Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,应用,BNP,水平对入院患者进行监控和风险分层,Alan Maisel MD,FACC,ACP,Professor of Medicine,University of California,San Diego Director Coronary Care Unit And Heart Failure Program San Diego Veterans Hospital,应用BNP水平对入院患者进行监控和风险分层Alan Mai,B-Natriuretic Peptide(BNP)应用BNP水平对入院患者进行 监控和风险分层课件,在美国，因心衰入院人数,=,每年一百万。总费用,=560,亿美元,住院治疗花费中，,70-75%,直接用于患者护理,心衰住院治疗后再入院,=6,个月内达,45%,心衰的治疗负担,在美国，因心衰入院人数=每年一百万。总费用=560亿美元 心,ADHF,中的,BNP,水平和院内死亡率,BNP,水平的分布,(pg/mL),在初期评估中，,77,467,例患者中有,48,629,例,(63%),作了,BNP,评估,.,在,ADHERE,项目中仅,3.3%,的患者 初始,BNP,水平,100 pg/mL,Fonarow et al,JACC 2007 in press,ADHF中的BNP水平和院内死亡率 BNP水平的分布(pg,入院,BNP,水平降低院内死亡率风险,vs.,保护心衰患者的心脏收缩功能,在初期评估中，,77,467,例患者中有,48,629,例,(63%),作了,BNP,评估,19,544,例左室射血分数,0.40,Q2 2003 to Q4 2004,P0.0001,P0.0001,LVEF,0.40,入院BNP水平降低院内死亡率风险 vs.保护心衰患者的心脏收,ADHERE,项目中,BNP,水平四分位数的患者结果,在初期评估中，,77,467,例患者中有,48,629,例,(63%),作了,BNP,评估,.,Q2 2003 to Q4 2004,Q1,(1730),P Value,Ventilation,3.1,3.7,3.9,4.1,P=0.0002,CPR,0.6,0.9,1.2,1.7,P0.0001,Ultrafiltrat,0.6,0.8,1.6,5.0,P0.0001,LOS(days),5.2,5.7,5.9,6.3,P0.0001,ICU admit%,12.8,15.4,16.6,19.6,P0.0001,ASx at DC,48.8,49.6,48.0,43.6,P0.0001,ADHERE项目中BNP水平四分位数的患者结果在初期评估中，,根据钠尿肽水平的滴定测量治疗,NP,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,根据钠尿肽水平的滴定测量治疗NP 水平高于基线，通常意味着容,24,小时治疗期间,BNP,和,PAW*,水平的变化,Msaisel,A.et al.,J Cardiac Failure,Vol.7,No.1,2001,N=15(responders),PAW(mm Hg),Hours,BNP(pg/ml),15,17,19,21,23,25,27,29,31,33,baseline,4,8,12,16,20,24,600,700,800,900,1000,1100,1200,1300,PAW,BNP,*,Pulmonary artery wedge.,24小时治疗期间 BNP 和PAW*水平的变化Msaisel,基于基线的每小时变化,%,Msaisel,A.et al.,J Cardiac Failure,Vol.7,No.1,2001,R=0.729,P,.05,PAW,0,2,4,6,0,1,2,3,4,5,6,7,BNP,Change per hour,PAW(mm Hg),BNP(pg/ml),0.0,0.2,0.4,0.6,0.8,1.0,0,10,20,30,40,基于基线的每小时变化%Msaisel,A.et al.,1156 Hospitalized pts.with systolic HF(mean LVEF 21%),Rx with iv diuretics and vasodilators).Fonarow.Rev Cardiovasc Med.2002;3(suppl 4):S18-S27,BNP,能作为替代指标吗,?,1156 Hospitalized pts.with sy,心衰,-,入院的原因,0,10,20,30,40,容量负荷过载,心律不齐,缺血,顺应性差,其它,%of Patients,心衰-入院的原因010203040容量负荷过载心律不齐缺血顺,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,BNP,水平,住院患者的BNP水平,Dry(NYHA Euvolemic state),容量超负荷患者,:BNP,水平,=,基线,BNP(,干,),加增加容量产生的,BNP,变化,(,湿,),BNP level(pg/ml),NYHA Class-Euvolemic(Dry)BNP,Wet(Change due to volume overload),Dry(NYHA Euvolemic state)容量超,基于基线的每小时变化,%,Msaisel,A.et al.,J Cardiac Failure,Vol.7,No.1,2001,R=0.729,P,.05,PAW,0,2,4,6,0,1,2,3,4,5,6,7,BNP,Change per hour,PAW(mm Hg),BNP(pg/ml),0.0,0.2,0.4,0.6,0.8,1.0,0,10,20,30,40,基于基线的每小时变化%Msaisel,A.et al.,H2N,H2N,COOH,COOH,COOH,pro-BNP(aa1-aa108,),Cleavage,BNP(aa77-aa108,),NT-proBNP(aa1-aa76),H,P,L,G,S,P,G,S,A,S,Y,T,L,R,A,P,R,S,P,K,M,V,Q,G,S,G,C,F,C,R,K,M,D,R,I,S,S,S,S,G,L,C,C,K,V,L,R,R,H,H,P,L,G,S,P,G,S,A,S,Y,T,L,R,A,P,R,S,P,K,M,V,Q,G,S,G,C,F,C,R,K,M,D,R,I,S,S,S,S,G,L,C,C,K,V,L,R,R,H,H2N,1,10,70,76,80,90,100,108,1,10,70,76,Myocard,Blood,pre-proBNP 1-134(134 Aa),Signal peptide(26 Aa),H2NH2NCOOHCOOHCOOHpro-BNP,28,17,14,6,3,kDa,Rec.A B C D E blank Rec.,Clinical BNP Results pg/,mL,:,A,B,C,D,E,Maisel,3920 3720 4010 2090 127,in,-,house Triage 1140 1440 1260,1570 584,在心衰患者中,BNP,主要的形式是,proBNP,proBNP,BNP,5 CHF patients:,Liang,Maisel et al.,JACC 2007,28171463kDa Rec.,Dry(NYHA Euvolemic state),容量负荷过载患者,:NP,水平,=,基线,NP(,干,),加,BNP,变化产生的,BNP level(pg/ml),NYHA Class-Euvolemic(Dry)BNP,Wet(NP precursers and fragments),Dry(NYHA Euvolemic state)容量负,连续,BNP,测定能,指导住院治疗吗,?,Courtesy of Damien Logeart.,连续BNP测定能指导住院治疗吗?,住院期间,BNP,值,Logeart D,et al,JACC,18 February 2004,Volume 43,Issue 4 Pages 635-641,住院期间BNP值Logeart D,et al,JACC,BNP,在急性充血性心力衰竭,住院治疗和结果评价,0,500,1000,1500,2000,2500,admission follow-up,(pg/mL),n=22Endpoints:13 deaths,9 re-admissions(30d),n=50No Endpoints,BNP+233 pg/mL,BNP-215 pg/mL,Cheng,Maisel.JACC 2001;37:386-91,BNP在急性充血性心力衰竭 住院治疗和结果评价050010,背景,:,本研究的目的是揭示在,BNP-,指导的治疗中,BNP,水平的变异及液体潴留程度以判断患者出院的最佳时机,方法及结果,:,我们回顾性分析了,186,例急性心衰入院患者,.,所有患者进行了系列生化检查和,BNP,测定。根据,BNP,水平滴定治疗以尽量达到出院时,BNP250 pg/mL.,出院时,BNP250 pg/mL,提示事件率明显升高,(78%).,对于前者，达到,BNP 250 pg/mL,所需时间与事件率无明显相关,(14 versus 18%,chi-square 5 0.3,NS).Cox,回归分析显示以,250 pg/mL,作为,BNP,临界值是事件发生的最准确预测因子,.,(Valle et al.J Cardiac Failure2007),21,(Valle et al.J Cardiac Failur,入院时,BNP,水平,临床症状稳定时,BNP,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,体液超负荷,体液超负荷,250 pg/ml,Valle&Aspromonte,JCF,入院时BNP水平临床症状稳定时BNP水平 250 pg/m,入院和出院前,BNP,值,(pg/mL),和住院时间,(,天,),12,10,8,6,4,2,0,BNP on,admission,BNP on,discharge,Length,of stay,398,123,481,127,1037,729,2.2,6.8,6.9,0,200,400,600,800,1000,1200,BNP1,BNP2,LOS,pg/ml,BNP 250 pg/ml on clinical stability,BNP 250 pg/ml,入院和出院前BNP值(pg/mL)和住院时间(天)1210,根据出院前,BNP,水平作出的,Kaplan-Meier,曲线显示累积死亡率和再入院率,BNP,250 pg/ml,BNP,250 pg/ml after,“intensive”treatment,Tarone-Wares test 700ng/l,n=41,events=38,Predischarge BNP 350-700ng/l,n=50,events=30,Predischarge BNP 350ng/l,n=111,events=18,p 0.0001,p 0.0001,15.2,5.1,1,Logeart et