《BNP和急性冠脉综合征（ACS)课件-精选文档.ppt》由会员分享，可在线阅读，更多相关《BNP和急性冠脉综合征（ACS)课件-精选文档.ppt（58页珍藏版）》请在三一文库上搜索。
1、心肌供血障碍后局部心肌变化规律 急性冠脉供血减少 局部心肌氧分压下降 心肌代谢改变 心肌功能下降（RWMA、CO、PCWP) 心电图缺血性ST-T改变 心绞痛、心肌梗死 犬LAD套扎恢复LAD血流 冠脉急性闭塞再灌注对局部心肌功能影响 评价ACS的方法 临床症状及既往病史 12导联心电图 心脏标志物 ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and NonST-Segment Elevation Myocardial Infarction Pathophysiology C
2、oronary artery disease Coronary inflammtion Plaque instability/disruption Myocardial ischemia Myocardial necrosis Ventricular overload Biochemical marker Risk factors(eg,cholesterol） CRP,Scd40lL, MPO Choline, PAPP-A FFAu, IMA Cardiac troponion, CK-MB, myoglobin BNP, NT-proBNP 心脏标志物 ACS新的标记物 BNP BNP由
3、心室肌分泌, 在心室扩张和压力负荷时 BNP水平反映神经内分泌激活和疾病的进展 短暂心肌缺血致LV壁张力增加使BNP即使无MI和心功不全 BNP水平可确定是否要强化药物治疗和介入治疗 BNP测定达 80pg/ml 是心衰时神经内分泌激活的閾值 IL-6 血浆浓度反映斑块不稳定的程度和PCI后再狭窄的情况 IL-6在ACS时是很强的独立的增加死亡的标志 PAPP-A (Pregnancy Associated plasma Protein A) 在腐蚀和破裂的斑块中表达,在 UA/MI 时血清PAPP-A明显 American Journal of Critical Care. 2002, vo
4、lume 11 BNPACS危险分层及预后新的标志物 ACS危险分层及预后新的标志物 Plasma Natriuretic Peptide Levels and Acute Coronary Syndrome q 1995年，Hama等发现BNP主要来自位于梗死区域与非梗死区域交界 的缺血损伤心肌细胞及梗死区存活的缺血损伤心肌细胞中（该区域脑钠 素核糖核酸和脑钠素颗粒的数量显著增加） q Marumoto等研究发现，运动试验诱发急性心肌缺血的心绞痛患者血 浆BNP水平明显升高，进一步证实心肌缺血可致血浆脑钠素水平的升高 Hama N,Itoh H, Shirabami G, et al. Ci
5、rculation,1995,92: 1558-1564 Marumoto K, Hamada M, Hiwada K. Clin Sci(Colch),1995,88:551-56 2004 ACC ( America College of Cardiology ) BNP Consensus Panel 2004: A Clinical Approach for the Diagnostic, Prognostic, Screening, Treatment Monitoring, and Therapeutic Roles of Natriuretic Peptides in Cardi
6、ovascular Diseases (CHF. 2004; 105 suppl 3:130) 2004 CHF, Inc. BNP-早期预测急性心梗的新指标 Bsssan,et al.Eur Heart J 2005,26:234 631例主诉胸痛或12小时前可能由于急性心肌缺血导致胸 部不适的急诊患者（胸痛发作时间为15h，中位数2h） 入院时心电图无ST段抬高 入院立即检测血浆BNP、CK-MB和cTNI，并留院随访 Bsssan,et al.Eur Heart J 2005,26:234 72例患者最终诊断为NSTEMI。其中11例患者仅有TnI升 高，3例仅有CK-MB升高，57例T
7、nI和CK-MB均升高 NSTEMI患者BNP的中位值为203.5pg/ml，而UA和非 急性冠脉综合征患者分别为77.9pg/ml和27.7pg/ml (P100pg/ml为判定指 标后可多识别出22例NSTEMI患者(占未诊断者的60%) Bsssan,et al.Eur Heart J 2005,26:234 在入院时，BNP诊断NSTEMI的敏感性显著增加， BNP、CK-MB和TnI分别为70.8%、45.8%和 50.7%(P =2.26 者 Circulation. 2004 Sep 14;110(11):1387-91. UA/NSTEMI继发心衰危险的评分研究 4681468
8、1名名OPUS-TIMI 16OPUS-TIMI 16 研究中不伴研究中不伴CHFCHF的的 UA/NSTEMIUA/NSTEMI 病人病人 1010个月随访期个月随访期 观察心衰的发生率观察心衰的发生率 多参数分析多参数分析 Am Heart J. 2004 Jul;148(1):173-80 心衰发生率30天时为4.9% ，10 个月时升至 5.6% 5项因素与心衰发生的联系有显著性意义:年龄65岁心 率100次/分，糖尿病史，超声心动图异常，冠脉造影 证实的冠心病史 具备危险因素增加，心衰危险增高10倍 UA/NSTEMI继发心衰危险的评分研究 Am Heart J. 2004 Jul;
9、148(1):173-80 UA/NSTEMI继发心衰危险的评分研究 TACTICS-TIMI 18研究验证该危险评分结果与6个月时 心衰的发生显著相关 TACTICS-TIMI 18研究时发现危险因素增加同时BNP 测值的中位数成倍升高 BNP测值加入评估使准确性提高 UA/NSTEMI病人简便的评估方法有助于 区分心衰的高危患者 Am Heart J. 2004 Jul;148(1):173-80 BNP 水平与急性心肌梗死患者Killip心功能分级的相关性研究 阜外医院 2002年9月-2003年9月273例AMI患者的研究 2004 ACC ( America College of C
10、ardiology ) Consensus Statement 7 BNP Measurement in Sudden Death, Acute Coronary Syndrome, and Coronary Artery Disease: 7.1 BNP is a significant independent predictor of mortality in HF. Changes in BNP over time are associated with morbidity and mortality. This provides physicians with an opportuni
11、ty to provide more aggressive treatment to these patients 2004 ACC ( America College of Cardiology ) Consensus Statement 7 BNP Measurement in Sudden Death, Acute Coronary Syndrome, and Coronary Artery Disease: 7.2 When used together in a combined strategy, BNP and cardiac troponin provide a more eff
12、ective tool for identifying patients at increased risk for clinically important cardiac events related to HF and acute coronary syndrome. Multi-marker panels that include BNP, troponin, and C-reactive protein are now available and each of these markers provides unique and independent information wit
13、h regard to patient outcomes 美国临床生化学会（NACB）实践指南2004 Recommendations for use of biochemical markers for risk stratification in ACS Class I 5. Patients with suspected ACS should undergo early risk stratification based upon an integrated assessment of symptoms, physical exam findings, ECG findings, and
14、 biomarkers Use of biochemical markers in the initial evaluation of ACS Class I 6. A cardiac troponin is the preferred marker for risk stratification and, if available, should be measured in all patients with suspected ACS. In patients with a clinical syndrome consistent with ACS, a maximal concentr
15、ation exceeding the 99th percentile of values for a reference control group (with acceptable precision) should be considered indicative of increased risk of death and recurrent ischemic events Class IIa 8. Measurement of hs-CRP may be useful, in addition to a cardiac troponin, for risk assessment in
16、 patients with a clinical syndrome consistent with ACS. The benefits of therapy based on this strategy remain uncertain Class IIa 9. Measurement of B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) may be useful, in addition to a cardiac troponin, for risk assessment in patients wit
17、h a clinical syndrome consistent with ACS. The benefits of therapy based on this strategy remain uncertain Class IIb 13. A multi-marker strategy that includes measurement of two or more pathobiologically diverse biomarkers in addition to a cardiac troponin, may aid in enhancing risk stratification i
18、n patients with a clinical syndrome consistent with ACS. BNP and hs-CRP are the biomarkers best studied using this approach. The benefits of therapy based on this strategy remain uncertain A Clinical decision-making Recommendations for the use of biochemical cardiac markers for therapeutic decision-
19、 making Class I Among patients with a clinical history consistent with ACS, an increased concentration of cardiac troponin should prompt application of ACS management guidelines for patients with indicators of high risk use of biochemical markers in the management of NSTE ACS Class III 14. Applicati
20、on of management guidelines for ACS should not be based solely upon measurement of natriuretic peptides 15. Application of management guidelines for ACS should not be based solely upon measurement of C-reactive protein use of biochemical markers in the management of NSTE ACS Predictive value of MPO
21、for incidence of death and nonfatal myocardial infarction Baldus S et al, Circulation 2003 心脏生化标志物联合应用 Morrow and Braunwald. Biomarkers in Acute Coronary Syndromes. Circulation 2003;108:250-252. Cardiac Biomarker TAT（ turnaround time ） Biosite Triage BNP Test Biosite Triage Point of Care Test(POCT) BNP The First FDA-approved BNP Test Rapid, Whole Blood Testing 15 Minute Time to Result Quantitative Measurements： 55000 pg/mL Hand Held, Portable System Stored memory, Printed Results Hospital Information System Interface THE END！ Thank you very much!