生化指标在心力衰竭诊疗和治疗中角色

1、生化指标在心力衰竭诊疗和治疗中角色心功能/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LevelsAdapted from Cohn JN. Cardiology. 1997;88:26.血浆去甲肾上腺素(pg/mL)NLHF血浆肾素激活(ng/mL/h)15129630NLHF精氨酸血管加压素(pg/mL)126420NLHF利钠肽(pg/mL)300250200150100500NLHF内皮素-1(pg/mL)86420NLHF6005004003002001000心衰

2、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-pro BNP肌钙蛋白其他：神经激素指标等 Pre-Pro-BNP1-13426-氨基信号序列N-端Pro-BNP1-76BNP77-108Pro-BNP1-108t1/2 = 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-proBNP2005年ESC/AHA心衰防治指南推荐脑钠肽作为心衰的诊断指标Diagnostic assessments supporting the presence of heart failure2008 ESC guidelineB

3、NP/NT-pro BNP2008 ESC guideline BNP/NT-pro BNP的诊断价值 阴性预测值 阳性预测值 BNP 97% 90% （500pg/ml) NT-proBNP 99% 98% (2000pg/ml) 影响BNP/NT-pro BNP的因素BNP/NT-pro BNP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Neurohormonal markersN

4、orepinephrine, renin, aldosterone, endothelinAlthough useful in research, evaluation of neuroendocrine activation is not required.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Plasma Brain Natriuretic Peptide-Guided Therapy to Improve Outcome in Heart Failure: The STARS-BNP Multicenter Study 220 NYHA IIIII

5、patients Multicenter JACC 2007;49:1733-9Number of Changes in Medical Therapy During the First 3 Months-Compare clinical group vs. BNP group JACC 2007;49:1733-9Changes in Medical Therapy During the Titration Phase in BNP Group and Clinical groupJACC 2007;49:1733-9JACC 2007;49:1733-9Event-Free (Hospit

6、alization for Heart Failure or Death Related to Heart Failure) SurvivalSTARS-BNP Study Conclusiona BNP-guided strategy reduces the incidence of a combined end point (death and hospital stay related to heart failure) compared with a standard strategy. The result is mainly obtained through an increase

7、 in ACEI and beta-blocker dosages.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Conditions associated with a poor prognosis in heart failure2008 ESC guidelineCopyright restrictions may apply.NT-pro BNP与预后Absolute values (median and interquartile range) of NT-proBNP plasma levels of patients subdivided on th

8、e basis of their clinical courseCopyright restrictions may apply. Mortality and cardiovascular hospitalisation free survival curves on the basis of their median NT-proBNP levels at dischargeNT-proBNP与预后Copyright restrictions may apply.Mortality and cardiovascular hospitalisation free survival curves

9、 for the patients subdivided on the basis of their NT-proBNP levels combined with NYHA classCopyright restrictions may apply.TnT与心衰预后Copyright restrictions may apply.mortality and cardiovascular hospitalisation free survival curves on the basis of their NT-proBNP levels combined with the detection o

10、f cTnTPrediction of cardiac death or CV hospitalization:CART analysis低钠与预后MUSIC risk score:a simple method for predicting mortality in patients with chronic heart failureMUSIC Risk score for each type of mortality2009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/A