吗啡治疗急性左心衰主要基于其生理益处支持,并不依赖随机临床试验。 ① 吗啡可以抑制交感神经,舒张静脉,降低外周血管阻力,使回心血量减少,降低心脏前负荷,也可以扩张小动脉,降低心脏后负荷; ② 其次,吗啡具有的镇静止痛作用能缓解烦躁、焦虑、恐惧等情绪; ③ 另外,吗啡还可以降低呼吸中枢对二氧化碳的敏感性,松弛支气管平滑肌,使呼吸变深变慢,降低氧耗,改善患者呼吸困难症状。
迄今为止,没有随机对照试验评估吗啡对 AHF 患者住院死亡率或全因死亡率的影响。大部分急诊科乃至心内科医师仍将吗啡作为治疗急性左心衰竭的常用药物。 然而,我们注意到,有一项多中心随机对照试验(MIMO 试验)[8] 正在进行,旨在评估吗啡在急性心衰中的疗效和安全性,这不仅将填补我们在吗啡相关不良反应和风险方面的知识空白,而且有助于指导临床试验关于 AHF 患者使用吗啡的决定。 在此之前,在治疗 AHF 患者时应谨慎使用吗啡,遵从指南,仅对严重/顽固性疼痛或焦虑且不合并持续低血压、严重慢性阻塞性肺疾病、意识障碍的患者,中小剂量缓慢静脉或皮下注射吗啡,并注意个体化监护。 策划:ly 参考文献:[1] Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205-209. doi:10.1136/emj.2007.050419.[2] McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [published online ahead of print, 2021 Aug 27]. Eur Heart J. 2021;ehab368. doi:10.1093/eurheartj/ehab368.[3] Orso D, Boaro G, Cassan E, Guglielmo N. Is morphine safe in acute decompensated heart failure? A systematic review of the literature. Eur J Intern Med. 2019;69:e8-e10. doi:10.1016/j.ejim.2019.08.016.[4] Vismara LA, Leaman DM, Zelis R. The effects of morphine on venous tone in patients with acute pulmonary edema. Circulation 1976;54(2):335–7.[5] Timmis AD, Rothman MT, Henderson MA, Geal PW, Chamberlain DA.Haemodynamic effects of intravenous morphine in patients with acute myocardial infarction complicated by severe left ventricular failure. Br Med J 1980;280(6219):980–2.[6] Caspi O, Naami R, Halfin E, Aronson D. Adverse dose-dependent effects of morphine therapy in acute heart failure. Int J Cardiol. 2019;293:131-136. doi:10.1016/j.ijcard.2019.06.015.[7] Huffman JC, Stern TA. The use of benzodiazepines in the treatment of chest pain: a review of the literature. J Emerg Med. 2003;25(4):427-437.[8] Dominguez-Rodriguez A, Burillo-Putze G, Garcia-Saiz MDM, et al. Study Design and Rationale of "A Multicenter, Open-Labeled, Randomized Controlled Trial Comparing MIdazolam Versus MOrphine in Acute Pulmonary Edema" : MIMO Trial. Cardiovasc Drugs Ther. 2017;31(2):209-213. doi:10.1007/s10557-017-6722-5.(▲▼上下滑动查看全部内容)