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何谓BNPBNP临床应用,5,Company Confidential 2010 Abbott,Case HF:,男性，65岁，主诉“进行性加重的呼吸困难1天。”查体：BP170/100mmHg，HR100bpm，律齐，无奔马律，两肺可及广泛干湿 罗音，无水肿。辅助检查：EKG：窦速，多源性早搏，左房、左室肥大，陈旧性Q波胸片（成像差）：未见心脏扩大床边B超：轻度室壁运动减退（陈旧性），收缩功能未见明显异常。TNI0.04ng/ml，血常规、电解质正常BNP未做既往史：高血压、COPD、陈旧性心梗、1年前心脏射血分数正常既往用药：2种吸入剂、可乐定、斯伐他汀,6,Company Confidential 2010 Abbott,Case HF：,接下来 诊断：COPD急性加重 处理：吸氧、喷雾、糖皮质激素患者自觉好转，2小时后准予回家,7,Company Confidential 2010 Abbott,Case HF：,接下来 3小时后患者感到严重呼吸困难，由急救车再次送至急诊室。 查体：BP160/110mmHg，HR140bpm,律绝对不齐（心监提示房 颤），两肺呼吸运动差。,COPD？心衰？肺栓塞？,8,Company Confidential 2010 Abbott,Case HF：,何种检查需要进一步检查？ BNP？ D二聚体？ CKMB、TNI？Order BNPBNP900pg/ml,9,Company Confidential 2010 Abbott,Case HF：,速尿40mg IV地尔硫卓 10 mg/h iv Nesiritide（脑促尿钠排泄肽（商品名：奈西立肽）2 mcg/kg po 后 0.01 mcg/kg/min 静脉用 24H后患者症状明显改善，心律恢复窦性，两肺呼吸音转清，24H尿量3000ml。复测BNP150 pg/mL,10,Company Confidential 2010 Abbott,Case HF：,最终转归：心超检查提示心脏舒张功能减退，E/A0.7予ACEI、受体阻滞剂治疗2天后出院,11,Company Confidential 2010 Abbott,Case HF：,思考,如何正确诊断呼吸困难？肺源性？心源性？,12,Company Confidential 2010 Abbott,35%病人无临床症状35%病人症状不典型缺少既往病史往往合并其他疾病常规EKG、X-rays无法特异区分心源性和肺源性疾病心超能够明确，但在急诊室不常规检查,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,何谓BNP？,15,Company Confidential 2010 Abbott,Brain natriuretic peptide (BNP),由心室心肌细胞释放的肽段1988首先由猪脑组织中分离出，但是由心室细胞首先合成生理作用：利尿，促尿钠排泄，抑制RAAS系统及交感系统，舒张血管平滑肌，以减少容量负荷BNP 是一个心脏激素,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,*当 eGFR 60 mL/min时，截断值为 1200 pg/mL,18,Company Confidential 2010 Abbott,BNP的临床应用,19,Company Confidential 2010 Abbott,Clinical Utility of BNP,心衰诊断预后的评价治疗监测急性冠脉综合征预后的评价,20,Company Confidential 2010 Abbott,BNP应用于心衰,21,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,所有BNP供应商建议以 100 pg/mL 作为判定值,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. 慢性肾功能衰竭患者的BNP水平会发生变化 (估计 GFR 60 ml/min), 重新定标后所获得的截断值约为 200 pg/mL. 然而, 当BNP水平极高或极低时，有助于对呼吸困难进行评估。,23,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Breathing Not Properly (BNP) Study1586位由于急性呼吸困难至急诊室就诊的患者患者就诊时予测定BNP,但急诊医生诊断时没有提供BNP的值急诊医生结合病史、体格检查及除BNP外其他相关实验室检查（eg. EKG，X-Ray，心超、及其他临床生化免疫检查）对病人做出诊断同时用2位心脏科专家各自结合所有的临床数据（除BNP）做出的诊断为标准心脏科专家做出诊断时未提供BNP值，未参考急诊医师的诊断,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诊断率,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曲线下面积临床判断是0.86BNP单独是0.90两者结合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,至急诊就诊的急性呼吸困难患者(N = 452),终点出院时间总的治疗费用,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组提高诊断率，能减少治疗费用,28,Company Confidential 2010 Abbott,BNP同样可用于心脏舒张功能不全的患者的诊断BNP升高程度不如收缩功能不全的患者，视舒张功能受损情况而定,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. 大约20%肺部疾病患者的BNP会上升, BNP水平的上升意味着心衰结合肺部疾病,肺源性心脏病的发生, 或意味着当呼吸困难,真正的病因是心衰时所发生的误诊 4.2. 当发生肺部栓塞时 (PE),三分之一患者会发生 BNP 上升 ,30,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,合并肺部疾病患者中BNP水平与心衰的关系,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独立预测因子,0,25,50,75,100,0,30,60,90,120,150,180,Death or Readmission, %,Follow-up, Days,Hazard Ratios,120天出院前测得的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，发生心衰或心衰恶化的可能性，发生心梗及心梗复发的可能性均明显升高 (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,配合多学科实践指南，BNP检测已成为评估心衰的标准： National Academy of Clinical Biochemistry(NACB)European Society of Cardiology(ESC)American College of Cardiology(AAC)American Heart AssociationBNP Consensus PanelBNP 能诊断及监控心衰BNP的结果值随年龄、肥胖度、及肾功能衰竭程度而变化 BNP 是高性价比的检测项目,37,Company Confidential 2010 Abbott,谢谢,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=.