N-proBNP在心衰诊断预后治疗的管理.ppt

N-proBNP在心衰诊断、预后、治疗的管理,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,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。,Independentpredictorsofacuteheartfailureindyspneicpatientsintheemergencydepartment急诊室呼吸困难患者急性心力衰竭的独立预测因素,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,NT-proBNP年龄分层降低了假阳性和假阴性，提高了阳性预测值ICON的三重界值无需根据肾功能对NT-proBNP界值进一步调整,Januzzi,etal,EurHeartJ2005Anwaruddin,etal,JACC,2006,诊断急性心力衰竭,国际氨基末端脑钠肽原协助数据,根据年龄分层的NT-proBNP“诊断”界值,NT-proBNP和BNP对有症状并疑诊为心衰患者的诊断路径,临床检查，心电图，胸部X线，超声心动图,利钠肽,慢性心衰不可能,慢性心衰可能,不确定,2008ESC心衰指南,EurHeartJ2008;29:2388-2442,脑钠肽在心衰诊断中有着重要的地位,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1620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-proBNP4002000pg/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,NT-proBNPandTherapyMonitoringforAcutelyDestabilizedHF急性不稳定性心力衰竭的NT-proBNP监测,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-proBNPlevel1000pg/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:499patientswithsystolicheartfailureEF45%,NYHAIIIV,priorhospitalizationforHF1year,andBNPlevel400pg/mLin75yrand800pg/mLin75yrClinicaloutcomeswerecomparedat18months.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),butinCHF,Greaterreductionsinpatientsyoungerthan75years,JAMA.2009;301(4):383-392,Age75yr,Age75yr,NT-proBNPguidedmanagementofchronicheartfailurebasedonanindividualtargetvalue,PRIMA-study,LucEurlings,StudyCoordinatorMaastrichtUniversityMedicalCenterMaastricht,theNetherlands,YigalPinto,PrincipalInvestigatorAcademicMedicalCenterAmsterdam,theNetherlands,ACCCongressOrlandoMarch29th2009,PRIMA-study,Prospective,randomized,single-blindedstudyAdmittedwithsymptomaticheartfailure;ElevatedNT-proBNPlevels1,700pg/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,p0.001,11/10110.9%,57/17133.3%,101of174patientsinNT-proBNPguidedgroup(58%)maintainedtheirtargetinmorethan75%ofvisits,按出院后维持NT-proBNP靶标作对照,Conclusions,ManagementofheartfailureguidedbyanindividuallydefinedoptimalNT-