生化指標(biāo)在心力衰竭診療和治療中角色

1、生化指標(biāo)在心力衰竭診療和治療中角色心功能/心衰標(biāo)志物的重要性無癥狀心衰/癥狀性心衰發(fā)病率早期/輕度心衰往往沒有心室結(jié)構(gòu)的改變，癥狀也不明顯心動超聲檢查往往還不能發(fā)現(xiàn)心室的改變相當(dāng)一部分心衰患者不能獲得及時(shí)診斷LevelsAdapted from Cohn JN. Cardiology. 1997;88:26.血漿去甲腎上腺素(pg/mL)NLHF血漿腎素激活(ng/mL/h)15129630NLHF精氨酸血管加壓素(pg/mL)126420NLHF利鈉肽(pg/mL)300250200150100500NLHF內(nèi)皮素-1(pg/mL)86420NLHF6005004003002001000心衰

2、與神經(jīng)激素激活心衰主要實(shí)驗(yàn)室指標(biāo)常規(guī)生化指標(biāo)：血?dú)夥治?，電解質(zhì)，肝腎功能，血常規(guī)等BNP/NT-pro BNP肌鈣蛋白其他：神經(jīng)激素指標(biāo)等 Pre-Pro-BNP1-13426-氨基信號序列N-端Pro-BNP1-76BNP77-108Pro-BNP1-108t1/2 = 18 分鐘 室壁張力增加t1/2 = 60-120 分鐘新的心功能標(biāo)志物BNP與NT-proBNP2005年ESC/AHA心衰防治指南推薦腦鈉肽作為心衰的診斷指標(biāo)Diagnostic assessments supporting the presence of heart failure2008 ESC guidelineB

3、NP/NT-pro BNP2008 ESC guideline BNP/NT-pro BNP的診斷價(jià)值 陰性預(yù)測值 陽性預(yù)測值 BNP 97% 90% （500pg/ml) NT-proBNP 99% 98% (2000pg/ml) 影響B(tài)NP/NT-pro BNP的因素BNP/NT-pro BNP升高急性冠脈綜合征慢性肺部疾病肺動脈高壓高血壓心房顫動 腎功能不全高齡感染影響B(tài)NP/NT-proBNP的因素肥胖者降低在急性肺水腫或急性二尖瓣關(guān)閉不全的早期階段，腦鈉肽可保持“正常”。 Troponin心肌缺血、心肌炎嚴(yán)重心衰、心衰失代償病人可有輕度升高Neurohormonal markersN

4、orepinephrine, renin, aldosterone, endothelinAlthough useful in research, evaluation of neuroendocrine activation is not required.生化指標(biāo)在心衰治療和預(yù)后中的價(jià)值根據(jù)生化指標(biāo)調(diào)整治療方案生化指標(biāo)對預(yù)后的預(yù)測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.生化指標(biāo)在心衰治療和預(yù)后中的價(jià)值根據(jù)生化指標(biāo)調(diào)整治療方案生化指標(biāo)對預(yù)后的預(yù)測Conditions associated with a poor prognosis in heart failure2008 ESC guidelineCopyright restrictions may apply.NT-pro BNP與預(yù)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與預(yù)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與心衰預(yù)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低鈉與預(yù)后MUSIC risk score:a simple method for predicting mortality in patients with chronic heart failureMUSIC Risk score for each type of mortality2009美國成人慢性心力衰竭診斷和治療指南 (更新版）測定BNP和NTproBNP有助于評估HF診斷不確定的急診患者。測定BNP和NTproBNP對于危險(xiǎn)分層有意義（證據(jù)級別A），增加了腦鈉肽對舒張性心衰和收縮性心衰患者在總體臨床評估中的“警示”作用 總 結(jié)生化指標(biāo)BNP/NT-proBNP對心力衰竭的診斷有重要的作用ESC/A