在心衰诊断预后治疗的管理ppt课件

N proBNP在心衰诊断 预后 治疗的管理 蚌埠市第三人民医院孙向东 内容 NT proBNP在心力衰竭患者诊断中的应用NT proBNPinthediagnosisofdefiniteheartfailureNT proBNP判断心衰预后及对治疗的反应NT proBNPinthejudgemenofprognosisofheartfailure应用NT proBNP指导急性失代偿性心竭的治疗NT proBNPandTherapyMonitoringforAcutelyDestabilizedHF 规范与指南 NT proBNP临床应用中国专家共识ExpertconsensusofclinicalapplicationofNT proBNPNT proBNP临床应用中国专家共识小组 关键词 脑钠肽 末端 型利钠肽原 心力衰竭 心血管疾病 eywords doi 10 3969 j issn 1672 5301 2011 06 001中图分类号 541 516文献标识码 文章编号1672 5301 2011 06 0401 08 在初级保健中被误诊为心力衰竭的比例 Framingham 40 McKee1971 Boston 42 Carlson1985 Kuopio 50 Remes1991 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 三大症状非特异性 气促 踝肿和疲劳 特别对于肥胖 老年和妇女 心衰体征仅提示心衰存在但仍需有心功能评价的客观证据 急诊室呼吸困难患者急性心力衰竭的独立预测因素Independentpredictorsofacuteheartfailureindyspneicpatientsintheemergencydepartment JanuzziJL Jr AmJCardiol2005 诊断心衰的三大常规 胸片是心衰初步诊断的重要部分心脏超声是现在的 金标准 仍不能完全解决急性呼吸困难的鉴别问题 到目前为止 由美国和欧洲心脏病协会推荐使用的BNP或NT proBNP是唯一用于诊断心力衰竭的实验室检测指标胸片 心脏超声和BNP NT proBNP检测是诊断心衰的三大常规 BNP和NT proBNP的检测分析 NT proBNP半衰期相对较长 浓度相对较稳定 含量相对较高 比BNP约高16 20倍 检测相对较容易 是较理想的预测标志物BNP半衰期相对较短 18分钟 检测血液时间要求高 在了解病人即刻情况时较有价值BNP或NT proBNP的临床应用价值基本相同每天或隔天检测BNP NT proBNP并无临床价值 治疗1W后才出现明显变化 AmJCardiol2004 93 1562 1563AmJCardiol2008 101 3A NT proBNP用于急性呼吸困难患者诊断的灰色地带值 AlthoughagestratificationofNT proBNPcut pointsfortheevaluationofpatientswithacutedyspneareducesthelikelihoodofagreyzonevalue thisfindingwasstillpresentin17 ofsubjectsintheICONstudy尽管临床工作中推荐采用NT proBNP切点标准的年龄分层方式可提高心衰的诊断水平 但仍然有17 患者的NT proBNP仍处于灰色地带值 AmJCardiol2008 101 3A DiagnosesassociatedwithanintermediateNT proBNPconcentrationbutwithoutacuteheartfailureascauseoftheirdyspneainICON ICON研究中NT proBNP中度升高但无急性心力衰竭患者的呼吸困难原因 vanKimmenadeRRJ AmJCardiol2006 对NT proBNP灰度值并不代表良性预测 更不能认为其为阴性结果 灰色区域 中心力衰竭的独立预测因子当NT proBNP400 2000pg ml时 主要根据临床判断 vanKimmenade etal AJC 2006 内容 NT proBNP在心力衰竭患者诊断中的应用NT proBNPinthediagnosisofdefiniteheartfailureNT proBNP判断心衰预后及对治疗的反应NT proBNPinthejudgemenofprognosisofheartfailure应用NT proBNP指导急性失代偿性心竭的治疗NT proBNPandTherapyMonitoringforAcutelyDestabilizedHF 急性心力衰竭 5000pg ml是短期预后的界值 判断急性心力衰竭短期 60天 预后 Januzzietal ArchInternMed2006 判断急性心力衰竭长期 1年 预后 对于1年危险度的分层 最佳界值是1000pg ml 急性不稳定性心力衰竭的NT proBNP监测NT proBNPandTherapyMonitoringforAcutelyDestabilizedHF SincecriteriafordeterminingrestabilizationfromdestabilizedHFincludeclinicalfactorsaswellasbiochemicalmeasures thefrequencyofNT proBNPmeasurementshouldbeoptimallyappliedattwotimepoints baseline presentation由于决定不稳定性心力衰竭到病情稳定包括临床因素和生化指标 NT proBNP的检测频率应该在两个时间点进行 基线 入院时 用于诊断 筛查及设定治疗的 起点 和病情稳定时 以决定是否可出院或治疗程度 NT proBNPinacuteHF BettencourtP Circulation2004 对急性失代偿性心衰住院患者治疗反应的检测 AlthoughprospectivestudiesontheeffectofNT proBNPmeasurementinguidingtherapyinacutedestabilizedHFarelacking observationaldatasuggestthata30 decreaseinNT proBNPvaluesduringhospitalizationforacutedestabilizedHFisareasonablegoal IfabaselinemeasureofNT proBNPisnotavailable aNT proBNPlevel 4000pg mlafteracutetreatmentisdesirable 尽管缺少关于检测NT proBNP指导缺血性心脏病治疗的前瞻性研究 观察性研究表明急性心衰病人经治疗后NT proBNP水平降低30 是合理的 如果不能提供基线NT proBNP水平 治疗后小于4000pg ml是理想水平 急性心力衰竭住院期间的NT proBNP应用流程AlgorithmforuseofNT proBNPduringhospitalizationforacuteHF NT proBNP与慢性性心衰的预后 在慢性心衰患者中 NT proBNp是与临床终点相关的最强的独立预测因子之一AmongpatientswithchronicHF repeateddeterminationsofNT proBNPlevelsappeartoconveyadditionalprognosticvalueforrelevantadverseoutcomes includingdeathordestabilizationofHFrequiringhospitalization andarethusrecommendedateachpatientevaluation 在慢性心衰患者中反复检测NT proBNP 能够提供独特的临床不良事件的预测 例如死亡 因为心衰恶化再入院等 故推荐在评价每个心衰患者时使用 NT proBNP与慢性性心衰的预后 Targetvaluesforoutpatientprognosticationremainrelativelyundefined However theriskformorbidityandmortalityinHFappearstoincreasemarkedlywithanNT proBNPconcentration 1000pg ml 门诊病人的靶目标水平仍未确定 但NT proBNP水平大于1000pg ml 则心衰的发病和死亡率明显上升 内容 NT proBNP在心力衰竭患者诊断中的应用NT proBNPinthediagnosisofdefiniteheartfailureNT proBNP判断心衰预后及对治疗的反应NT proBNPinthejudgemenofprognosisofheartfailure应用NT proBNP指导急性失代偿性心竭的治疗NT proBNPandTherapyMonitoringforAcutelyDestabilizedHF 检测NT proBNP能指导急性失代偿性心衰住院患者的治疗吗 NT proBNPlevelsdecreaseinresponsetotheadditionoftherapieswithprovenbenefitforHF includingACE inhibitors angiotensinreceptorblockers diuretics spironolactone exercisetherapyandbiventricularpacing 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 TheTrialofIntensifiedvsStandardMedicalTherapyinElderlyPatientsWithCongestiveHeartFailure TIME CHF design PatientswithchronicsystolicHFwererandomizedtointensifiedBNP guidedtherapyorstandardtherapyPatients 499patientswithsystolicheartfailure EF45 NYHAII IV priorhospitalizationforHF 1year andBNPlevel 400pg mLin 75yrand 800pg mLin 75yrClinicaloutcomeswerecomparedat18months Primaryoutcomes 18 monthsurvivalfreeofall causeHo spitalizationsandqualityoflife JAMA 2009 301 4 383 392 ACEIorARBand BlockerDosesDuringtheStudyTherewerenosignificantdifferencesbetweenthe2treatmentgroupsbyBNPlevel P 30 JAMA 2009 301 4 383 392 TIME CHF TIME CHF PrimaryandSecondaryOutcomes JAMA 2009 301 4 383 392 hospitalization freesurvival p 0 46 but inCHF Greaterreductionsinpatientsyoungerthan75years JAMA 2009 301 4 383 392 Age 75yr Age 75yr TIME CHF PrimaryandSecondaryOutcomes NT proBNPguidedmanagementofchronicheartfailurebasedonanindividualtargetvalue PRIMA study LucEurlings StudyCoordinatorMaastrichtUniversityMedicalCenterMaastricht theNetherlands YigalPinto PrincipalInvestigatorAcademicMedicalCenterAmsterdam theNetherlands ACCCongressOrlandoMarch29th2009 PRIMA study Prospective randomized single blindedstudyAdmittedwithsymptomaticheartfailure ElevatedNT proBNPlevels 1 700pg mlonhospitaladmissionNT proBNPguidedTreatmentIndividualNT proBNPtargetlevel Lowestlevelatdischargeor2weeksfollow up ClinicalguidedTreatmentFollow upat2weeks 1 3 6 9 12 15 21 24months Follow upupminimal1year PRIMA studyMainoutcomeACCOrlandoMarch2009 PRIMA study PRIMA studyMainoutcomeACCOrlandoMarch2009 TotalMortality PRIMA study Survival Time days P 0 208 NT proBNPguided Clinicalguided 46 17426 5 57 17133 3 Secondaryanalysis PRIMA study CardiovascularmortalitynsCombinedendpointCVmortality readmissionsnsHFrelatedreadmissionsnsCreatinineabove belowthemedian 123mcm L nsAgeabove below73yearsnsDischargeNT proBNPabove below2950pg mlns OnNT proBNPtargetanalysis Primaryendpoint PRIMA study OnNT proBNPTarget ClinicalGuidedgroup 院外平均存活天数 median IQR 721 578 730 p 001 664 435 726 101of174patientsinNT proBNPguidedgroup 58 maintainedtheirtargetinmorethan75 ofvisits按出院后维持NT proBNP靶标作对照 p 001 OnNT proBNPtarget Mortality PRIMA study OnNT proBNPTarget ClinicalGuidedgroup p 0 001 11 10110 9 57 17133 3 101of174patientsinNT proBNPguidedgroup 58 maintainedtheirtargetinmorethan75 ofvisits 按出院后维持NT proBNP靶标作对照