血浆肌钙蛋白I、B型钠尿肽及D-二聚体检测在急性肺栓塞预后评估中的意义

目的进一步证实血浆肌钙蛋白I（cTNI）、B型钠尿肽（BNP）及D-二聚体检测在急性肺栓塞预后评估中的意义。方法所有确诊为急性肺栓塞的患者入院时均定量检测血浆cTNI、BNP及D-二聚体浓度,必要时6 h后重复检测一次,评估患者死亡与以上指标的关系。结果在2009年1月至2010年12月间共有98例患者诊断为急性肺栓塞。随访结束时共有14例（14.3%）患者死亡。cTNI阳性组入院时心率较正常组增快,晕厥、心源性休克（即大块肺栓塞）及死亡的发生率明显高于正常组,年龄及入院时血压值小于正常组（P〈0.05）。ROC分析提示BNP取大于226.5 ng/L作为截断点对于死亡的阴性预测值为97.1%,ROC曲线下面积为0.829（95%CI 0.715～0.942）。D-二聚体的浓度为500～2499 ng/mL、2500～4999 ng/mL、≥5000 ng/mL的三组患者死亡率分别为7.8%、12%和41.2%,三组间比较差异有统计学意义（P=0.009）。多因素回归分析提示,与患者死亡相关因素有心源性休克（OR=2.931,95%CI 0.828～12.521,P=0.000）,cTNI≥0.3 ng/mL（OR=1.441,95%CI0.712～4.098,P=0.0043）,BNP≥226.5 ng/L（OR=1.750,95%CI 0.690～6.452,P=0.011）,以及D-二聚体≥5000 ng/mL（OR=1.275,95%CI 0.762～2.801,P=0.034）等。结论联合检测肺栓塞患者血浆cTNI、BNP及D-二聚体有助于在入院早期准确预测患者的预后,以指导进一步的治疗决策。

Prognostic Value of Troponin I,Brain Natriuretic Peptide and D-Dimer in Acute Pulmonary Embolism

Objective To investigate the prognostic value of troponin I(cTNI),brain natriuretic peptide(BNP) and D-dimer in acute pulmonary embolism(APE).Methods The plasma levels of cTNI,BNP,and D-dimer were measured in 98 consecutive patients with APE at the time of admission.The relationship between these parameters and mortality were evaluated.Results APE was diagnosed in 98 consecutive patients during January 2009 to December 2010,in which 49 were males and 49 were females.14(14.3%) patients died at the end of follow-up.The patients with positive cTNI tests had more rapid heart rates,higher rate of syncope,cardiogenic shock and mortality than the patients with normal serum cTNI.However the age and blood pressure were lower in the patients with abnormal serum cTNI(P<0.05).A receiver-operating characteristic curve analysis identified BNP≥226.5 ng/L was the best cut-off value(AUC 0.829,95%CI 0.715-0.942) with the negative predictive value of 97.1% for death.The mortality of the patients whose serum D-dimer level ranging from 500 to 2499 ng/mL,2500 to 4999 ng/mL,and ≥5000 ng/mL was 7.8%,12%,and 41.2%,respectively(P=0.009).Upon multivariate analysis,cardiogenic shock(OR=2.931,95%CI 0.828-12.521,P=0.000),cTNI≥0.3 ng/mL(OR=1.441,95%CI 0.712-4.098,P=0.0043),BNP>226.5 ng/L(OR=1.750,95%CI 0.690-6.452,P=0.011) and D-dimer≥5000 ng/mL(OR=1.275,95%CI 0.762-2.801,P=0.034) were independent predictors of death.Conclusions Combined monitoring of cTNI,BNP or D-dimer levels is helpful for prognosis prediction and treatment decision for APE patients.