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1、1 广东省人民医院心内科广东省人民医院心内科 广东省心血管病研究所广东省心血管病研究所 陈鲁原陈鲁原23充血性心力衰竭:在临床上是否易于诊断?4Januzzi JL,Jr.,Am J Cardiol 200556Januzzi,et al,Eur Heart J 2005Anwaruddin,et al,JACC,2006诊断急性心力衰竭7NT-proBNP 和 BNP对有症状并疑诊为心衰患者的诊断路径临床检查，心电图，胸部临床检查，心电图，胸部X X线，线，超声心动图超声心动图利钠肽利钠肽慢性心衰慢性心衰 不可能不可能慢性心衰慢性心衰 可能可能 不确定不确定2008 ESC 心衰指南心衰指南
2、 Eur Heart J 2008;29:2388-2442脑钠肽在心衰诊断中有着重要的地位脑钠肽在心衰诊断中有着重要的地位8Am J Cardiol 2004;93:1562-1563Am J Cardiol 2008;101:3A9NT-proBNP用于急性呼吸困难患者用于急性呼吸困难患者诊断的灰色地带值诊断的灰色地带值 Although age stratification of NT-proBNP cut-points for the evaluation of patients with acute dyspnea reduces the likelihood of a grey z
3、one value,this finding was still present in 17%of subjects in the ICON study 尽管临床工作中推荐采用尽管临床工作中推荐采用NT-proBNPNT-proBNP切点标准切点标准的年龄分层方式可提高心衰的诊断水平，但仍的年龄分层方式可提高心衰的诊断水平，但仍然有然有17%17%患者的患者的NT-proBNPNT-proBNP仍处于灰色地带值仍处于灰色地带值Am J Cardiol 2008;101:3A10van Kimmenade RRJ.Am J Cardiol 2006对NT-proBNP灰度值并不代表良性预测,更不
4、能认为其为阴性结果11van Kimmenade,et al,AJC,20061213急性心力衰竭急性心力衰竭,5000 pg/ml 是短期预后的界值是短期预后的界值14Januzzi et al.Arch Intern Med 2006对于对于1年危险度的分层，最佳界值是年危险度的分层，最佳界值是1000 pg/ml1516Dias2001000Survival without readmissions 1,00,80,60,40,20,0Decrease 30%Within 30%Increase 30%p0.0001Bettencourt P.Circulation 2004171819
5、20212223JAMA.2009;301(4):383-39224 ACEI or ARB and-Blocker Doses Duringthe StudyThere were no significant differences between the 2 treatment groups by BNP level(P=.30).JAMA.2009;301(4):383-39225JAMA.2009;301(4):383-392hospitalization-free survival(p=0.46),but in CHF26Greater reductions in patients
6、younger than 75 yearsJAMA.2009;301(4):383-392Age75yrAge75yr27 PRIMA-studyLuc Eurlings,Study CoordinatorMaastricht University Medical CenterMaastricht,the NetherlandsYigal Pinto,Principal InvestigatorAcademic Medical CenterAmsterdam,the NetherlandsACC Congress Orlando March 29th 200928 Prospective,ra
7、ndomized,single-blinded study Admitted with symptomatic heart failure;Elevated NT-proBNP levels 1,700 pg/ml on hospital admission NT-proBNP guided Treatment Individual NT-proBNP target level (Lowest level at discharge or 2 weeks follow-up)Clinical guided Treatment Follow-up at 2 weeks,1,3,6,9,12,15,
8、21,24 months;Follow-up up minimal 1 yearPRIMA-study Main outcome ACC Orlando March 200929PRIMA-studyPRIMA-study Main outcome ACC Orlando March 200930Total Mortality PRIMA-studySurvival(%)Time(days)P=0.208NT-proBNP guidedClinical guided46/17426.5%57/17133.3%31Secondary analysisPRIMA-study Cardiovascu
9、lar mortalityns Combined endpoint CV mortality/readmissionsns HF related readmissionsns Creatinine above/below the median(123 mcm/L)ns Age above/below 73 yearsns Discharge NT-proBNP above/below 2950 pg/mlns32On NT-proBNP target analysis:Primary endpointPRIMA-studyOn NT-proBNP TargetClinical Guided g
10、roup院外平均存活天数(median+IQR)721(578-730)p.001664(435-726)101 of 174 patients in NT-proBNP guided group(58%)maintained their target in more than 75%of visits 按出院后维持NT-proBNP靶标作对照p.00133On NT-proBNP target:Mortality(%)PRIMA-studyOn NT-proBNPTargetClinical Guided groupp0.00111/10110.9%57/17133.3%101 of 174
11、 patients in NT-proBNP guided group(58%)maintained their target in more than 75%of visits按出院后维持NT-proBNP靶标作对照34Conclusions Management of heart failure guided by an individually defined optimal NT-proBNP level does not appear favorable in the overall population However,maintaining this individual opt
12、imal NT-proBNP level portends significantly better outcome The PRIMA-study allows to identify patients where it is feasible to maintain the optimal NT-proBNP level and who may benefit from treatment guided by their own optimal NT-proBNPPRIMA-study3536Thank you37There were no significant differences between the 2 treatment groups by N-terminal BNP level(P=.30).JAMA.2009;301(4):383-392个人观点供参考，欢迎讨论
NproBNP在心衰诊断预后治疗的管理
