利能預(yù)防或延緩腎病的發(fā)展。 43/70 ACE inhibitors also attenuate the progression of renal insufficiency in patients with a variety of nondiabetic nephropathies and may arrest the decline in GFR even in patien