a dan z ye kronik kalp yetersizliği Page 24

lar>nda alt>n standart tedavi seçene¤i olarak yerini korumakta-
d>r. Kalp yetersizli¤inde kullan>lan baz> farmakolojik ajanlar
akut KY tablosu da dahil olmak üzere tüm evrelerde prognoza
olumlu katk>da bulunmaktad>r. Bu ajanlar beta blokerler, ADE
inhibitörleri, ARB'ler ve aldosteron antagonistleridir.

Semptomatik veya asemptomatik sol ventrikül disfonksi-

yonu olan KY hastalar>n>n tedavisinde ADE inhibitörlerinin
kullan>lmas> prognoz üzerine etkilidir ve mortaliteyi azalt>r
(13). Aldosteron antagonisti, ADE inhibitörü ve ARB kombi-
nasyonundan oluflan üçlü tedavinin artan yan etkiler sebebiyle
KY tedavisinde birlikte uygulanmamas> gerekti¤ini belirtil-
mektedir (14-16). Büyük ölçekli randomize çal>flmalar>n sonuç-
lar> aldosteron antagonistlerini KY tedavisinin önemli bir par-
ças> haline getirmifltir. Aldosteron antagonistleri azalm>fl sol
ventrikül sistolik fonksiyonu olan, orta-ciddi semptomlu tüm
KY hastalar>nda kullan>lmal>d>r (16-19). ßblokerlerin uzun bir
süre KY'de kontraendike kabul edilmesine ra¤men literatür in-
celendi¤inde bu ajanlar>n KY tedavisinde prognoz üzerine
olumlu etkileri anlafl>lm>flt>r (20). Yap>lan çal>flmalar ßbloker-
lerin KY tedavisinin önemli köfle tafllar>ndan biri oldu¤unu bi-
ze göstermektedir.

Kaynaklar

ESC Guidelines for the diagnosis and treatment of acute and chro-
nic heart failure 2008: the Task Force for the Diagnosis and Treat-
ment of Acute and Chronic Heart Failure 2008 of the European So-
ciety of Cardiology. Eur Heart J. 2008;29(19):2388-442.

2009 Focused update incorporated into the ACC/AHA 2005 Guide-
lines for the Diagnosis and Management of Heart Failure in Adults
A Report of the American College of Cardiology Foundation/Ame-
rican Heart Association Task Force on Practice Guidelines Develo-
ped in Collaboration With the International Society for Heart and
Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1-e90.

Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ.More
`malignant' than cancer? Five-year survival following a first admis-
sion for heart failure Eur J Heart Fail. 2001;3(3):315-22.

Schocken DD, Benjamin EJ, Fonarow GC et al. Prevention of heart
failure: a scientific statement from the American Heart Association
Councils on Epidemiology and Prevention, Clinical Cardiology,
Cardiovascular Nursing, and High Blood Pressure Research; Qua-
lity of Care and Outcomes Research Interdisciplinary Working Gro-
up; and Functional Genomics and Translational Biology Interdiscip-
linary Working Group. Circulation. 2008;117(19):2544-65.

Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Jo-
int National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52.

American Diabetes Association. Standards of medical care in diabe-
tes: 2006 [published correction appears in Diabetes Care.
2006;29:1192]. Diabetes Care. 2006;29 (suppl 1):S4-S42.

Yusuf S, Sleight P, Pogue J, et al., for the The Heart Outcomes Pre-
vention Evaluation Study Investigators. Effects of an angiotensin-
converting-enzyme inhibitor, ramipril, on cardiovascular events in
high-risk patients. N Engl J Med. 2000;342:145-53.

Heart Outcomes Prevention Evaluation Study Investigators. Effects
of ramipril on cardiovascular and microvascular outcomes in peop-
le with diabetes mellitus: results of the HOPE study and MICRO-
HOPE substudy. Lancet. 2000;355:2539.

Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, Ste-
venson LW. Clinical assessment identifies hemodynamic profiles
that predict outcomes in patients admitted with heart failure. J Am
Coll Cardiol 2003;41:1797804.

10. Hershberger RE, Nauman D, Walker TL, Dutton D, Burgess D. Ca-

re processes and clinical outcomes of continuous outpatient support
with inotropes (COSI) in patients with refractory endstage heart fa-
ilure. J Card Fail. 2003 Jun;9(3):180-7.

11. Rose EA, Gellins AC, Moskowitz AJ, Heitjan DF, Stevenson LW,

Dembitsky W, et al., for the Randomized Evaluation of Mechanical
Assistance for the Treatment of Congestive Heart Failure (RE-
MATCH) Study Group. Long-term use of a left ventricular assist de-
vice for endstage heart failure. N Engl J Med 2001;345:1435-43.

12. Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff

B, et al. Combined cardiac resynchronization and implantable car-
dioversion defibrillation in advanced chronic heart failure: The MI-
RACLE ICD Trial. JAMA 2003;289:2685-94.

13. Unger T. The role of the reninangiotensin system in the develop-

ment of cardiovascular disease. Am J Cardiol. 2002;89:3A-9A.

14. Pfeffer M, McMurray J, Velazquez E, et al. Valsartan, captopril or

both in myocardial infarction complicated by heart failure, left ven-
tricular dysfunction or both. N Engl J Med 2003; 349:1893-906.

15. Granger C, McMurray J, Yusuf S, et al. Effects of candesartan in pa-

tients with chronic heart failure and reduced left-ventricular systo-
lic function intolerant to angiotensin-converting-enzyme inhibitors:
the CHARM Alternative trial. Lancet. 2003;362:772-6.

16. Rocha R, Williams GH. Rationale for the use of aldosterone antago-

nists in congestive heart failure. Drugs. 2002;62(5):723-31.

17. Struthers A, Krum H, Williams GH.. A comparison of the aldostero-

ne-blocking agents eplerenone and spironolactone. Clin Cardiol.
2008 Apr;31(4):153-8.

18. 18- Weber KT, Brilla CG: Structural basis for pathologic left ventri-

cular hypertrophy. Clin Cardiol 1993, 16:II10II14.

19. Rouleau JL, de Champlain J, Klein M, et al.: Activation of neurohu-

moral systems in postinfarction left ventricular dysfunction. J Am
Coll Cardiol 1993, 22:390-8.

20. Waagstein F, Hjalmarson AC, Wasir HS. Apex cardiogram and

systolic time intervals in acute myocardial infarction and effects of
practolol. Br Heart J. 1974;36:1109-21.

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A'DAN Z'YE KRON