作者：米勒之声

Calcium Channel Blockers in Acute Care: The Links and Missing Links Between Hemodynamic Effects and Outcome Evidence

急症护理中的钙通道阻滞剂：血流动力学效应与结局证据之间的联系和缺失的联系

Jin Wang David L. McDonagh Lingzhong Meng

翻译 苏洋

Abstract

Calcium channel blockers (CCBs) exert profound hemodynamic effects via blockage of calcium flux through voltage-gated calcium channels. CCBs are widely used in acute care to treat concerning, debilitating, or life-threatening hemodynamic changes in many patients. The overall literature suggests that, for systemic hemodynamics, although CCBs decrease blood pressure, they normally increase cardiac output; for regional hemodynamics, although they impair pressure autoregulation, they normally increase organ blood flow and tissue oxygenation. In acute care, CCBs exert therapeutic efficacy or improve outcomes in patients with aneurysmal subarachnoid hemorrhage, acute myocardial infarction and unstable angina, hypertensive crisis, perioperative hypertension, and atrial tachyarrhythmia. However, despite the clear links, there are missing links between the known hemodynamic effects and the reported outcome evidence, suggesting that further studies are needed for clarification. In this narrative review, we aim to discuss the hemodynamic effects and outcome evidence for CCBs, the links and missing links between these two domains, and the directions that merit future investigations.

摘要

钙通道阻滞剂 (CCBs) 通过电压门控钙通道阻断钙通量，产生深刻的血流动力学效应。 CCBs广泛用于急救治疗，以治疗许多患者的相关、虚弱或危及生命的血流动力学变化。总体文献表明，对于全身血流动力学，虽然 CCBs降低血压，但它们通常会增加心输出量；对于局部血流动力学，虽然它们会损害压力自动调节，但它们通常会增加器官血流量和组织氧合。在急症护理中，CCBs对动脉瘤性蛛网膜下腔出血、急性心肌梗死和不稳定型心绞痛、高血压危象、围手术期高血压和房性快速性心律失常患者发挥治疗作用或改善预后。然而，尽管有明确的联系，但已知的血流动力学效应与报告的结局证据之间存在缺失的联系，这表明需要进一步的研究来澄清。 在这篇叙述性综述中，我们旨在讨论 CCBs的血流动力学效应和结局证据、这两个领域之间的联系和缺失的联系，以及值得进一步研究的方向。

Key Points

关键点

尽管存在一些明确的联系，但钙通道阻滞剂产生的血流动力学效应与其临床应用相关的结局证据之间仍有许多缺失的联系。

这些缺失的环节暗示了未来的研究方向。

1 Introduction

Since the discovery of calcium channel blockers (CCBs) in the mid-1960s [1], they have been widely used or investigated for the treatment of hypertension, angina pectoris, cardiac arrhythmias, left ventricular diastolic dysfunction, Raynaud’s phenomenon, migraine, esophageal spasm, and bipolar disorder [2]. These medical conditions are characterized by a chronic course and are typically managed by doctors specializing in a non-acute care setting. In contrast, CCBs are also widely used in emergency departments, intensive critical units, and perioperative environments, all of which are distinguished by the rapidity of disease onset, the severity of the patient’s condition, and the intensity of the care needed.

自1960年代中期发现钙通道阻滞剂 (CCBs) 以来 [1]，它们已被广泛用于治疗高血压、心绞痛、心律失常、左心室舒张功能障碍、雷诺现象、偏头痛、食管痉挛和双相情感障碍 [2]。这些医疗状况的特点是慢性病程，通常由专门从事非急性护理领域的医生管理。 相比之下，CCBs还广泛用于急诊科、重症监护病房和围手术期环境，所有这些都以疾病发作的速度、患者病情的严重程度和所需护理的强度来区分。

The scenarios in acute care in which CCBs are typically used include aneurysmal subarachnoid hemorrhage (aSAH), intracerebral hemorrhage, acute myocardial infarction, hypertensive crises, and surgery under general anesthesia. These conditions frequently involve drastic systemic or regional hemodynamic changes. Hemodynamics is the magnitude and efficiency of blood circulation in the cardiovascular system and through different tissue beds. Its management is a crucial task in acute care. Although a complicated concept, hemodynamics can be pragmatically viewed as a ladder involving seven essential steps: intravascular volume, preload, cardiac output (CO), blood pressure (BP), organ perfusion, oxygen delivery, and tissue oxygen consumption–supply balance (Fig. 1) [3]. Although the effects of CCBs on BP are well-known, their effects on other hemodynamic aspects are less familiar to most physicians or care providers. Arguably, the effects of CCBs on organ perfusion and tissue oxygenation may be more essential than those on BP since the purpose of BP is to drive blood flow for organ perfusion and tissue oxygen supply. Therefore, it is apposite to specifically and comprehensively review the hemodynamic effects of CCBs in acute care.

在急诊中，CCBs通常使用的场景包括动脉瘤样蛛网膜下腔出血(aSAH)、脑出血、急性心肌梗死、高血压危象和全身麻醉下的手术。这些情况经常涉及到剧烈的全身性或区域性血流动力学改变。血流动力学是指心血管系统和通过不同组织床的血液循环的大小和效率。它的管理是急诊护理中的一项关键任务。虽然血流动力学是一个复杂的概念，但实际上可以将其视为一个阶梯，包括七个基本步骤：血管内容量、前负荷、心输出量(CO)、血压(BP)、器官灌注、氧输送和组织氧消耗-供应平衡(图1)[3]。虽然CCBs对血压的影响是众所周知的，但大多数医生或护理人员对其对其他血液动力学方面的影响却不太熟悉。可以说，CCBs对器官灌注和组织氧合的影响可能比对BP的影响更重要，因为BP的目的是驱动器官灌注和组织供氧的血流。因此，对CCBs在急诊治疗中的血流动力学效应进行全面、具体的评价是合适的。

图1 CCBs对血流动力学和心血管系统的共同作用。血流动力学被概念化为阶梯结构 [3]。CCBs 钙通道阻滞剂，CO 心输出量 ， HR 心率, PA 压力自动调节, SV 每搏输出量 ， SVR 全身血管阻力, ↑ 表示增加, ↓ 表示减少, ↔ 表示结果不一致

The aims of this narrative review are to (1) review the hemodynamic effects of CCBs, (2) summarize the outcome evidence related to their use in acute care, and (3) discuss the links and missing links between the hemodynamic effects and outcome evidence for CCBs. This review does not review the discovery, development, and clinical use of CCBs in chronic settings as they have already been discussed [1, 2, 4–6].

本叙述性综述的目的是(1)回顾CCBs的血流动力学效应，(2)总结与其在急性护理中使用相关的结局证据，(3)讨论CCBs的血流动力学效应和结局证据之间的联系和缺失的联系。这篇综述没有回顾慢性环境中CCBs的发现、开发和临床应用，因为它们已经被讨论过了[1，2，4-6]。

2 Two Pharmacologic Classes of CCBs

CCBs的两个药理学类别

The CCBs are divided pharmacologically into dihydropyridines and non-dihydropyridines:

CCBs在药理学上分为二氢吡啶类和非二氢吡啶类

The dihydropyridines are primarily vasodilators and differ in their time to onset and duration. Clevidipine is a rapid-onset, short-acting intravenous drug, making it highly titratable [7]. Nicardipine is also intravenous but longer acting and less rapidly titratable as a result. Nifedipine, nimodipine, isradipine, and amlodipine are longer acting, predominantly enteral dihydropyridines.

二氢吡啶类药物主要是血管扩张剂，起效时间和持续时间不同。氯维地平是一种速效、短效的静脉注射药物，使其高度可滴定[7]。尼卡地平也是静脉注射的，但作用时间更长，滴定速度较慢。硝苯地平、尼莫地平、伊拉地平和氨氯地平作用时间更长，主要是肠内二氢吡啶类。

The non-dihydropyridines are less vasodilatory and predominantly atrioventricular (AV) nodal blockers. The predominant drugs are diltiazem and verapamil. Both are available in parenteral and enteral formulations.

非二氢吡啶类药物血管扩张性较差，主要为房室结阻滞剂。主要药物为地尔硫卓和维拉帕米。两者都有肠胃外和肠内制剂。

3 Hemodynamic Effects of Calcium Channel Blockers (CCBs)

3 钙通道阻滞剂(CCBs)的血流动力学效应

In this discussion, we differentiate hemodynamics and the cardiovascular system because these two concepts are related but different. Hemodynamics, defined as the magnitude and efficiency of blood circulation in the cardiovascular system and through different tissue beds, is the result of the work by the cardiovascular system. Before the discussion on the hemodynamic effects of CCBs, we first briefly review their effects on the cardiovascular system.

在这次讨论中，我们区分血流动力学和心血管系统，因为这两个概念既相关又不同。血流动力学，定义为心血管系统和通过不同组织床的血液循环的大小和效率，是心血管系统工作的结果。在讨论CCBs的血流动力学效应之前，我们首先简要回顾它们对心血管系统的影响。

3.1 Effects of CCBs on the Cardiovascular System

CCBs对心血管系统的影响

In summary, the cardiovascular effects of CCBs are diverse; varying; dependent on drug, dose, course, and condition; and the result of complex interplays between direct and indirect effects.

综上所述，CCBs对心血管的影响是多样的；不同的；依赖于药物、剂量、病程和条件；以及直接和间接影响之间复杂相互作用的结果。

3.2 Effects of CCBs on Systemic Hemodynamics

CCBs对全身血流动力学的影响

Systemic hemodynamics refers to the global and overall magnitude and efficiency of blood circulation and is typically measured by parameters including BP, CO, and systemic vascular resistance (SVR) (Fig. 1).

全身血流动力学是指整体血液循环的大小和效率，通常由包括BP、CO和全身血管阻力(SVR)在内的参数来衡量(图1)。

However, it is important to emphasize that the effects of CCBs on systemic hemodynamics are dependent on drug, disease, and anesthetic. For example, diltiazem reduces CO in normotensive humans, an effect that is likely secondary to a decrease in SV without a significant increase in HR [27], and this differs from the effects observed for most CCBs (i.e., a rare exception). The doses of verapamil and nifedipine that decrease BP in hypertensive humans have minimal effect on BP in normotensive humans [25]. The effect of verapamil on CO differs between conscious [28] and anesthetized dogs [29].

然而，需要强调的是，CCBs对全身血流动力学的影响依赖于药物、疾病和麻醉剂。例如，地尔硫卓降低了血压正常的人的CO，这种效应可能继发于SV的降低而不会显著增加HR[27]，这与在大多数CCBs中观察到的效果不同(即，罕见的例外)。维拉帕米和硝苯地平降低高血压患者血压的剂量对正常血压患者的血压影响很小[25]。维拉帕米对清醒[28]和麻醉狗[29]的CO的影响不同。

3.3 Effects of CCBs on Regional Hemodynamics

CCBs对局部血流动力学的影响

The effects of CCBs on regional hemodynamics are dependent on drug [9], organ [35], disease [36], and anesthesia [37]. For example, different CCBs increase coronary blood flow differently: nifedipine > diltiazem = verapamil [9]. Additionally, nicardipine increases cerebral blood flow, whereas diltiazem does not [38].

CCBs对局部血流动力学的影响取决于药物[9]、器官[35]、疾病[36]和麻醉[37]。例如，不同的CCBs增加冠脉血流量的方式不同：硝苯地平>地尔硫卓=维拉帕米[9]。此外，尼卡地平增加脑血流量，而地尔硫卓不增加[38]。

3.4 Effects of CCBs on Pressure Autoregulation

CCBs对压力自动调节的影响

Perfusion pressure is one of the factors that determines organ blood flow. However, due to the corresponding change in flow resistance, a change in perfusion pressure may not always lead to a change in blood flow. This phenomenon is embodied in pressure autoregulation (PA), a mechanism that upholds stable organ blood flow despite changes in perfusion pressure [39]. Impaired PA renders organ blood flow pressure-passive and less tolerant to perfusion pressure fluctuations. Multiple factors related to the patient, disease, physiology and medications affect PA [39–41]. Before discussing the effects of CCBs on PA, it is prudent to first briefly review the mechanism underlying PA, although it is complicated and remains to be fully elucidated.

灌注压是决定器官血流量的因素之一。然而，由于血流阻力的相应变化，灌注压的变化并不总是导致血流量的变化。这种现象体现在压力自动调节(PA)中，这是一种在灌注压改变的情况下维持稳定器官血流的机制[39]。PA受损导致器官血流压力被动，对灌注压波动的耐受性降低。与患者、疾病、生理和药物有关的多种因素都会影响PA[39-41]。在讨论CCBs对PA的影响之前，谨慎的做法是首先简要回顾PA背后的机制，尽管它很复杂，还有待充分阐明。

4 The Outcome Evidence Related to CCB Application in Acute Care

与CCB在急诊应用相关的结局证据

4.1 Aneurysmal Subarachnoid Hemorrhage

动脉瘤性蛛网膜下腔出血

Oral nimodipine improves clinical outcome after aSAH. However, there are missing links between what we have learned about the hemodynamic effects of CCBs and the outcome evidence in this patient population.

口服尼莫地平可改善aSAH后的临床结果。然而，在我们所了解的CCBs的血流动力学效应和这一患者群体的结局证据之间还缺少联系。

4.2 Acute Myocardial Infarction or Unstable Angina

急性心肌梗死或不稳定型心绞痛

In summary, verapamil and diltiazem (non-dihydropyridines) can be used to treat unstable angina or non–STsegment elevation myocardial infarction; however, their use should be carefully considered, and the therapeutic effect is limited to symptom control. Their favorable hemodynamic effects, i.e., dilating stenotic coronary segments and lacking prominent HR-accelerating and myocardial oxygen consumption-increasing effects [102, 103], do not translate into an outcome benefit in this patient population, another example of the missing links between the hemodynamic effects of CCBs and outcome evidence.

综上所述，维拉帕米和地尔硫卓(非二氢吡啶类)可用于治疗不稳定型心绞痛或非ST段抬高性心肌梗死，但应慎用，疗效仅限于症状控制。它们良好的血流动力学效应，即扩张狭窄的冠状动脉节段，缺乏显著的心率加速和心肌耗氧量增加效应[102,103]，并没有转化为对该患者群体的预后益处，这是CCBs的血流动力学效应和预后证据之间缺失联系的另一个例子。

4.3 Hypertensive Crisis in Nonsurgical Patients

非手术患者的高血压危象

In summary, certain CCBs are among the choices of drugs for the treatment of hypertensive crisis; intravenous nicardipine can effectively and safely lower BP in patients with hypertensive emergency, whereas oral nifedipine retard is recommended as a first-line therapy for hypertensive urgency, especially for pregnant women. The long-term outcomes associated with the type of pharmacologic treatment of hypertensive crisis have not been reported.

综上所述，某些CCBs是治疗高血压危象的药物选择之一；静脉注射尼卡地平可以有效且安全地降低高血压危症患者的血压，而口服硝苯地平缓释剂被推荐作为高血压急症的一线治疗药物，特别是对孕妇。与高血压危象的药物治疗类型相关的长期结果尚未报道。

4.4 Hemodynamic Management in Perioperative Care

围手术期护理中的血流动力学管理

CCBs clearly play an important role in the management of perioperative hemodynamics. However, their effects should also be tested with regard to long-term outcomes and not just BP control and atrial tachyarrhythmia reduction limited to the immediate perioperative period. It needs to be noted that when BP is decreased following intravenous nicardipine administration, tissue oxygenation is increased in anesthetized surgical patients (Fig. 2); whether this hemodynamic effect can be translated into an outcome benefit remains to be tested, another example of the missing links between the hemodynamic effects of CCBs and outcome evidence.

CCBs显然在围手术期血流动力学管理中起着重要作用。然而，它们的效果也应该在长期结果方面进行测试，而不仅仅是限于围手术期即刻的血压控制和房性快速性心律失常的减少。需要注意的是，当静脉注射尼卡地平后血压降低时，麻醉手术患者的组织氧合增加(图2)；这种血流动力学效应是否能转化为结果益处还有待测试，这是CCBs的血流动力学效应和结局证据之间缺失联系的另一个例子。

4.5 Safety Profile and Side Effects Associated with CCBs

与CCBS相关的安全特性和副作用

As with all drugs, CCBs have both therapeutic effects and side effects. The dihydropyridine CCBs may lead to tachycardia, headache, lightheadedness, flushing, and dosedependent peripheral edema in as many as 20–30% of patients [130]. The non-dihydropyridines can cause dosedependent constipation, which may occur in as many as 25% of patients, as well as bradycardia and worsening CO [2]. In terms of mortality and major cardiovascular events, previous studies present somewhat conflictive findings associated with the chronic use of CCBs for hypertension treatment [5, 6, 131–133]; however, the evidence based on chronic care may not be generalizable to patients requiring acute care. Nonetheless, safety concerns have been raised regarding the use of CCBs in acute care. For example, the once popular use of oral (sublingual) nifedipine in the treatment of hypertensive emergencies was put on moratorium because of the seriousness of reported adverse events (such as stroke, acute myocardial infarction, and death) and a lack of clinical documentation attesting to a benefit [134].

与所有药物一样，CCBs既有治疗作用，也有副作用。在多达20-30%的患者中，二氢吡啶类CCBs可能会导致心动过速、头痛、头晕、面色发红和剂量依赖性的外周水肿[130]。非二氢吡啶类可以引起剂量依赖性便秘，这可能在多达25%的患者中发生，和心动过缓和CO恶化一样[2]。在死亡率和主要心血管事件方面，以前的研究提出了一些与慢性使用CCBs治疗高血压相关的相互矛盾的结果[5，6,131-133]；然而，基于慢性护理的证据可能无法推广到需要急性护理的患者。尽管如此，对于CCBs在急性护理中的使用还是提出了安全问题。例如，曾经流行的口服(舌下)硝苯地平治疗高血压危症被暂停，因为报道的不良事件(如中风、急性心肌梗死和死亡)的严重性，以及缺乏证明其益处的临床文件[134]。

5 The Links and Missing Links Between the Hemodynamic Effects of and Outcome Evidence for CCBs

CCBs的血流动力学效应与结局证据之间的联系和缺失的联系

CCBs have distinct hemodynamic properties. Systemically, they normally decrease BP while increasing CO; regionally, they normally increase organ blood flow and tissue oxygenation but decrease perfusion pressure and impair PA. Although CCBs impair PA of organ blood flow, they may not worsen or may actually improve the impaired cerebral PA in patients with aSAH. Overall, the hemodynamic profile of CCBs is diverse but appears advantageous in situations where CO and tissue perfusion are in jeopardy.

CCBs具有明显的血流动力学特性。在全身方面，它们通常降低血压，同时增加CO；从局部来看，它们通常增加器官血流量和组织氧合，但降低灌注压，损害PA。尽管CCBs损害了器官血流的PA，但它们可能不会恶化或实际上可能改善aSAH患者受损的脑PA。总体而言，CCBs的血流动力学特征是多样的，但在CO和组织灌注受到威胁的情况下似乎是有利的。

Indeed, CCBs are widely used in acute care involving drastic changes in hemodynamics or the cardiovascular system. Highlighted uses include the use of oral nimodipine in aSAH, the conditional use of verapamil and diltiazem for symptom control in acute myocardial infarction or unstable angina, the use of intravenous nicardipine for hypertensive emergency and perioperative hypertension, the use of oral nifedipine retard for hypertensive urgency, and the use of verapamil and diltiazem for the prevention or treatment of atrial tachyarrhythmia after thoracic surgery.

事实上，CCBs被广泛用于涉及血液动力学或心血管系统剧烈变化的急性护理。重点用途包括口服尼莫地平治疗aSAH，有条件地使用维拉帕米和地尔硫卓控制急性心肌梗死或不稳定型心绞痛的症状，静脉注射尼卡地平治疗高血压危症和围手术期高血压，口服硝苯地平缓释剂治疗高血压急症，以及使用维拉帕米和地尔硫卓预防或治疗胸部手术后房性快速性心律失常。

However, there are missing links between what we know about the hemodynamic effects of CCBs and what we have learned about their outcome evidence (Table 1). For example, although oral nimodipine improves post-aSAH outcomes, there is no evidence showing improved cerebral blood flow following its administration. Although verapamil and diltiazem appear to have advantageous coronary circulation profiles, their use in acute myocardial infarction or unstable angina is limited to symptom control if there are no contraindications and β-blockers and nitrates have been fully used but ineffective. Although intravenous nicardipine is effective in controlling BP in patients with hypertensive emergency or perioperative hypertension, there is a lack of evidence showing its long-term benefit.

然而，我们对CCB s 的血流动力学影响的了解与我们对其 结局 证据的了解之间缺乏联系(表1)。例如，尽管口服尼莫地平改善了 a SAH后的预后，但没有证据表明 给药 后改善了脑血流。虽然维拉帕米和地尔硫卓似乎具有有利的冠状动脉循环 特性 ，但如果没有禁忌症，并且β阻滞剂和硝酸酯类药物已经充分使用但无效，它们在急性心肌梗死或不稳定心绞痛中的使用仅限于症状控制。尽管静脉注射尼卡地平能有效控制高血压 危 症或围手术期高血压患者的血压，但缺乏其长期 益处的 证据。

The potential causes for these missing links are multifold. First, pure hemodynamic research has limitations because, being normally conducted in small homogeneous samples and under strictly controlled conditions, pure hemodynamic research tends to be explanatory only, i.e., not pragmatic and reflective of the complicated real-world patient care. Second, the wellbeing of hemodynamics is important; however, the outcome is not all about hemodynamics. Third, hemodynamics is far more complicated than most people think. Using BP for hemodynamic management in every patient is likely an oversimplified and inadequate approach. We need to be cautious in that our knowledge about hemodynamics may still be too superficial or the knowledge may have been inadequately disseminated or applied. Fourth, we have neither a means to reliably and practically monitor hemodynamics (not just BP but also CO and tissue perfusion) nor to routinely or selectively use a hemodynamic monitor that provides valuable information in a particular patient. Fifth, we may have set incorrect hemodynamic goals, including the parameters to be prioritized and the thresholds beyond which intervention should be instituted. Sixth, we may be overlooking important side effects associated with the CCBs used to achieve the therapeutic goals.

造成这些缺失环节的潜在原因是多方面的。首先，纯血流动力学研究具有局限性，因为纯血流动力学研究通常是在小的同质样本和严格控制的条件下进行的，往往只是解释性的，即不能切合实际和反映复杂现实世界的患者护理。其次，血液动力学的健康状况很重要；然而，结果并不完全与血流动力学有关。第三，血流动力学比大多数人想象的要复杂得多。在每个患者中使用BP进行血流动力学管理可能是一种过于简单和不适当的方法。我们需要谨慎，因为我们对血流动力学的了解可能仍然过于肤浅，或者这些知识可能没有得到充分的传播或应用。第四，我们既没有可靠和实用的方法来监测血流动力学(不仅是血压，还有CO和组织灌注)，也没有办法常规或选择性地使用血流动力学监测仪来为特定患者提供有价值的信息。第五，我们可能设定了不正确的血流动力学目标，包括优先考虑的参数和应该实施干预的阈值。第六，我们可能忽略了与用于实现治疗目标的CCBs相关的重要副作用。

Future efforts should focus on improving the technology used for hemodynamic measurement. Hemodynamics is not only BP and HR (the “vital signs”); we also need to pay due attention to flow-oriented parameters, including CO, organ perfusion, and tissue oxygenation. This requires a hemodynamic monitor that is accurate, precise, cost sensitive, non- or minimally invasive, and provides continuous bedside measurement. It is intriguing to see improved CO and tissue oxygenation in the face of decreased BP following nicardipine administration in anesthetized patients (Fig. 2). The question is whether this hemodynamic effect can be translated into outcome benefits. The use of a CCB based on favorable hemodynamic properties should be tested by outcome evidence. Future trials are needed to determine when improved organ perfusion equals improved patient outcome.

未来的努力应该集中在改进用于血流动力学测量的技术上。血流动力学不仅仅是血压和心率(“生命体征”)，我们还需要对血流导向的参数给予应有的关注，包括CO、器官灌注和组织氧合。这就要求血液动力学监测仪准确、精确、成本敏感、无创或微创，并提供连续的床边测量。有趣的是，在麻醉患者使用尼卡地平后血压下降的情况下，CO和组织氧合得到了改善(图2)。问题是这种血流动力学效应能否转化为结局收益。基于良好的血流动力学特性的CCB的使用应该通过结局证据来检验。还需要进一步的试验来确定器官灌注的改善何时等于患者预后的改善。

6 Conclusions 结论

CCBs are a class of heterogeneous pharmacological agents that exert profound impacts on both systemic and regional hemodynamics. Although CCBs decrease BP and impair PA, they commonly increase CO, organ perfusion, and tissue oxygenation. There exists promising evidence attesting to the therapeutic efficacy and outcome benefits following CCB administration in acute care, including aSAH, acute myocardial infarction, unstable angina, hypertensive crisis, perioperative hypertension, and atrial tachyarrhythmias. There are physiological rationales supporting the use of CCBs in acute care; however, there are certain missing links between the known hemodynamic effects exerted by CCBs and the outcome benefits related to their clinical use. Future efforts should further explore the appropriate use of CCBs in acute care, in a drug-, disease-, and anesthetic-dependent context, with a focus on hemodynamic optimization and outcome improvement.

CCBs是一类对全身和局部血流动力学都有深远影响的异质药物。尽管CCBs降低血压并损害PA，但它们通常会增加CO、器官灌注和组织氧合。有很有希望的证据表明，在急性重症监护中应用CCB具有良好的疗效和结局效益，包括aSAH、急性心肌梗死、不稳定心绞痛、高血压危象、围手术期高血压和房性快速性心律失常。在急性护理中使用CCBs有一定的生理学基础；然而，CCBs的已知血流动力学效应与临床使用相关的结局益处之间存在某些缺失的联系。未来的努力应进一步探索在药物、疾病和麻醉依赖的情况下，在急症护理中适当使用CCBs，重点是血流动力学优化和结局改善。

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