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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,室壁张力增加,t1/2=60-
2、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/NT-pro BNP升高急性冠脉综
3、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,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
4、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 clinical group vs.BNP group,JACC 2007;49:1
5、733-9,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 strategy reduces the incidence of a comb
6、ined 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 prognosis in heart failure,2008 ESC guidelin
7、e,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 clinical course,Copyright restrictions may apply.,M
8、etra,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 apply.,Metra,M.et al.Eur J Heart Fail 2007 9:776-786;doi
9、: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 J Heart Fail 2007 9:776-786;doi:10.1016/j.ejheart.2007.05.0
10、07,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 combined with the detection of cTnT,Prediction of cardiac death or CV
11、 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!,
