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慢性心力衰竭患者脑利钠肽水平与左室质量指数相关性研究 河北医科大学第三医院心内科 李海滨 摘要目的:本文旨在研究脑利钠肽(brain natriuretic peptide, BNP)对慢性心力衰竭(chronic heare failure, CHF)的诊断价值和CHF患者血浆BNP水平与左室质量指数的相关性。方法:选择65例CHF患者(心功能级)及48例正常对照组。采用酶联免疫吸附法测定两组血浆BNP水平;超声心动图测定左室质量指数。并将CHF患者的BNP水平与左室质量指数作相关性分析。结果:CHF患者的BNP水平与左室质量指数显著高于正常对照组(562.4182.1)pg/mL比84.29.6pg/mL(P0.001)和(168.2658.33)g/m2比(112.1814.50)g/m2(P0.001);BNP水平与左室质量指数呈显著正相关(r=0.387;P0.01),取正常对照组BNP浓度的+1.96s为正常上限值,BNP诊断CHF的敏感性为92%,特异性为93%。在CHF组,血浆BNP浓度在不同心功能分级之间也有显著差异(P0.01)。结论:血浆BNP水平对于诊断CHF具有较高的敏感性和特异性,并且与LVMI密切相关。关键词 心力衰竭 利钠肽,脑The Relationship Between the Level of Brain Natriuretic Peptide and Left Ventricular Mass Index in Patients with Chronic Heart Failure LI Haibin, Cao Haiyu, LIU KunshenDepartment of Cardiology, First Affiliated Hospital, Hebei Medical University, Shijiazhuang (050031),HebeiAbstractObective:To estimate the diagnostic value of the level of plasma brain natriuretic peptide (BNP) in patients with chronic heare failure (CHF) and the relationship between the level of BNP and left ventricular mass index.Methods:65 cases of CHF and 48 healthy cases were selectd into the study.The plasma concentrations of BNP were measured by enzyme-linked immunosorbent assay.Left ventricular mass index was measured by two-dimentional echocardiography.Results:The plasma concentrations of BNP and left ventricular mass index were much higher in CHF patients than those in healthy subjects (562.4282.1)pmol/L vs 184.298.6pmol/L(P0.001)and(168.2658.33)g/m2 vs (112.1814.50)g/m2(P0.001).The correlations between the level of BNP and left ventricular mass index in CHF patients (r=0.387;P0.01).The sensitivity of 92%,specificity of 93% for BNP in diagnosis of CHF were evaluated according to the of BNP in henlty subjects as the normal high limit.There were significant differences of BNP level among NYHA in CHF patients(P0.05).Conclusion:Plasma BNP level may be the more valuable for diagnosis of CHF【Key】Heartfailure; natriuretic peptide,brain脑利钠肽(brain natriuretic peptide, BNP)是一种含32个氨基酸的多肽,其主要来源是心室12,左心功能不全时,由于容量负荷引起的心室压力改变,心室肌扩张而快速合成,释放入血,可作为心室重构复原的评估指标。已经证实3,BNP与左室功能不良的程度呈正相关,是心衰诊断的最佳指标。本研究通过测定慢性心力衰竭(chronic heare failure, CHF)患者的BNP水平与左室质量指数及正常人的BNP水平,探讨血浆BNP水平在CHF患者和非CHF患者间的差异性以及CHF患者血浆BNP水平与左室质量指数的相关性。1资料与方法入选对象 筛选我院2002年3月至2003年1月心内科心力衰竭患者(NYHA 级 LVEF40%)65例(CHF组),其中,男性44例,5673岁,平均63.56.6岁,女性21例,5872岁,平均65.24.5岁。NYHA心功能级35例,级30例;该组患者胸片示心胸比例平均0.630.05,且均有不同程度肺淤血,超声心动图示左室舒张末期内径5872mm,平均为63.86.5mm。其中,陈旧性心肌梗死27例,高血压病心力衰竭26例,扩张型心肌病心力衰竭12例。查体正常者48例(健康对照组):其中男性26例,女性22例,年龄3675岁,平均66.75.5岁。心电图无异常,超声心动图排除心脏结构和心功能异常。并排除严重肝、肾功能不全、内分泌疾病、严重先心病、心律失常和瓣膜病患者。方法 采用酶联免疫吸附法检测BNP,所有受检者均在入院确诊后空腹12小时以上,清晨7:008:00采血,采血时平卧位,休息15分钟以上,采集肘正中静脉血3ml,加入含抑肽酶的EDTA抗凝管中,1500转/分(离心半径为9.7厘米)离心10分钟后,分离血浆,置于70超低温冰箱保存,待标本收集完全后同批测定两组血浆BNP水平。采用德国西门子公司生产的SONOLINE型超声诊断仪,探头频率2.5MHz,于胸骨左缘长轴心室舒张末期二维取样,M型二尖瓣腱索水平测定左室射血分数,左室舒张末期内径,左室舒张末期容积,左室收缩末期容积,室间隔厚度,左室后壁厚度。根据公式(左室舒张末期容积左室收缩末期容积)/左室舒张末期容积计算出左室射血分数;根据身高和体重计算体表面积,按Devereux公式计算左心室质量指数(g/m2)=1.04(左室舒张末期内径+左室后壁厚度+室间隔厚度)3左室舒张末期内径313.6体表面积;超声仪所用技术参数对所有的测试对象相同,并至少测量3个连续周期,取其平均值,且与测定血浆BNP水平同期进行。统计学处理 所用数据输入SPSS10.0统计软包进行统计,计量资料用均数标准差表示,并进行正态性检验。计量资料采用t检验,相关分析采用直线回归分析法计算相关系数。检验水准P0.05为有统计学意义。2结 果2.1 两组BNP浓度和左心室质量指数、左室舒张末期容积,左室收缩末期容积、每搏输出量、左室射血分数比较。CHF组与健康对照组血浆BNP水平相比,前者明显高于后者,且有统计学差异(P0.001)。CHF组左心室质量指数、左室舒张末期容积,左室收缩末期容积、每搏输出量、左室射血分数等值均显著高于健康对照组(P均0.001)。(表1)表1 两组血浆BNP水平及各超声指标比较 (s)组别 例数 BNP(pg/mL) LVMI(g/m2) EDV(ml) ESV(ml) SV(ml) LVEF(%) 正常对照组 48 84.29.6 112.1814.50 104.210.6 46.25.8 49.76.2 64.55.2 CHF组 65 562.4182.1* 168.2658.33* 202.150.3* 166.542.1* 36.44.8* 36.32.8* 注:与正常对照组相比,*P均0.001 BNP:脑利钠肽,LVMI:左心室质量指数,EDV:左室舒张末期容积,ESV:左室收缩末期容积,SV:每搏输出量,LVEF:左室射血分数.2.2 CHF组血浆BNP水平与左心室质量指数具有显著正相关性(r=0.387;P0.01)。2.3取正常对照组BNP浓度的+1.96s为正常上限值,血浆BNP的上限为88.6pg/mL,以此为标准,诊断CHF的敏感性为92%,特异性为93%。2.4 在CHF组中,心功能级的血浆BNP浓度比心功能级显著增高(P0.01)。3 讨 论众多研究表明,BNP有助于CHF的诊断、判断治疗效果、以及预后评价4。本研究显示,CHF组与正常对照组相比,血浆BNP水平与左心室质量指数显著高于正常对照组(P0.001),且CHF组血浆BNP水平与左心室质量指数具有显著正相关性。这不仅说明在CHF时,由于内源性心脏激素系统的代偿作用使BNP分泌增多,更说明血浆BNP水平与左室充盈压高低和左室重构密切相关。我们取正常对照组BNP浓度的+1.96s为正常上限值,血浆BNP的上限为88.6pg/mL,以此为标准,诊断CHF的敏感性为92%,特异性为93%。据伦敦一项研究证实6,BNP诊断心衰的敏感性,特异性分别为97%,84%,与本研究结果相比,特异性略低,可能与本研究样本数量较少有关。另外,我们结果还显示心功能级的血浆BNP浓度比心功能级显著增高,这说明症状性心衰的病人,BNP增高程度与心衰的严重程度相关;国外研究中最早证实了这一点78。2001年Maisel等9选取未进行超声检查并排除已确诊心衰的患者进行BNP测定,并与超声检查的结果进行对比,发现两种方法结果相似,说明BNP是心衰筛选的优秀方法,是可应用于床旁的简单、快速指标,较超声心动图方便快捷。4 参考文献1.Tsutamoto T. 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