在心衰诊断预后治疗的管理课件幻灯

1 N-proBNP在心衰诊断、预后、 治疗的管理 广东省人民医院心内科 广东省心血管病研究所 陈鲁原 2 内 容 nNT-proBNP在心力衰竭患者诊断中的应用 NT-proBNP in the diagnosis of definite heart failure nNT-proBNP判断心衰预后及对治疗的反应 NT-proBNP in the judgemen of prognosis of heart failure n应用NT-proBNP指导急性失代偿性心竭的治疗 NT-proBNP and Therapy Monitoring for Acutely Destabilized HF 3 在初级保健中被误诊为心力衰竭的比例： - Framingham: 40% (McKee 1971) - Boston:42% (Carlson 1985) - Kuopio: 50% (Remes 1991) 急诊室中25-50%的失代偿心力衰竭病人被误诊 充血性心力衰竭: 在临床上是否易于诊断? l l 三大症状非特异性（气促、踝肿和疲劳）三大症状非特异性（气促、踝肿和疲劳）, ,特别特别 对于肥胖、老年和妇女。对于肥胖、老年和妇女。 l l 心衰体征仅提示心衰存在心衰体征仅提示心衰存在，但仍需有心功能评，但仍需有心功能评 价的客观证据。价的客观证据。 4 Independent predictors of acute heart failure in dyspneic patients in the emergency department 急诊室呼吸困难患者急性心力衰竭的独立预测因素 Elevated NT-proBNP NT-proBNP升高 44.021.0-91.075 岁岁 (n=519) 86%66% 88%84%90% 总计总计 85%88%82%82% 90%900 pg/ml所有 50-75 岁岁 (n=554) 95%99%76%93% 97%450 pg/ml所有 1000 pg/ml. 门诊病人的靶目标水平仍未确定，但 NT-proBNP 水平大于1000 pg/ml ，则心衰的发病和死亡率明 显上升 21 内 容 nNT-proBNP在心力衰竭患者诊断中的应用 NT-proBNP in the diagnosis of definite heart failure nNT-proBNP判断心衰预后及对治疗的反应 NT-proBNP in the judgemen of prognosis of heart failure n应用NT-proBNP指导急性失代偿性心竭的治疗 NT-proBNP and Therapy Monitoring for Acutely Destabilized HF 22 检测NT-proBNP能指导 急性失代偿性心衰住院患者的治疗吗？ lNT-proBNP levels decrease in response to the addition of therapies with proven benefit for HF, including ACE-inhibitors, angiotensin receptor blockers, diuretics, spironolactone, exercise therapy and biventricular pacing. l已往已经证明有益的心衰冶疗（包括ACEI、血管紧张素受 体阻滞剂、利尿剂、安体舒通、运动疗法和双心室腔起搏 ）均可降低NT-proBNP水平 23 The Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) ldesign: Patients with chronic systolic HF were randomized to intensified BNP-guided therapy or standard therapy lPatients: 499 patients with systolic heart failure EF 45%, NYHA II IV, prior hospitalization for HF 1 year, and BNP level 400 pg/mL in 75yr and 800 pg/mL in 75yr lClinical outcomes were compared at 18 months. l Primary outcomes: 18-month survival free of all-cause Ho- spitalizations and quality of life JAMA. 2009;301(4):383-392 24 ACEI or ARB and -Blocker Doses Duringthe Study There were no significant differences between the 2 treatment groups by BNP level (P=.30). JAMA. 2009;301(4):383-392 TIME-CHF 25 TIME-CHF: Primary and Secondary Outcomes JAMA. 2009;301(4):383-392 hospitalization-free survival (p = 0.46), but in CHF 26 Greater reductions in patients younger than 75 years JAMA. 2009;301(4):383-392 Age75yr Age75yr 27 NT-proBNP guided management of chronic heart failure based on an individual target value PRIMA-study Luc Eurlings, Study Coordinator Maastricht University Medical Center Maastricht, the Netherlands Yigal Pinto, Principal Investigator Academic Medical Center Amsterdam, the Netherlands ACC Congress Orlando March 29th 2009 28 PRIMA-study Prospective, randomized, single-blinded study Admitted with symptomatic heart failure ; Elevated NT-proBNP levels 1,700 pg/ml on hospital admission NT-proBNP guided Treatment Individual NT- proBNP target level (Lowest level at discharge or 2 weeks follow-up) Clinical guided Treatment Follow-up at 2 weeks, 1,3,6,9,12,15,21,24 months ; Follow-up up minimal 1 year PRIMA-study Main outcome ACC Orlando March 2009 29 PRIMA-study Number of increases HF medication NT-proBNP Clinical P n174171 Diuretics 1681200.018 Beta blockers 10595ns ACE-inhibitors 77550.099 AT-II antagonists4122ns Aldosteron antagonists1915ns Digoxin1419ns Total4243260.006 PRIMA-study Main outcome ACC Orlando March 2009 30 Total Mortality PRIMA-study Survival (%) Time (days) P=0.208 NT-proBNP guided Clinical guided 46/174 26.5% 57/171 33.3% 31 Secondary analysis PRIMA-study Cardiovascular mortalityns Combined endpoint CV mortality / readmissionsns HF related readmissionsns Creatinine above / below the median (123 mcm/L)ns Age above / below 73 yearsns Discharge NT-proBNP above / below 2950 pg/mlns 32 On NT-proBNP target analysis: Primary endpoint PRIMA-study On NT-proBNP Target Clinical Guided group 院外平均存活天数 (median + IQR) 721 (578-730) p.001 664 (435-726) 101 of 174 patients in NT-proBNP guided group (58%) maintained their target in more than 75% of visits 按出院后维持NT-proBNP靶标作对照 p.001 33 On NT-proBNP target: Mortality (%) PRIMA-study On NT-proBNP Target Clinical Guided group p0.001 11/101 10.9% 57/171 33.3% 101 of 174 patients in NT-proBNP guided group (58%) maintained their target in more than 75% of visits 按出院后维持NT-proBNP靶标作对照 34 Conclusions Management of heart failure guided by an individually defined optimal NT-proBNP level does not appear favorable in the overall population However, maintaining this individual optimal NT-proBNP level portends significantly better outcome The PRIMA-study allows to identify patients where it is feasible to maintain the optimal NT-proBNP level and who may benefit from treatment guided by their own optimal NT-proBNP PRIMA-study 35 血浆中利钠肽:在HF诊断和慢性HF患者管理 （结束语） 在HF诊断和慢性HF患者管理中，血浆中利钠肽浓度是有 用的生物标志物。利钠肽可作为HF诊断、分期、住院/出 院的依据 利钠肽也可能有助于在出院之前评估预后，并且监测HF 治疗的有效性