脑利钠肽对急性呼吸困难的鉴别诊断意义

目的　探讨血清脑利钠肽 (brainnatriureticpeptide,BNP)水平变化在急性呼吸困难患者中鉴别诊断的意义。方法　酶联免疫吸附法检测 5 6例充血性心力衰竭 (congestiveheartfailure ,CHF)患者 (CHF组 )和 38例有急性呼吸困难表现的非CHF患者 (非CHF组 )的血清BNP 32浓度 ,并与 30例健康成人作为正常对照组。结果　 (1)CHF组、非CHF组和对照组的BNP水平分别为 (86 7 5± 334 5 )、 (113 6± 2 8 6 )、(10 9 3± 37 6 )ng/L ,CHF组BNP水平明显高于非CHF组和对照组 ,差异均有显著性 (P <0 0 1)。 (2 )血清BNP水平对CHF的诊断界值为 12 0ng/L时 ,其灵敏度、特异性和阴性预测值分别为 10 0 %、 86 7%和86 8%。 (3)CHF组BNP水平在心功能不同分级之间有显著差异 ,与NYHA分级呈正相关 (r=0 82 5 ,P <0 0 1) ;与左心室射血分数呈负相关 (F =- 0 75 6 ,P <0 0 1)。结论　血清BNP水平对于心原性呼吸困难的鉴别诊断具有重要临床意义。     

B-type natriuretic peptide in the diagnosis of heart failure in the emergency department

B-type natriuretic peptide (BNP) is increasingly being used as a diagnostic marker in the diagnosis of heart failure. Here we evaluate the evidence base for its utility in the ED. Clinical trials suggest that it is more accurate than clinical acumen especially when emergency physicians have diagnostic problems. BNP appears more accurate than any clinical findings or radiological signs. In conjunction with considered clinical judgement, knowledge of its limitations and variable cut-off points, BNP can be of considerable utility to the emergency physician.     

急诊呼吸困难患者测定B型尿钠肽的诊断价值

目的 评价BNP水平对急诊呼吸困难病因鉴别诊断的意义。方法 呼吸困难患者共85例，比较心源性和肺源性呼吸困难患者的BNP水平、左室射血分数（LVEF）等。将肺源性组分为四个亚组：肺部炎症（A）组、单纯慢性阻塞性肺病（B）组、慢性阻塞性肺病伴右心衰（C）组、肺动脉栓塞（D）组，比较各组的BNP水平。结果 心源性呼吸困难组BNP较肺源性组明显升高（P〈0．001），而LVEF明显低于后者（P〈0．001）。心源性呼吸困难患者LVEF与BNP呈高度负相关（r=-0．663，P〈0．001）。右心功能受累的C、D组BNP值分别都比有心功能未受累的A、B组高（P〈0．05）。结论 对急性呼吸困难患者测定BNP可判别心源性和肿源性病因。在肺源性疾病中，BNP对是否合并右心功能受累有鉴别诊断意义。     

脑钠肽对高龄呼吸困难患者鉴别诊断作用探讨

目的 评价血浆脑钠肽（BNP）浓度测定在高龄呼吸困难患者中鉴别诊断的作用价值。方法 对64例高龄呼吸困难患者根据病史、体征、相关检查确定高龄呼吸困难的主要原因。分为高龄心衰组（33例）和高龄非心源性呼吸困难组（31例）,相应设60-79老年（一般老年）对照组。运用快速荧光免疫法测定各组患者血浆BNP浓度。结果 高龄心衰组心脏扩大,房颤或房扑发生率及LVEF、BNP值显著高于高龄非心源性呼吸困难组（P〈0.01）。高龄心衰组心脏扩大、房颤、房扑发生率及LVEF、BNP值与一般老年心衰组（32例）比较无显著差异（P〉0.05）。而高龄非心源性呼吸困难组BNP值显著高于一般老年非心源性呼吸困难组（32例）（P〈0.01）。结论 BNP对高龄呼吸困难鉴别诊断与一般老年人同样具有特异的重要作用,但在高龄人群中BNP预测值受到增龄的影响,应在鉴别诊断中引起重视。     

急诊室脑钠肽测定在呼吸困难鉴别诊断中的应用

目的:探讨在急诊室用快速检测脑钠肽(BNP)的方法来鉴别心源性和肺源性呼吸困难的临床价值.方法:在急诊室对199例呼吸困难患者行常规实验室检查、血气分析、心电图、胸片和心脏彩超检查,参照Framingham标准等回顾诊断是否伴有心力衰竭(充血性心力衰竭),分为心源性呼吸困难组和肺源性呼吸困难组,采用双抗夹心免疫酶法(ELISA)快速测定全血标本中的BNP水平,心脏多普勒超声检查心脏左室射血分数(EF),胸部X线片测量心胸比(CTR),比较心源性和肺源性呼吸困难患者血浆BNP水平、EF、CTR的差异.结果:心源性呼吸困难组BNP(861.43±63.4)pg/mL、EF(42.3±3.6)％、CTR 0.598 4±0.045 1,肺源性呼吸困难组BNP(196.38±23.5)pg/mL、EF(65.6±8.3)％、CTR 0.466 2±0.038 2,两组数据比较差异有统计学意义(其中BNP P=0.001,EF P=0.016,CTRP=0.025).结论:心源性呼吸困难组BNP与EF值、CTR有显著相关性.急诊室快速BNP检测可以作为鉴别两类呼吸困难的重要实验室指标.     

The role of B-type natriuretic peptide in heart failure

The use of BNP as a diagnostic and therapeutic tool in the management of heart failure is promising. Additional studies need to be done regarding the use of BNP as a diagnostic tool to clarify its intrapatient and interpatient variability, especially over time. Nesiritide is the first new intravenous agent for the treatment of acute decompensated heart failure since the introduction of milrinone. It is an effective vasodilator and enhances the effect of concomitant diuretic therapy. Nesiritide may have some benefit on long-term outcomes by prolonging survival, decreasing hospitalizations, or enhancing quality of life. Whether it can or should be used as chronic therapy in end-stage patients remains to be determined.     

Impact of point-of-care B-type natriuretic peptide (BNP) measurement on medical decision-making for older emergency department patients with dyspnea

Measurement of B-type natriuretic peptide (BNP) has been shown to aid in the Emergency Department (ED) diagnosis of heart failure. We sought to determine how point-of-care BNP measurement influences real-world medical decision-making. Using a commercially available, point-of-care assay, BNP levels were measured in a convenience sample of ED patients over the age of 55 years who complained of dyspnea. Blinded to BNP results, emergency physicians were asked to formulate a differential diagnosis and management plan for each patient. Immediately thereafter, BNP results were disclosed and the physicians were asked what (if any) decisions they would change. With physicians blinded to BNP results, 24 of 88 patients (27%) were given a primary diagnosis of heart failure, and 18 patients (20%) were given a secondary or alternative diagnosis of heart failure. For the former group, disclosure of BNP results resulted in no changes in diagnosis or management. For the latter group, disclosure of BNP results caused heart failure to become the primary diagnosis in 4 patients (22%), and led to five changes in medical management. For the 46 patients initially given neither a primary nor secondary diagnosis of heart failure, disclosure of BNP results caused heart failure to become the primary diagnosis in one patient (2%) and a secondary diagnosis in 4 patients (9%), and led to five changes in medical management. Thus, for ED patients with a primary clinical diagnosis of heart failure, BNP testing had no impact on medical decision-making. However, for other patients with dyspnea, elevated BNP levels did influence medical decision-making, particularly when heart failure was in the differential diagnosis.     

氨基末端B型钠尿肽原在急诊呼吸困难患者诊治中的应用

目的研究氨基末端B型钠尿肽原（NT-proBNP）水平检测在急诊室呼吸困难患者诊治及充血性心力衰竭（CHF）患者心功能分级中的应用价值,并探讨CHF患者的NT-proBNP最佳诊断阀值。方法利用胶体金法对急诊的405例呼吸困难患者进行NT-proBNP检测,比较心源性呼吸困难[主要指CHF患者,166例（41%）]和非心源性呼吸困难患者[239例（59%）]之间血浆NT-proBNP水平。结果166例由CHF引起的呼吸困难患者血浆NT-proBNP的中位数（四分位数）为4 245（1 535-11 158）ng/L,明显高于239例由非CHF引起的呼吸困难患者[中位数（四分位数）为175（35-489）ng/L]（P〈0.001）。NYHA分级Ⅱ、Ⅲ、Ⅳ级的CHF患者的NT-proBNP水平[中位数（四分位数）分别为1 358（1 098-2 966）、3 252（1 322-9 089）、5 980（2 674-12 143）ng/L],两两比较差异均有统计学意义（P（0.05）。血浆NT-proBNP诊断CHF的最佳阈值为900 ng/L,其敏感性为90%、特异性为85%,受试者工作特征（ROC）曲线下面积为0.843,约登指数为0.75。〈50岁和≥50岁的患者分别以450 ng/L及900 ng/L作为诊断阀值具有良好的敏感性（94%、91%）和特异性（90%、81%）。结论对于急诊室呼吸困难患者,NT-proBNP水平的检测用于诊断或者排除CHF及在心功能分级上具有重要价值,可以作为诊断CHF的独立性指标。NT-proBNP水平低于300 ng/L则基本上可以排除CHF。     

Usefulness of B-type natriuretic peptide in elderly patients with acute dyspnea

Objective Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is particularly difficult in elderly patients. The aim of our study was to evaluate B-type natriuretic peptide (BNP) in patients older than 65 years presenting with acute dyspnea.Design Prospective study.Setting Medical emergency department of a 2000-bed urban teaching hospital.Patients Patients aged over 65 years presenting with acute dyspnea and a respiratory rate more than 25/min or a PaO₂ below 70 mmHg, SpO₂ less than 92%, PaCO₂ higher than 45 mmHg with pH less than 7.35, were included. BNP levels, measured blind at admission were compared with the final diagnosis (CPE or no CPE) as defined by experts.Intervention None.Measurements and results Three hundred eight patients (mean age of 80 years) were enrolled in the study. The median BNP was 575 pg/ml [95% confidence interval (CI): 410–898] in the CPE group (n=141) versus 75 pg/ml (95% CI: 59–98) in the no CPE group (n=167) (p<0.001). The best threshold value of BNP was 250 pg/ml, with a sensitivity and specificity for CPE of 0.78 (95% CI: 0.71–0.84) and 0.90 (95% CI: 0.84–0.93), respectively. The area under the ROC curve was 0.874±0.081 (p<0.001). The accuracy of BNP-assisted diagnosis was higher than that of the emergency physician (0.84 versus 0.77, p<0.05).Conclusion Analysis of BNP is useful in elderly patients with acute dyspnea, but the threshold value is higher than that previously determined.Presented, in part, at the 30^th annual congress of the Société de Réanimation de Langue Française, Paris, January 2002 (abstract no. SP 94).     

氨基末端B型钠尿肽原在急诊呼吸困难患者诊治中的应用

目的研究氨基末端B型钠尿肽原(NT-proBNP)水平检测在急诊室呼吸困难患者诊治及充血性心力衰竭(CHF)患者心功能分级中的应用价值,并探讨CHF患者的NT-proBNP最佳诊断阀值。方法利用胶体金法对急诊的405例呼吸困难患者进行NT-proBNP检测,比较心源性呼吸困难[主要指CHF患者,166例(41%)]和非心源性呼吸困难患者[239例(59%)]之间血浆NT-proBNP水平。结果166例由CHF引起的呼吸困难患者血浆NT-proBNP的中位数(四分位数)为4 245(1 535~11 158)ng/L,明显高于239例由非CHF引起的呼吸困难患者[中位数(四分位数)为175(35~489)ng/L](P<0.001)。NYHA分级Ⅱ、Ⅲ、Ⅳ级的CHF患者的NT-proBNP水平[中位数(四分位数)分别为1 358(1 098~2 966)、3 252(1 322~9 089)、5 980(2 674~12 143)ng/L],两两比较差异均有统计学意义(P(0.05)。血浆NT-proBNP诊断CHF的最佳阈值为900 ng/L,其敏感性为90%、特异性为85%,受试者工作特征(ROC)曲线下面...     

检测B型利钠肽对急诊呼吸困难的鉴别诊断意义

目的:探讨B型利钠肽(B-type natriuretic peptide,BNP)用于甄别急诊呼吸困难中的充血性心力衰竭(congestive heart failure,CHF)的早期诊断意义.方法:130例急诊呼吸困难患者,根据临床资料及左心室射血分数(left ventricul ejection fraction,LVEF)分为CHF组(78例)和非CHF组(52例).采用干式快速免疫荧光法定量分析检测血液中的BNP浓度.结果:CHF组BNP浓度为(732±53)ng/L,显著高于非CHF组的(71±34)ng/L(P＜0.01);以BNP 100ng/L作为阈值区分呼吸困难是否为CHF所致,其敏感度、特异度、准确性分别为92%、96%、93%;在CHF组中,BNP浓度在不同心功能级别之间差异有统计学意义(P＜0.01),随心功能不全加重而升高.猝死者的BNP值高于存活者.结论:BNP水平对于CHF的诊断具有较高的灵敏度、特异度和准确性.对于鉴别呼吸困难是否为心源性具有重要意义.     

N末端B型钠尿肽原对充血性心力衰竭患者预后及危险分层评价的价值

目的通过对充血性心力衰竭（CHF，心衰）患者的随访研究，探寻影响心衰预后的因素，并对N末端B型钠尿肽原（NT-proBNP）对CHF患者预后及危险分层价值进行评价。方法对我院明确诊断为CHF的97例住院患者，测定入院时血清NT-proBNP、心肌肌钙蛋白T（cTnT）、心肌肌钙蛋白I（cTnI）、肌酸激酶MB型同工酶（CK-MB）以及纽约心脏病协会心功能分级（NYHA分级）和左室射血分数（LVEF）等指标。随访观察患者心脏事件的再发生。结果97例心衰患者，中位随访423d（43～505d），发生心脏事件23例（23．7％）。发生终点事件组与未发生终点事件组相比，患者的年龄（83比73，P=0．000）、NYHA分级（3比2，P=0．002）、NT-proBNP（973pg／ml比212．35pg／ml，P=0．002）、cTnT（0比0，P=0．011）以及cTnI（0．04比0．02，P=0．038）中位数水平均明显偏高。Cox比例风险模型分析显示，在包括了年龄、NYHA分级、LVEF、LogNT-proBNP、cTnT、cTnI及CK．MB等指标后，只有年龄和NT-proBNP是独立的心脏事件再发生的预后因素，OR分别为1．17和（95％CI：1．09～1．24，P〈0．1301）和3．17（95％CI：1．76～5．69，P〈0．001）。以NT-proBNP中位数水平302．1pg／ml对心衰患者进行危险分层，NT-proBNP〉302．1pg／ml的心衰患者，其心衰后心脏事件再发生的风险是NT-proBNP≤302．1pg／ml患者的4．63倍（95％CI：1．80～9．46，P=0．0008）。年龄〉74岁的心衰患者，其心脏事件再发生的风险是年龄≤74岁的心衰患者的5．40倍（95％CI：2．16～11．52，P=0．0002）。其他NYHA分级、LVEF、cTnT、cTnI及CK-MB等指标对心衰后心脏事件再发生均没有预后价值。结论NT-proBNP可以用于对心衰患者进行心衰后心脏事件再发生的预后分析及危险分层评估。     

Cardiac ultrasound helps for differentiating the causes of acute dyspnea with available B-type natriuretic peptide tests

Introduction

The aim of this study was to evaluate the role of cardiac ultrasound in diagnosing acute heart failure (AHF) in patients with acute dyspnea with available plasma B-type natriuretic peptide (BNP) level.

Methods

Patients with acute dyspnea presenting to the emergency department (ED) of a tertiary medical center were prospectively enrolled. The enrolled 84 patients received both BNP tests and cardiac ultrasound studies and were classified into AHF and non–heart failure groups.

Results

Plasma BNP levels were higher in the AHF group (1236 ± 1123 vs 354 ± 410 pg/mL; P < .001). The AHF group had larger left ventricular end-diastolic dimension (LVEDD; 32 ± 7 vs 27 ± 4 mm/m²; P < .001) and worse left ventricular ejection fraction (52% ± 18% vs 64% ± 15%; P = .003). Multiple logistic regression analysis showed that both BNP levels more than 100 pg/mL and LVEDD were independent predictors for AHF. In patients with plasma BNP levels within gray zone of 100 to 500 pg/mL, LVEDD was larger in the AHF group than that in the non–heart failure group (29 ± 4 vs 26 ± 4 mm/m²; P = .044).

Conclusion

Both LVEDD by cardiac ultrasound and BNP levels can help emergency physicians independently diagnose AHF in the ED. In patients with plasma BNP levels within 100 to 500 pg/mL, cardiac ultrasound can help differentiate heart failure or not.     

The use of recombinant human B-type natriuretic peptide (nesiritide) in the management of acute decompensated heart failure

Nesiritide is a synthetic human B-type natriuretic factor that has a balanced arterial and venous dilator effect, with natriuretic, diuretic, anti-aldosterone and antisympathetic action. It was launched in the US for the treatment of acute decompensated heart failure (ADHF) in August 2001 and, recently, in Switzerland and Israel. It has been demonstrated to provide more rapid and sustained haemodynamic stabilisation than glyceryl trinitrate and significant symptomatic improvement vs. placebo at 3 h, and to be safer than dobutamine. The main side effects associated with nesiritide therapy are asymptomatic and symptomatic hypotension, which are treated with dose reduction. When compared to dobutamine, the increased acquisition costs of nesiritide are completely offset by reduced intensity of hospital admissions and reduced readmission rate at 3 weeks.     

The use of B-type natriuretic peptide to diagnose congestive heart failure.

This paper explains the background and current use of B-type natriuretic peptide (BNP) assays to differentiate congestive heart failure (CHF) from other causes of dyspnea. With a large and growing elderly population, CHF is being diagnosed much more often in emergency rooms in the United States. Doctors need a way to quickly distinguish whether a patient with respiratory distress is suffering from cardiac insufficiency or another etiology. BNP is released from the ventricles in response cardiac overload from CHF or some other form of left ventricular systolic dysfunction. Therefore, the detection and measurement of BNP is a fast and accurate method of determining if CHF is the cause of a patient's breathing difficulties.     

B-type natriuretic peptide testing for detection of heart failure

The incidence of heart failure (HF) is on the increase with the aging population. Heart failure can manifest as either systolic or diastolic dysfunction. Systolic dysfunction causes impaired ventricular contractility with an ejection fraction of less than 45%. In contrast, diastolic dysfunction is evidenced by impaired ventricular relaxation and an ejection fraction greater than 45%. The diagnosis of HF is challenging with patients who present with acute dyspnea and a history of chronic obstructive pulmonary disease or pneumonia. The pathophysiology of HF and the resulting compensatory mechanisms involve a complex neuroendocrine response that includes a release of natriuretic peptides including B-type natriuretic peptides (BNPs). Elevation of BNP is in response to ventricular wall stress and volume overload from HF. BNP promotes natriuresis, diuresis, and vasodilitation and therefore counteracts some of the deleterious effects of the neuroendocrine response in HF Recently, a new laboratory test for BNP has been developed to assist in rapid identification of patients with HF. Research studies have shown that BNP testing assists in differentiating between cardiac and pulmonary causes of acute dyspnea and could be used to evaluate effectiveness of therapy and as a predictor for length of stay and readmission.