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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,急性心肌梗死后血,BNP,水平与,心功能的相关性分析,阜外心血管病医院,冠心病诊治中心,毛懿,杨跃进,高润霖,?,血,BNP,水平与心力衰竭患者心功能相关性良,好，心功能越差，血,BNP,水平越高。,?,AMI,是导致缺血性心力衰竭的主要原因。,AMI,后一周，收缩和舒张功能已有损害，且梗死,面积越大，缺血时间越长，患者心功能受损,越严重。心功能减低的程度与心肌缺血严重,程度和心肌梗死面积大小密切相关。,?,研究,AMI,后，血,BNP,水平与,Killip,分级、,LVEDd,、,LVEF,、,CK-MB,、和,TnT,的相关性，为临床上,应用血,BNP,水平评估,AMI,患者心功能状态，提,供依据。,?,方法：,顺序入选,2002,年,10,月,2003,年,10,月在我,CCU,住,院,AMI,患者,230,例及正常对照,111,例，在,AMI,后第,2-7,天,测定血,BNP,水平，用乙二胺四乙酸（即,EDTA,）抗凝管,肘静脉取血，床旁检测血,BNP,水平。顺序检测正常对照,组血,BNP,水平。在,AMI,发病后第,6-24,小时抽静脉血查血,CK-MB,和,TnT 2-5,次，取最高值为峰值；在测量,BNP,水,平前后,48,小时内，查,LVEDd,、,LVEF,。,?,按照心功能,Killip,分级，不同,LVEF,，不同,LVEDd,分组，,对比各组间,CKMB,、,TnT,、,LVEDd,、,LVEF,和,BNP,水平；,?,分析,BNP,与其它指标的相关性；,?,绘制受试者工作特性曲线（,receiver operator,characteristic,；,ROC,曲线），确定诊断失代偿性心力衰,竭及心源性休克的最佳指标和阈值。,1,，,AMI,后随,Killip,分级血,LnBNP,水平梯次升高,对照组,Killip ,*,Killip ,*,Killip ,*,Killip ,*,0,1,2,3,4,5,6,7,对照组,Killip ,Killip ,对照组,Killip ,Killip ,Killip ,Killip ,2,，不同,LVEF,组,LnBNP,水对比,对照组,(LnBNP),LVEF50,*,50%LVEF40,*,LVEF40%,*,0,1,2,3,4,5,6,7,对照组(LnBNP),LVEF40%,对照组(LnBNP),LVEF50,50%LVEF,40,LVEF40%,3.AMI,患者不同,LVEDd,组,LnBNP,水平对比,对照组,LVEDD50mm,*,50mmLVEDD,55mm,*#,LVEDD55mm,*#,0,1,2,3,4,5,6,对照组,LVEDD55mm,对照组,LVEDD50mm,50mmLVEDD,55mm,LVEDD55mm,4,AMI,后患者,LnBNP,水平与心功能指标的相,关性分析,LnBNP,LVEDd,（,mm,）,LVEF,（）,Killip,分级,Killip,分,级,r,0.534,0.169,-0.378,1,P,0.000,0.010,0.000,lnBNP,r,1,0.166,-0.405,0.534,P,0.012,0.000,0.000,AMI,患者,LnBNP,、,LVEDd,、,LVEF,和,Killip,分级,多元线性回归分析,B,SB,P,95% CI,下限,上限,LVEDd,3.784,0.006,0.539,-0.008,0.016,LVEF,-1.876,0.006,0.004,-0.031,-0.006,LnBNP,0.360,0.048,0.000,0.266,0.455,不同指标诊断,AMI,后失代偿性心力衰竭,ROC,曲线对比,ROC Curve,Diagonal segments are produced by ties.,1 - Specificity,1.00,.75,.50,.25,0.00,S,e,n,s,i,t,i,v,i,t,y,1.00,.75,.50,.25,0.00,Source of the Curve,Reference Line,心肌梗塞后,TnT,峰值,心肌梗塞后,CKMB,峰值,LVEF,LVEDD,心肌梗塞后,3-7,天内的,b,np,水平,0.90-1 = excellent (A),0.80-0.90 = good (B),0.70-0.80 = fair (C),0.60-0.70 = poor (D),0.50-0.60 = fail (F),5.BNP,水平对,AMI,后并发失代偿性心力衰竭的诊断意义,不同心功能指标（,124,例患者）诊断,AMI,失代偿心力衰竭,ROC,曲线参数对比,AUC,标准误,P,95,可信区间（,CI,）,BNP,0.745,0.46,0.000,0.656,，,0.835,CK-MB,0.535,0.052,0.054,0.432,，,0.637,TnT,0.512,0.053,0.084,0.408,0.615,LVEF,0.357,0.050,0.006,0.260,0.455,LVEDd,0.514,0.052,0.791,0.412,0.616,不同,BNP,阈值诊断,AMI,患者失代偿性心,力衰竭的参数列表,BNP(pg/ml),敏感性,特异性,阳性预测值,阴性预测值,准确性,250.5,0.977,0.625,0.653,0.769,0.702,259,0.977,0.631,0.662,0.744,0.710,266,0.977,0.631,0.662,0.744,0.710,272.5,0.763,0.631,0.652,0.745,0.694,?,根,据,ROC,曲,线,拐,点,选,择,BNP,约,为,260pg/ml,时，敏感性与特异性之和最大，,准确度最高，阳性预测值为,66.2,，是,诊断失代偿性心力衰竭的最佳阈值。,6,，,BNP,水平对首次,AMI,后心源性休克的诊断意义,不同心功能指标诊断心源性休克的,ROC,曲线的参数对比,AUC,标准误,P,95,可信区间（,CI,）,BNP,0.759,0.078,0.002,0.606,，,0.912,CK-MB,0.631,0.072,0.110,0.491,，,0.772,TnT,0.574,0.072,0.664,0.433,0.716,LVEF,0.335,0.083,0.044,0.172,0.498,LVEDd,0.471,0.080,0.722,0.315,0.627,不同心功能参数诊断,AMI,后心源性休克的,ROC,曲线,ROC Curve,Diagonal segments are produced by ties.,1 - Specificity,1.00,.75,.50,.25,0.00,S,e,n,s,i,t,i,v,i,t,y,1.00,.75,.50,.25,0.00,Source of the Curve,Reference Line,心肌梗塞后,3-7,天内的,b,np,水平,心肌梗塞后,TnT,峰值,心肌梗塞后,CKMB,峰值,LVEF,LVEDD,诊断心源性休克的,BNP,阈值相关参数列表,BNP(pg/,ml),敏感性,特异性,阳性预测,值,阴性预测,值,准确性,500,0.714,0.700,27.5%,95.0%,68.5,497.5,0.786,0.700,27.5%,96.4%,70.9,483,0.786,0.691,27.3%,95.9,70.0%,480,0.786,0.690,26.4%,95.1,69.8,464,0.786,0.682,26.1%,94.6,68.7%,?,ROC,曲线拐点提示在,BNP,约为,500 pg/ml,时，敏感性与特异性之和最大，准确度,最高，阴性预测值为,95.0,，是诊断心,源性休克的最佳阈值。,?,结果：,?,AMI,患者,BNP,水平，随着,Killip,分级升高和,LVEF,的降低,而梯次显著升高,(P,均,0.05,0.001),；,BNP,水平在,LVEDd,55mm,组的显著高于,55mm,组（,P,均,0.001,），,LVEF,亦显著为低（,P,均,0.001,）；而,CK-MB,和,TnT,在两组间均,无显著性差异（,P,均,0.05,）；仅,CK-MB,在,Killip,级组显,著高于,-,级组（,P,均,0.001,）。,?,LnBNP,、,LVEDd,、,LVEF,与,Killip,分级成直线相关（,P,均,0.05,0.001,），其中,LnBNP,的相关性最好，是预测,Killip,分级的独立相关因素；此外,LnBNP,与,LVEDd,、,LVEF,相关性良好（,r=0.166,、,-0.405, P0.05,0.001,）。,?,在众多指标中，,BNP,水平诊断失代偿性心力衰竭和心,源性休克的,AUC,最大（,P,0.001,），是最佳诊断指标。,在,BNP,260pg/ml,时，诊断失代偿性心力衰竭的敏感性,（,SN,）：,79.7,，准确度（,AC,）：,71%,。；在,BNP,500pg/ml,时，预测心源性休克的阴性预测值,(NPV),：,95.0,AC,：,68.5%,。,结论,?,AMI,患者,BNP,水平与,Killip,分级、,LVEDd,成正相关，与,LVEF,负相关。,AMI,后第,2-,7,天的血,BNP,水平检测,有助于评估心功,能状态，诊断失代偿性心力衰竭和排除,心源性休克状态。对临床工作，有重要,的指导意义。,?,心力衰竭诊断标准：,1,，肺循环、体循,环淤血的临床表现；,2,，器官和组织供,血不足综合征；,3,，射血分数（,LVEF,）,小于,45,。,?,心源性休克诊断标准：低血压，收,缩压,12kpa(90mmhg ),，或原有高血,压病患者，收缩压比原有水平下降,10.7kpa(80mmhg),以上者；四肢厥冷；,大汗或多汗；脉搏细速；尿少，,每小时尿量低于,20ml,；神志淡漠或烦,躁等组织灌注不足的体征。,NRG, non-remodelling group; RG, remodelling group.,1pg/ml,到,5000pg/ml (0.29Pmol/L,到,1440.9Pmol/L,）,Taken from:Clinical Science (1999),96, (129,136) (Printed in Great Britain),?,按照,Killip,分级法对,AMI,后心功能分级：,?,I,级：无心衰症状；,?,II,级：轻至中度的心力衰竭，肺部湿啰,音出现范围小于两肺野的,50%;,?,III,级：重度心力衰竭，肺部湿啰音出现,范围大于两肺野的,50%,；,?,IV,级：出现心源性休克。,?,Killip,分级,I,级被定义为心功能正常或代,偿性心力衰竭，,Killip,分级,II,、,III,、,IV,级为失代偿性心力衰竭。,?,1pg/ml,到,5000pg/ml (0.29Pmol/L,到,1440.9Pmol/L),?,Triage, Biosite,
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