心梗心衰心标准BNP临床进展

1、心梗心衰心标准BNP临床进展主要内容心血管的学科发展背景BNP发展史BNP在心血管科的应用病例分析心血管科的发展与困惑大发展的三个年代 介入时代 循证时代 预防时代 心血管医生的思考 医学的意义 意义的基石早预防早救治早诊断拜斯汀事件分析诊断治疗检验医学心血管标志物快速发展的原因巨大优势在心血管疾病发展的各个阶段快速诊断炎症:心血管疾病 (CVD): 主要的心脏标志物心肌损伤:左心室肥大 充血性心衰MPO , hs-CRPBNPcTnI, Myo, CK-MB mass高血压及坏死心脏 重塑 末期心衰心血管检验中的主要标志物心肌损伤标志物心力衰竭标志物心肌炎性标志物BNP 发展史1981, d

2、e Bold et al. first reported a potent diuretic and natriuretic factor in rat atrial extracts1984, Kangawa et al. identified atrial natriuretic peptide (ANP)1988, B-type or brain natriuretic peptide (BNP)1990, C-type natriuretic peptide (CNP)Natriuretic peptide family: ANP, BNP, CNP, DNP(dendroaspis)

3、, UrodilatinBNP 是心衰定量标志物 促进排尿利钠抑制RAAANPBNP =CNP体积压力 左室收缩功能障碍+左室舒张功能障碍+瓣膜功能障碍+右室功能障碍 降低外周血管抵抗 (降低血压)Iwanaga Y et al. JACC. 2006;47:742-8.肌细胞Pre-proBNP (134 aa)proBNP (108 aa)信号缩氨酸 (26 aa)分泌物NT-proBNP (1-76)BNP (77-108)BNP/NT-proBNP的分泌和释放ZJZJBNP的形成和分解pre-proBNP1-134Meprin ABNP7-32DPP-IV = dipeptidyl p

4、eptidaseIVDPP-IVBNP3-32proBNP1-108BNP1-32NT-proBNP1-76proBNP1-108Signal peptide (26 amino acids)BNP levels in patients with diagnosis of CHF and baseline left ventricular dysfunction. Diagnosis of CHF was based on independent assessment by 2 cardiologists blinded to BNP values. Values are expressed

5、as mean +/- SEM Dao, Q., Maisel, A. et al. J. American College of Cardiology, No. 2, 2001.ZJBNP Concentration (pg/ml)186 22791 1652013 266N = 27N = 34N = 36BNP concentrations for the degree of CHF severityMildModerate Severe05001000150020002500J. Cardiac Failure 7(2):183-9 2001ZJLg BNP (pmol/l)LVEF

6、(%)020406080 10001.02.03.0y=-0.7, p0.001Davis et al. Lancet 1994; 343:440-444.BNP vs. EF by EchocardiographyZJBNP Levels in patients with dyspnea caused by CHF or chronic obstructive pulmonary diseaseJ. Cardiac Failure 7(2):183-9 2001ZJHow BNP affectsInfluences on BNP Levelsdiuretics,ACEI,angiotensi

7、n-II receptor blockers reduce BNPconcentrationsMedications used in HFdigoxin and some beta blockers appear to increase BNPconcentrationsExercise causes a short-term increase in BNP levelsBNP方法学发展放射免疫法免疫荧光法免疫夹心法电化学发光法快速微粒体免疫荧光法(RAMP) 日本盐野义BNP检测首创者1878年，盐野义成立于日本大阪，致力于医药研究1993年，盐野义推出BNP检测(Biosite 2000年

8、)2006年，盐野义与加拿大Response合作，推出Shionogi BNP POCT现在，O&D 与Response 将之引入国内，即 RAMP BNP检测BNP方法学发展放射免疫法免疫荧光法免疫夹心法电化学发光法快速微粒体免疫荧光法(RAMP) BNP的地位划时代的意义，心衰诊断的“金标准”；2000年通过FDA、CE和SFDA的认证；2002年BNP检测被评为国际医学十大新闻之一；2004年NACB和ACC分别推出BNP临床应用的指南或专家共识；2007年推出中国BNP专家共识；2008年推出北美欧洲BNP专家共识。可能的优点稳定性好重复性好与中心检验的相关性好低值精度好多级质量控制利

9、于POCT的开展病例报告5 Days ago Case 45岁男性，突发胸痛伴发呼吸困难5小时吸烟肥胖高血压5 Days ago Case 诊断步骤胸痛的鉴别诊断应筛查的疾病危险分层预后判断治疗决策物理检查心率增快血压升高心脏杂音Diagnosis ECG - STEMIAcute inferior myocardial infarction. Diagnosis ECG - STEMIHyperacute phase of extensive antero-lateral myocardial infarction. Acute mitral flail occlusionstent imp

10、lantationPulmonary Edema due to Heart FailureMeasuring Jugular Venous PressureTodayWhat is the acute coronary syndrome?acutelife-threatingcoronary event The clinical presentation of the ischaemic heart diseaseasymptomatic (silent ischaemia!)CHFstable angina pectorismalignant arrhythmia / sudden deat

11、hST elevation myocardial infarction (STEMI)Non-ST elevation ACSUnstable anginaNon-ST elevation myocardial infarction (NSTEMI)Acute Coronary Syndrome(ACS)病理生理斑块破裂血栓形成炎性病变Plaque rupture and platelet activation thrombus formationcurrent complaint:painthere are a lot of importment data of the pain:local

12、isationradiationonset of the painthe type (press, smart,cutting)dinamic of the pain (continouosly, ongoing, undulaiting)answer to the medical therapy 临床症状In case of STEMIVery important the quick diagnosis!TIME=MYOCARDIUM=LIFE!If the time window 12 hopen artery theory = open the occluded coronary artery save the myocardium!If the patient