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Файл:Взгляд на фармацию. Учебное пособие для студентов фармацевтического факультета
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10. TREATMENT OF HEART FAILURE
e statement that lanatoside is replacing homicide as a leading
cause of death is greatly exaggerated. However, approximately
20% of hospitalized patients receiving digitalis preparations
manifest some evidence of toxicity. e frequency of adverse
reactions can and should be reduced without depriving patients
of the benets of digitalis. is drug remains the key to eective
therapy for heart failure. Old concepts of «digitalization» have
contributed to frequent digitalis toxicity. New knowledge of the
pharmacology of digitalis, the development of more eective
diuretic agents, and clearer insight into the physiology of
myocardial failure allow safer and more eective treatment. is
information will enable physicians to become more comfortable
and condent in the use of these agents.
e major eect of digitalis is to increase the strength and velocity
of myocardial contraction. is is accomplished by making more
calcium available to the contractile proteins. Increased contractility
is evident in the failing or normal myocardium, regardless of the
presence of a fast or slow ventricular rate, sinus rhythm, or atrial
arrhythmias. Digitalis administration to patients in heart failure
ordinarily results in increased stroke volume, increased cardiac
output, and decreased pulmonary arterial pressure, with ultimate
reduction in blood volume and central venous pressure. Digitalis
does not harm the normal heart. Homeostatic control mechanisms
prevent the enhanced contractility of normal myocardium from
leading to a needless increase in cardiac output.
Another major physiological eect of digitalis is vagal stimulation.
is decreases atrioventricular conduction and is helpful in
controlling the rapid ventricular rate in atrial brillation and utter.
e vagal eect of digitalis is also useful in treating paroxysmal
supraventricular tachycardias.
Digoxin
Digoxin is the most versatile of the cardiac glycosides and is not
signicantly bound to serum proteins. It is the drug of choice in
241
routine practice, and may be administered orally, intramuscularly,
or intravenously. It is intermediate in duration of action between
ouabian and digitoxin. e onset of actionof digoxin is within 5
to 30 minutes aer intravenous administration,so it is eective in
most urgent situations. e duration of action is such that daily
maintenance doses are suitable except for severe heart failure, when
it should be given at 12-hour intervals. Toxic reaction from digoxin
subsides much more rapidly than it does from digitoxin, which is
largely bound to serum proteins and has a much longer half-life.
Digitoxin is more unpredictable in action, since it is extensively
recycled through the liver in the enterohepatic cycle. Drugs
aecting microsomal enzyme action such as diphenylhydantoin,
phenylbutazone, and barbiturates, as well as exchange resins such
as cholestyramine resin markedly inuence its eectiveness.
Digoxin, a pure glycoside, has many advantages over the vagaries of
a crude drug such as digitalis leaf. However, variation in the potency
and absorption of digoxin preparations by dierent manufacturers
warrants prescribing the product of a manufacturer known to have
a good record of quality control.
Digoxin is excreted largely by the kidney, and the rate is related
directly to creatinine clearance. e dose should be reduced to
50% of the usual dose in moderate renal impairment and to about
30% of the usual dose in severe renal impairment. Otherwise, the
appropriate dose is largely determined by the level of metabolism
and the body muscle mass.
Dose Individualized. e dose must be individualized. e usual
maintenance dose for an average adult is between 0.25 and 0.50 mg
daily. However, it may vary from 0.125 mg on alternate days (renal
failure) to 0.75 mg daily. Older, smaller individuals require much
less than robust, younger individuals. Contrary to former teaching, an initial loading dose with full digitalization to near toxicity
is not necessary or desirable to enhance myocardial contractility.
Digitalization is not an all-or-none state. Improved contractility is
dose-related: any dose strengthens myocardial contraction. Many
patients do not require full digitalization. Loading doses are indi-
242
cated if prompt maximum eect is required and the patient has not
been receiving digitalis previously. However, loading doses should
be much smaller than the 2 to 5 mg advocated in the past. Large
loading doses are a common cause of digitalis toxicity. e loading dose of digoxin should be about three times the estimated daily
maintenance dose, and should rarely exceed 1.0 to 1.5 mg.
Diuretics
Diuretics play an important role in the treatment of heart failure
by eliminating excess sodium and water when the compensatory
mechanism of uid retention has produced deleterious side eects
such as pulmonary congestion. Salt intake should be restricted so
additional diuretic will not be required for an excess sodium intake.
Such needless diuresis depletes body stores of potassium, chloride,
magnesium, water-soluble vitamins, and many other unknown
essential body constituents.
It should be emphasized that diuretic do not enhance myocardial
contractility. Excessive reduction of extracellular uid may
neutralize the body’s compensatory eorts to utilize the Starling
principle, causing a further decrease in cardiac output, with
decreased tissue perfusion, oliguria, and mental confusion. e
tendency of diuretics to lower systemic blood pressure is an added
benet, since pressure work is the most expensive work the heart
performs. A dilated ventricle is at a severe mechanical disadvantage
in performing pressure work.
Lowering blood pressure reduces resistance to systolic emptying
of the le ventricle. In the process of diuresis, large amounts of
potassium are oen lost along with sodium. Low serum potassium
level predisposes to ventricular arrhythmias and digitalis toxicity.
e alert clinician should anticipate and prevent potassium depletion
with concurrent administration of potassium-sparing agents,
such as spironolactone (Aldactone) or triamterene (Dyrenium).
If potassium depletion occurs, it should be promptly corrected.
Potassium-depleted patients are usually chloridedepleted, so
eective therapy requires replacement with potassium chloride.
243
11. HEART MASSAGE
What it does
By compressing the chest manually, you’re doing the work of a
heart that’s stopped beating. e action forces blood along the blood
vessels at sucient pressure so blood reaches the brain, keeping the
person alive.
External chest compression is always carried out with mouthto-mouth breathing. e combination of the two is called cardiopulmonary resuscitation (CPR). You start o with two breaths into
the casualty’s mouth and follow with heart massage.
1. Make absolutely sure the heart has stopped beating-this is
called a ‘cardiac arrest’. Remember a pulse may be very faint, fast
or slow. Never perform heart massage on someone whose heart is
still beating.
2. Lie casualty at on a rm surface and nd the breastbone, which
runs down the middle of the chest, with the ribs on either side.
3. Place the heel of one hand in the middle of the lower half of the
breastbone
- below dotted line,
- roughly two-ngers-width above end of breastbone, and where
the heart is. Cover this hand with heel of other, locking ngers
together.
4. Lean forward over the casualty, keep arms straight. Press down
rmly on breastbone to depress chest a couple of inches, then
release pressure. Repeat for about 15 compressions before giving
another two mouth-to-mouth breaths but don’t worry if you lose
count. en start chest compressions again.
5. Aer four cycles of breathing/compressions – about a minute
in all – check for a pulse. If present, stop compressions at once.
Continue with mouth-to mouth until natural breathing returns.
Check pulse and breathing until help arrives. If there’s still no pulse,
repeat as above.
244
CURRICULUM VITAE
Personal details
Name Jane Smith
Address 7 Ash Covent Road, London, PT 47 IR
Tel: 0254 781395
E mail: janes@ nts.ppu.co.uk
Nationality British (may be or may be not inserted)
Date of birth 15/12/76
Marital status Single
1. Personal prole I am reliable, well organized, and used to
working on my own initiative. I am comfortable working as part of a team.
2. Key skills Familiar with Microso Word and Excel
Condent communicator
Good problem-solver
Self-motivated
Fluent in English
Clean driving licence
3. Work experience
2000 – present
Marketing Assistant: Pharmaceutical Corporation «Glaxo Wellcome».
Duties include planning and implementing
all advertising and promotion
1998 – 2000
4. Education
Dec. 1997
1994 – 1997
1987 – 1994
Pharmacist’s assistant, Boots, London.
Certicate in Pharmacy
London University: BPh
Minster College Secondary School, Wells
Reading, landscape painting, tennis
Interests
5. References Available on request
245
1. Give a brief description of your most important personal
qualities relevant to the post you are applying for.
2. Key skills relevant to the job you are oen listed before
employment history. Useful phrases include: Experienced …,
experienced in …, with a good knowledge of … .
3. is can also be called «Experience» or «Employment history».
Start the list with your most recent job and nish with the earliest
one. You should also include relevant training courses, voluntary
work, etc.
4. is can also be called «Qualications» or «Educational
qualications». Start with your most recent qualications nish
with your secondary education. It is not necessary to include details
of your primary education.
5. References (the people that the employer can contact to get
information about you) can be listed either at the end of the CV or
included in a separate letter.
246
FORMAL LETTER
1.
P. Cook & Co LTD
123 King’s Crescent, Brighton, BR 3 GJF
Tel: 0222 123456, Fax: 0222 123555
www. Cook catering. Com
Boots Company
2.
100 South Road
London SE 1 3PL
3.
19th September 2007
4.
Your ref: FT/fr
Our ref: CC/mt /08/02
5.
Dear Sir/Madam
6.
Re: Discount agreement
7.
I am writing to enquire about the discount opportunities you are
oering, as detailed in yesterday’s Financial Mail.
8.
P. Cook is a medium-size company with 10 years’ experience in
the pharmacy business. We believe we have much to oer your
organization because of our specialized services and established
clientele, and wish to explore a mutually benecial discount
agreement. I enclose a prospectus for your information.
9.
I look forward to hearing from you in the near future.
10.
Yours faithfully
Mandy Taylor
11.
pp Christina Cook
Managing Director
12.
ccP. Cook, T.A. Cook
13.
Enc
247
1. e name of the Company and its address, phone, and fax
details generally appear at the top of the page, together with any
Internet and e-mail details.
2. Put the address of the recipient on the le-hand side. If you
know the name of the person and his/her title, add these above
the address too.
3. e data can appear on the le-or right-hand side of the
letter; though the most usual style is to have everything
aligned to the le.
4. Add the recipient’s and your own le references if needed. Ref is
short for «reference».
5. You can start your letter in one of the following ways:
1. If you don’t know the name – Dear Sir/Madam or
Dear Sir or Madam
2. If you know the name – Dear Mr (surname) (for a man)
Dear Ms (surname) (for a woman)
6. Write the subject of your letter here. Re comes from Latin and
means «wit reference to».
7. You can also start your letter in a number of other ways:
ank you for your letter of…,
I am writing in response to …,
/regarding …/ to inform you that /of…/ to complain about…
th
Further to my letter of 16
July …
I would like to enquire about/whether …
8. Give further details about the purpose of your letter here.
9. You can also close your letter in the following ways:
ank you in advance for your help …
I would be most grateful if you could inform me …
Please let me know if …
Please phone to conrm the details …
I look forward to hearing from you/ receiving your reply.
10. You can write the following expressions before your name.
1. If you don’t know the person:
Yours faithfully, Yours truly
248
2. If you know the person you are writing to:
Yours sincerely, Sincerely
3. Other, less formal, ways of ending your letter:
With best wishes, Best wishes, Regards
11. pp means that the letter was signed by Mandy Taylor on behalf
of Christina Cook.
12. cc means that a copy of the letter is being sent to the people
mentioned.
13. Enc means that documents are being enclosed with the letter.
249
ENGLISH GRAMMAR IN TABLES
УПОТРЕБЛЕНИЕ АРТИКЛЕЙ
1.
)
1. ,
,
.
2. , .
3. ,
.
4. ,
(
).
is is a book. e
book is interesting.
In summer the sun
shine brightly.
Open the window,
please.
Pass me the bread,
please.
Where is the
water?
.
.
.
,
.
,
,
.
?
5. one of,
some of, many of,
each of, most of,
all, both.
250
One of the students missed the
lesson.
Most of the ar-
ticles are easy to
translate.
All the boys will go
on an excursion
.
.
.
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