生化指标在心力衰竭诊断和治疗中的角色.ppt

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,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-proBNP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,2019年ESC/AHA心衰防治指南推荐脑钠肽作为心衰的诊断指标,Diagnosticassessmentssupportingthepresenceofheartfailure,2019ESCguideline,BNP/NT-proBNP,2019ESCguideline,BNP/NT-proBNP的诊断价值,阴性预测值阳性预测值BNP97%90%（500pg/ml)NT-proBNP99%98%(2000pg/ml),影响BNP/NT-proBNP的因素,BNP/NT-proBNP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,Neurohormonalmarkers,Norepinephrine,renin,aldosterone,endothelinAlthoughusefulinresearch,evaluationofneuroendocrineactivationisnotrequired.,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,PlasmaBrainNatriureticPeptide-GuidedTherapytoImproveOutcomeinHeartFailure:TheSTARS-BNPMulticenterStudy,220NYHAIIIIIpatientsMulticenter,JACC2019;49:1733-9,NumberofChangesinMedicalTherapyDuringtheFirst3Months-Compareclinicalgroupvs.BNPgroup,JACC2019;49:1733-9,ChangesinMedicalTherapyDuringtheTitrationPhaseinBNPGroupandClinicalgroup,JACC2019;49:1733-9,JACC2019;49:1733-9,Event-Free(HospitalizationforHeartFailureorDeathRelatedtoHeartFailure)Survival,STARS-BNPStudyConclusion,aBNP-guidedstrategyreducestheincidenceofacombinedendpoint(deathandhospitalstayrelatedtoheartfailure)comparedwithastandardstrategy.TheresultismainlyobtainedthroughanincreaseinACEIandbeta-blockerdosages.,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,Conditionsassociatedwithapoorprognosisinheartfailure,2019ESCguideline,Copyrightrestrictionsmayapply.,Metra,M.etal.EurJHeartFail20199:776-786;doi:10.1016/j.ejheart.2019.05.007,NT-proBNP与预后,Absolutevalues(medianandinterquartilerange)ofNT-proBNPplasmalevelsofpatientssubdividedonthebasisoftheirclinicalcourse,Copyrightrestrictionsmayapply.,Metra,M.etal.EurJHeartFail20199:776-786;doi:10.1016/j.ejheart.2019.05.007,MortalityandcardiovascularhospitalisationfreesurvivalcurvesonthebasisoftheirmedianNT-proBNPlevelsatdischarge,NT-proBNP与预后,Copyrightrestrictionsmayapply.,Metra,M.etal.EurJHeartFail20199:776-786;doi:10.1016/j.ejheart.2019.05.007,MortalityandcardiovascularhospitalisationfreesurvivalcurvesforthepatientssubdividedonthebasisoftheirNT-proBNPlevelscombinedwithNYHAclass,Copyrightrestrictionsmayapply.,Metra,M.etal.EurJHeartFail20199:776-786;doi:10.1016/j.ejheart.2019.05.007,TnT与心衰预后,Copyrightrestrictionsmayapply.,Metra,M.etal.EurJHeartFail20199:776-786;doi:10.1016/j.ejheart.2019.05.007,mortalityandcardiovascularhospitalisationfreesurvivalcurvesonthebasisoftheirNT-proBNPlevelscombinedwiththedetectionofcTnT,PredictionofcardiacdeathorCVhospitalization:CARTanalysis,低钠与预后,MUSICriskscore:asimplemethodforpredictingmortalityinpatientswithchronicheartfailure,MUSICRiskscoreforeachtypeofmortality,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-proBNP对心力衰竭的诊断有重要的作用ESC/AHA心衰防治指南推荐脑钠肽作为心衰的诊断指标,根据BNP/N