应用BNP水平对入院患者进行监控和风险分层课件.ppt

1、Alan Maisel MD, FACC, ACPProfessor of Medicine, University of California, San Diego Director Coronary Care Unit And Heart Failure Program San Diego Veterans Hospital 在美国，因心衰入院人数在美国，因心衰入院人数=每年一百万。总费每年一百万。总费用用=560亿美元亿美元 住院治疗花费中，住院治疗花费中，70-75%直接用于患者护理直接用于患者护理 心衰住院治疗后再入院心衰住院治疗后再入院=6个月内达个月内达45% 心衰的治疗负担心衰

2、的治疗负担(pg/mL)在初期评估中，在初期评估中，77,467例患者中有例患者中有 48,629 例例 (63%)作了作了BNP评估评估.在在ADHERE项目中仅项目中仅 3.3%的患者的患者 初始初始 BNP水平水平 100 pg/mLFonarow et al, JACC 2007 in press在初期评估中，在初期评估中，77,467例患者中有例患者中有 48,629 例例 (63%)作了作了BNP评估评估19,544 例左室射血分数例左室射血分数 0.40Q2 2003 to Q4 20041.42.83.86.401234567InHospital MortalityQ1 (23

3、10)P0.00011.52.72.8500.511.522.533.544.55InHospital MortalityQ1 (1230)P0.0001LVEF 0.40在初期评估中，在初期评估中，77,467例患者中有例患者中有 48,629 例例 (63%)作了作了BNP评估评估.Q2 2003 to Q4 2004Q1 (1730)P ValueVentilation3.13.73.94.1P=0.0002CPR0.60.91.21.7P0.0001Ultrafiltrat0.60.81.65.0P0.0001LOS (days)5.25.75.96.3P0.0001ICU admit

4、 %12.815.416.619.6P0.0001ASx at DC48.849.648.043.6P0.0001NP 水平高于基线，通常意味着容量负荷过重NP水平对需维持的等量体液和监控治疗有帮助NP水平能帮助医生决定合适的出院时机Msaisel, A. et al. J Cardiac Failure, Vol. 7, No. 1, 2001N = 15 (responders)PAW (mm Hg)HoursBNP (pg/ml)15171921232527293133baseline48121620246007008009001000110012001300PAWBNP*Pulmona

5、ry artery wedge.Msaisel, A. et al. J Cardiac Failure, Vol. 7, No. 1, 2001R= 0.729P .05PAW024601234567BNPChange per hourPAW (mm Hg)BNP (pg/ml)0.00.20.40.60.81.00102030401156 Hospitalized pts. with systolic HF (mean LVEF 21%), Rx with iv diuretics and vasodilators). Fonarow. Rev Cardiovasc Med. 2002;3

6、(suppl 4):S18-S27BNP能作为替代指标吗能作为替代指标吗? 钠尿肽研究提示医生治疗心衰不够积极，出院前的BNP水平可能是是否需要进一步的治疗的一个有用指标Cleland JCF, Goode K. Natriuretic peptide for heart failure. Fashionable? Useful ? Necessary ? Eur J Heart Fail 2004;6:253-255. 住院患者的住院患者的BNPBNP水平水平25050080017505001000150020002500IIIIIIIVDry ( NYHA Euvolemic state)

7、BNP level (pg/ml)NYHA Class - Euvolemic (Dry) BNPWet (Change due to volume overload)Msaisel, A. et al. J Cardiac Failure, Vol. 7, No. 1, 2001R= 0.729P .05PAW024601234567BNPChange per hourPAW (mm Hg)BNP (pg/ml)0.00.20.40.60.81.0010203040H2NH2NCOOHCOOHCOOHpro-BNP (aa1 - aa108)CleavageBNP (aa77 - aa108

8、)NT-proBNP (aa1 - aa76)HPLGSPGSASYTLRAPRSPKMVQGSGCFCRKMDRISSSSGLCCKVLRRHHPL GSP GS ASY TLR APRSPKMVQGSGCFCRKMDRISSSSGLCCKVLRRHH2N110707680901001081107076pre-proBNP 1 - 134(134 Aa)Signal peptide(26 Aa)28171463kDa Rec. A B C D E blank Rec. Clinical BNP Results pg/mL: A BCDEMaisel3920 3720 4010 2090 12

9、7in-house Triage 1140 1440 1260 1570 584proBNP BNP5 CHF patients:Liang, Maisel et al., JACC 200725050080017505001000150020002500IIIIIIIVDry ( NYHA Euvolemic state)BNP level (pg/ml)NYHA Class - Euvolemic (Dry) BNPWet (NP precursers and fragments)连续连续BNPBNP测定能指导住院治疗吗测定能指导住院治疗吗? ? Courtesy of Damien Lo

10、geart.住院期间住院期间BNP值值Logeart D, et al, JACC, 18 February 2004, Volume 43, Issue 4 Pages 635-64105001000150020002500admission follow-up(pg/mL)n=22Endpoints:13 deaths 9 re-admissions (30d)n=50No EndpointsBNP +233 pg /mLBNP -215 pg /mLCheng,Maisel. JACC 2001;37:386-91(Valle et al. J Cardiac Failure2007)

11、21入院时入院时BNP水平水平临床症状稳定时临床症状稳定时BNP水平水平24小时的重点治疗正常液体量体液超负荷 250 pg/ml积极治疗积极治疗体液超负荷体液超负荷 250 pg/mlValle & Aspromonte, JCF121086420BNP onadmissionBNP ondischargeLength of stay39812348112710377292.26.86.9020040060080010001200BNP1BNP2LOSpg/mlBNP 250 pg/ml on clinical stabilityBNP 250 pg/mlDays18015012090603

12、00Event-free Survival1,0,8,6,4,20,0BNP 250 pg/mlBNP 250 pg/ml after“intensive” treatmentTarone-Wares test 700ng/ln =41, events =38Predischarge BNP 350 - 700ng/ln =50, events =30Predischarge BNP 350ng/ln =111, events =18p 0.0001p 0.000115.25.11BNP Changes Over TimeAll PatientsTimeBaseline24h72hD/C30day60day 180daylog BNP2.42.52.62.72.82.9Italian Red in prep- Disomma, Maisel et alItalian Red in prep- Disomma, Maisel et alDischarge BNPAUC .630 day BNPAUC .7Italian Red in prep- Disomma, Maisel et alPeacock, NEJM May 15, 08Peacock, NEJM May 15, 08