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1、生化指标在心力衰竭 诊断和治疗中的角色,浙江大学医学院附属第二医院 心脏中心 王建安 项美香,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,心衰与神经激素激活,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-BNP1-134,26-氨基信号序列,N-端 Pro-BNP1-76,BNP77-108,Pro-BNP1-108,t1/2 = 18 分钟,室壁张力增
2、加,t1/2 = 60-120 分钟,新的心功能标志物BNP与NT-proBNP,2005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 failure,2008 ESC guideline,BNP/NT-pro BNP,2008 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/
3、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 markers,Norepinephrine, renin, aldosterone, endothelin Although useful in research, evaluation of neuroendocrine activation is not requ
4、ired.,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 patients Multicenter,JACC 2007;49:1733-9,Number of Changes in Medical Therapy During the First 3 Months -Compare clinica
5、l group vs. BNP group,JACC 2007;49:1733-9,Changes in Medical Therapy During the Titration Phase in BNP Group and Clinical group,JACC 2007;49:1733-9,JACC 2007;49:1733-9,Event-Free (Hospitalization for Heart Failure or Death Related to Heart Failure) Survival,STARS-BNP Study Conclusion,a BNP-guided st
6、rategy 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 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 p
7、rognosis in heart failure,2008 ESC guideline,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,NT-pro BNP与预后,Absolute values (median and interquartile range) of NT-proBNP plasma levels of patients subdivided on the basis of their cl
8、inical course,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,Mortality and cardiovascular hospitalisation free survival curves on the basis of their median NT-proBNP levels at discharge,NT-proBNP与预后,Copyright restrictions may app
9、ly.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,Mortality and cardiovascular hospitalisation free survival curves for the patients subdivided on the basis of their NT-proBNP levels combined with NYHA class,Copyright restrictions may apply.,Metra, M. et al. Eur
10、 J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,TnT与心衰预后,Copyright restrictions may apply.,Metra, M. et al. Eur J Heart Fail 2007 9:776-786; doi:10.1016/j.ejheart.2007.05.007,mortality and cardiovascular hospitalisation free survival curves on the basis of their NT-proBNP levels comb
11、ined with the detection of cTnT,Prediction 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 failure,MUSIC Risk score for each type of mortality,2009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/AHA心衰防治指南推荐脑钠肽作为心衰的诊断指标,根据BNP/NT-proBNP指标调整治疗方案可进一步减少心血管事件，提高存活率。 BNP/NT-pro BNP 、tropinin、血钠水平也是心力衰竭患者预后的指标。,总 结,结 语,注重生化指标在心衰患者中的应用 应用生化指标进一步指导心衰患者的诊断、治疗和病情评估，改善患者的预后,thank you!,