生化指標(biāo)在心力衰竭診斷和治療中的角色

1、生化指標(biāo)在心力衰竭診斷和治療中的角色,浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院心臟中心王建安 項(xiàng)美香,心功能/心衰標(biāo)志物的重要性,,無癥狀心衰/癥狀性心衰發(fā)病率,早期/輕度心衰往往沒有心室結(jié)構(gòu)的改變，癥狀也不明顯心動(dòng)超聲檢查往往還不能發(fā)現(xiàn)心室的改變,相當(dāng)一部分心衰患者不能獲得及時(shí)診斷,,心衰與神經(jīng)激素激活,心衰主要實(shí)驗(yàn)室指標(biāo),常規(guī)生化指標(biāo)：血?dú)夥治?，電解質(zhì)，肝腎功能，血常規(guī)等BNP/NT-pro BNP肌鈣蛋白其他：神經(jīng)激素指標(biāo)等,P

2、re-Pro-BNP1-134,26-氨基信號(hào)序列,N-端Pro-BNP1-76,BNP77-108,Pro-BNP1-108,,,,,,t1/2 = 18 分鐘,,室壁張力增加,t1/2 = 60-120 分鐘,新的心功能標(biāo)志物——BNP與NT-proBNP,2005年ESC/AHA心衰防治指南推薦腦鈉肽作為心衰的診斷指標(biāo),Diagnostic assessments supporting the presence of heart

3、 failure,2008 ESC guideline,,BNP/NT-pro BNP,2008 ESC guideline,BNP/NT-pro BNP的診斷價(jià)值,陰性預(yù)測(cè)值 陽性預(yù)測(cè)值 BNP 97% 90%

4、 （500pg/ml) NT-proBNP 99% 98% (2000pg/ml),影響B(tài)NP/NT-pro BNP的因素,BNP/NT-pro BNP升高急性冠脈綜合征慢性肺部疾病肺動(dòng)脈高壓高血壓心房顫動(dòng) 腎功能不全高齡感染,影響B(tài)NP/NT-proBNP的因素,肥胖者

5、降低在急性肺水腫或急性二尖瓣關(guān)閉不全的早期階段，腦鈉肽可保持“正?！?。,Troponin,心肌缺血、心肌炎嚴(yán)重心衰、心衰失代償病人可有輕度升高,Neurohormonal markers,Norepinephrine, renin, aldosterone, endothelinAlthough useful in research, evaluation of neuroendocrine activation is no

6、t required.,生化指標(biāo)在心衰治療和預(yù)后中的價(jià)值,根據(jù)生化指標(biāo)調(diào)整治療方案生化指標(biāo)對(duì)預(yù)后的預(yù)測(cè),Plasma Brain Natriuretic Peptide-Guided Therapy to Improve Outcome in Heart Failure: The STARS-BNP Multicenter Study,220 NYHA II~III patients Multicenter,JACC 2007

7、;49:1733-9,Number of Changes in Medical Therapy During the First 3 Months----Compare clinical group vs. BNP group,JACC 2007;49:1733-9,Changes in Medical Therapy During the Titration Phase in BNP Group and Clinical group

8、,JACC 2007;49:1733-9,JACC 2007;49:1733-9,Event-Free (Hospitalization for Heart Failure or Death Related to Heart Failure) Survival,STARS-BNP Study Conclusion,a BNP-guided strategy reduces the incidence of a combined end

9、point (death and hospital stay related to heart failure) compared with a standard strategy. The result is mainly obtained through an increase in ACEI and beta-blocker dosages.,生化指標(biāo)在心衰治療和預(yù)后中的價(jià)值,根據(jù)生化指標(biāo)調(diào)整治療方案生化指標(biāo)對(duì)預(yù)后的預(yù)測(cè)

10、,Conditions associated with a poor prognosis in heart failure,,2008 ESC guideline,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,NT-pro BNP與預(yù)后,Absol

11、ute values (median and interquartile range) of NT-proBNP plasma levels of patients subdivided on the basis of their clinical course,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:

12、10.1016/j.ejheart.2007.05.007,Mortality and cardiovascular hospitalisation free survival curves on the basis of their median NT-proBNP levels at discharge,NT-proBNP與預(yù)后,Copyright restrictions may apply.,Metra, M. et al. E

13、ur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,Mortality and cardiovascular hospitalisation free survival curves for the patients subdivided on the basis of their NT-proBNP levels combined with NYHA cl

14、ass,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,TnT與心衰預(yù)后,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:1

15、0.1016/j.ejheart.2007.05.007,mortality and cardiovascular hospitalisation free survival curves on the basis of their NT-proBNP levels combined with the detection of cTnT,Prediction of cardiac death or CV hospitalization

16、:CART analysis,低鈉與預(yù)后,MUSIC risk score:a simple method for predicting mortality in patients with chronic heart failure,MUSIC Risk score for each type of mortality,,2009美國成人慢性心力衰竭診斷和治療指南 (更新版）,測(cè)定BNP和NTproBNP有助于評(píng)估HF診斷不確定的

17、急診患者。測(cè)定BNP和NTproBNP對(duì)于危險(xiǎn)分層有意義（證據(jù)級(jí)別A），增加了腦鈉肽對(duì)舒張性心衰和收縮性心衰患者在總體臨床評(píng)估中的“警示”作用,總 結(jié),生化指標(biāo)BNP/NT-proBNP對(duì)心力衰竭的診斷有重要的作用ESC/AHA心衰防治指南推薦腦鈉肽作為心衰的診斷指標(biāo),根據(jù)BNP/NT-proBNP指標(biāo)調(diào)整治療方案可進(jìn)一步減少心血管事件，提高存活率。BNP/NT-pro BNP 、tropinin、血鈉水平也是心力衰竭患者預(yù)