生化指标在心力衰竭诊断和治疗中的角色

生化指标在心力衰竭 诊断和治疗中的角色 浙江大学医学院附属第二医院 心脏中心 王建安 项美香 心功能/心衰标志物的重要性 无症状心衰/症状性心衰发病率 早期/轻度心衰往往没 有心室结构的改变， 症状也不明显 心动超声检查往往还 不能发现心室的改变 相当一部分心衰患者 不能获得及时诊断 Levels Adapted from Cohn JN. Cardiology. 1997;88:26. 血浆 去甲肾上腺素 (pg/mL) NLNLHFHF 血浆 肾素激活 (ng/mL/h) 15 12 9 6 3 0 NLNLHFHF 精氨酸 血管加压素 (pg/mL) 12 6 4 2 0 NLNLHFHF 利钠肽 (pg/mL) 300 250 200 150 100 50 0 NLNLHFHF 内皮素-1 (pg/mL) 8 6 4 2 0 NLNLHFHF 600 500 400 300 200 100 0 心衰与神经激素激活 心衰主要实验室指标 常规生化指标：血气分析，电解质，肝 肾功能，血常规等 BNP/NT-pro BNP 肌钙蛋白 其他：神经激素指标等 Pre-Pro-BNP1-134 26-氨基信号序列 N-端 Pro-BNP1-76 BNP77-108 Pro-BNP1-108 t1/2 = 18 分钟 室壁张力增 加 t1/2 = 60-120 分钟 新的心功能标志物BNP与NT-proBNP 2005年ESC/AHA心衰防治指南推荐 脑钠肽作为心衰的诊断指标 Diagnostic assessments supporting the presence of heart failure 2008 ESC guideline BNP/NT-pro BNP 2008 ESC guideline BNP/NT-pro BNP的诊断价值 阴性预测值 阳性预测值 BNP 97% 90% （500pg/ml) NT-proBNP 99% 98% (2000pg/ml) 影响BNP/NT-pro BNP的因素 BNP/NT-pro BNP升高 急性冠脉综合征 慢性肺部疾病 肺动脉高压 高血压 心房颤动 肾功能不全 高龄 感染 影响BNP/NT-proBNP的因素 肥胖者降低 在急性肺水肿或急性二尖瓣关闭不全的 早期阶段，脑钠肽可保持“正常”。 Troponin 心肌缺血、心肌炎 严重心衰、心衰失代偿病人可有轻 度升高 Neurohormonal markers Norepinephrine, renin, aldosterone, endothelin Although useful in research, evaluation of neuroendocrine activation is not required. 生化指标在心衰 治疗和预后中的价值 根据生化指标调整治疗方案 生化指标对预后的预测 Plasma Brain Natriuretic Peptide- Guided Therapy to Improve Outcome in Heart Failure: The STARS-BNP Multicenter Study 220 NYHA IIIII patients Multicenter JACC 2007;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 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 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. 生化指标在心衰 治疗和预后中的价值 根据生化指标调整治疗方案 生化指标对预后的预测 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与预后 Absolute 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: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与预后 Copyright restrictions may apply. Metra, M. et al. Eur 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 class 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与心衰预后 Copyright restrictions may apply. Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/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:CART analysis 低钠与预后 MUSIC risk score:a simple method for predicting mortality in patients with chronic heart failure MUSIC Risk score for each type of mortality 2009美国成人慢性心力衰竭诊断 和治疗指南 (更新版） 测定BNP和NTproBNP有助于评估HF诊 断不确定的急诊患者。 测定BNP和NTproBNP对于危险分层有 意义（证据级别A），增加了脑钠肽对 舒张性心衰和收缩性心衰患者在总体临 床评估中的“警示”作用 总 结 生化指标BNP/NT-proBN