TNI and BNP

1,Company Confidential 2010 Abbott,B-Type Natriuretic Peptide （BNP）,2,Company Confidential 2010 Abbott,3,Company Confidential 2010 Abbott,4,Company Confidential 2010 Abbott,Overview,案例：HF何謂BNPBNP臨床應(yīng)用,5,Company Confidential 2010 Abbott,Case HF:,男性，65歲，主訴“進(jìn)行性加重的呼吸困難1天?！辈轶w：BP170/100mmHg，HR100bpm，律齊，無(wú)奔馬律，兩肺可及廣泛干濕 羅音，無(wú)水腫。輔助檢查：EKG：竇速，多源性早搏，左房、左室肥大，陳舊性Q波胸片（成像差）：未見(jiàn)心臟擴(kuò)大床邊B超：輕度室壁運(yùn)動(dòng)減退（陳舊性），收縮功能未見(jiàn)明顯異常。TNI0.04ng/ml，血常規(guī)、電解質(zhì)正常BNP未做既往史：高血壓、COPD、陳舊性心梗、1年前心臟射血分?jǐn)?shù)正常既往用藥：2種吸入劑、可樂(lè)定、斯伐他汀,6,Company Confidential 2010 Abbott,Case HF：,接下來(lái) 診斷：COPD急性加重 處理：吸氧、噴霧、糖皮質(zhì)激素患者自覺(jué)好轉(zhuǎn)，2小時(shí)后準(zhǔn)予回家,7,Company Confidential 2010 Abbott,Case HF：,接下來(lái) 3小時(shí)后患者感到嚴(yán)重呼吸困難，由急救車(chē)再次送至急診室。 查體：BP160/110mmHg，HR140bpm,律絕對(duì)不齊（心監(jiān)提示房 顫），兩肺呼吸運(yùn)動(dòng)差。,COPD？心衰？肺栓塞？,8,Company Confidential 2010 Abbott,Case HF：,何種檢查需要進(jìn)一步檢查？ BNP？ D二聚體？ CKMB、TNI？Order BNPBNP900pg/ml,9,Company Confidential 2010 Abbott,Case HF：,速尿40mg IV地爾硫卓 10 mg/h iv Nesiritide（腦促尿鈉排泄肽（商品名：奈西立肽）2 mcg/kg po 后 0.01 mcg/kg/min 靜脈用 24H后患者癥狀明顯改善，心律恢復(fù)竇性，兩肺呼吸音轉(zhuǎn)清，24H尿量3000ml。復(fù)測(cè)BNP150 pg/mL,10,Company Confidential 2010 Abbott,Case HF：,最終轉(zhuǎn)歸：心超檢查提示心臟舒張功能減退，E/A0.7予ACEI、受體阻滯劑治療2天后出院,11,Company Confidential 2010 Abbott,Case HF：,思考,如何正確診斷呼吸困難？肺源性？心源性？,12,Company Confidential 2010 Abbott,35%病人無(wú)臨床癥狀35%病人癥狀不典型缺少既往病史往往合并其他疾病常規(guī)EKG、X-rays無(wú)法特異區(qū)分心源性和肺源性疾病心超能夠明確，但在急診室不常規(guī)檢查,HF in ED,13,Company Confidential 2010 Abbott,from the BNP Consensus Panel 2004,Consensus Statement 2：Using BNP Levels to Help Triage Patients Presenting to the ED With Dyspnea,14,Company Confidential 2010 Abbott,何謂BNP？,15,Company Confidential 2010 Abbott,Brain natriuretic peptide (BNP),由心室心肌細(xì)胞釋放的肽段1988首先由豬腦組織中分離出，但是由心室細(xì)胞首先合成生理作用：利尿，促尿鈉排泄，抑制RAAS系統(tǒng)及交感系統(tǒng)，舒張血管平滑肌，以減少容量負(fù)荷BNP 是一個(gè)心臟激素,16,Company Confidential 2010 Abbott,BNP from Cardiac Myocytes,Blood,Cardiomyocyte,Mair et al. Clin Chem Lab Med 39:571-88.,17,Company Confidential 2010 Abbott,BNP vs NT-proBNP,*當(dāng) eGFR 60 mL/min時(shí)，截?cái)嘀禐?1200 pg/mL,18,Company Confidential 2010 Abbott,BNP的臨床應(yīng)用,19,Company Confidential 2010 Abbott,Clinical Utility of BNP,心衰診斷預(yù)后的評(píng)價(jià)治療監(jiān)測(cè)急性冠脈綜合征預(yù)后的評(píng)價(jià),20,Company Confidential 2010 Abbott,BNP應(yīng)用于心衰,21,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,所有BNP供應(yīng)商建議以 100 pg/mL 作為判定值,Dickstein K.E heart J.2008;29:2388-2422,22,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,from the BNP Consensus Panel Consensus Statement 3, renal disease:3.1. 慢性腎功能衰竭患者的BNP水平會(huì)發(fā)生變化 (估計(jì) GFR 60 ml/min), 重新定標(biāo)后所獲得的截?cái)嘀导s為 200 pg/mL. 然而, 當(dāng)BNP水平極高或極低時(shí)，有助于對(duì)呼吸困難進(jìn)行評(píng)估。,23,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Breathing Not Properly (BNP) Study1586位由于急性呼吸困難至急診室就診的患者患者就診時(shí)予測(cè)定BNP,但急診醫(yī)生診斷時(shí)沒(méi)有提供BNP的值急診醫(yī)生結(jié)合病史、體格檢查及除BNP外其他相關(guān)實(shí)驗(yàn)室檢查（eg. EKG，X-Ray，心超、及其他臨床生化免疫檢查）對(duì)病人做出診斷同時(shí)用2位心臟科專(zhuān)家各自結(jié)合所有的臨床數(shù)據(jù)（除BNP）做出的診斷為標(biāo)準(zhǔn)心臟科專(zhuān)家做出診斷時(shí)未提供BNP值，未參考急診醫(yī)師的診斷,24,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Silver MA, et al. Congest Heart Fail. 2004;10:1-30.,N = 1586,Breathing Not Properly Study,BNP提高HF診斷率,25,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,McCullough PA, et al. Circulation. 2002;106:416-422.,N = 1586,Optimal BNP cutoff point determined at 100 pg/mL,在ED，ROC曲線下面積臨床判斷是0.86BNP單獨(dú)是0.90兩者結(jié)合0.93,26,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Mueller C, et al. N Engl J Med. 2004;350:647-654.,N = 452,至急診就診的急性呼吸困難患者(N = 452),終點(diǎn)出院時(shí)間總的治療費(fèi)用,BNP for Acute Shortness of Breath Evaluation (BASEL) Study,27,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Mueller C, et al. N Engl J Med. 2004;350:647-654.,N = 452,BASEL Study: BNP組提高診斷率，能減少治療費(fèi)用,28,Company Confidential 2010 Abbott,BNP同樣可用于心臟舒張功能不全的患者的診斷BNP升高程度不如收縮功能不全的患者，視舒張功能受損情況而定,Breathing Not Properly Multinational Study 447 patients with acute dyspnea in the ED Maisel et al. JACC. 2003;41:2010-2017,34,413,821,Diagnostic Utility of BNP in HF,29,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,合并肺部疾病 from the BNP Consensus Panel Consensus Statement 4：pulmonary disease:4.1. 大約20%肺部疾病患者的BNP會(huì)上升, BNP水平的上升意味著心衰結(jié)合肺部疾病,肺源性心臟病的發(fā)生, 或意味著當(dāng)呼吸困難,真正的病因是心衰時(shí)所發(fā)生的誤診 4.2. 當(dāng)發(fā)生肺部栓塞時(shí) (PE),三分之一患者會(huì)發(fā)生 BNP 上升 ,30,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,合并肺部疾病患者中BNP水平與心衰的關(guān)系,McCullough, Wu, et al. Acad Emerg Med 2003;10:198-204,31,Company Confidential 2010 Abbott,Prognostic Utility of BNP in HF,Logeart D, et al. J Am Coll Cardiol. 2004;43:635-641.,*Predischarge BNP level,N = 202,BNP是心衰患者死亡率及再住院率的獨(dú)立預(yù)測(cè)因子,0,25,50,75,100,0,30,60,90,120,150,180,Death or Readmission, %,Follow-up, Days,Hazard Ratios,120天出院前測(cè)得的BNP值80% risk,32,Company Confidential 2010 Abbott,Monitoring of Therapy,Patients, %,Hospitalization for Heart Failure or Death Related to Heart Failure,BNP-Guided Therapya (n = 110)Conventional Therapyb (n = 110),p.001,The STARS-BNP Study,aMedical therapy increased with a goal of BNP 80 pg/mL，其死亡的可能性，發(fā)生心衰或心衰惡化的可能性，發(fā)生心梗及心梗復(fù)發(fā)的可能性均明顯升高 (p.005),de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021.,Patients, %,At 30 Days,At 10 Months,*p30kg/m2）,36,Company Confidential 2010 Abbott,conclusion,配合多學(xué)科實(shí)踐指南，BNP檢測(cè)已成為評(píng)估心衰的標(biāo)準(zhǔn)： National Academy of Clinical Biochemistry(NACB)European Society of Cardiology(ESC)American College of Cardiology(AAC)American Heart AssociationBNP Consensus PanelBNP 能診斷及監(jiān)控心衰BNP的結(jié)果值隨年齡、肥胖度、及腎功能衰竭程度而變化 BNP 是高性?xún)r(jià)比的檢測(cè)項(xiàng)目,37,Company Confidential 2010 Abbott,謝謝,38,Company Confidential 2010 Abbott,39,Company Confidential 2010 Abbott,Prognostic Utility of BNP in ACS TACTICS-TIMI 18,若患者其BNP 80 pg/mL，其7天(2.5% versus 0.7%; p=.