心力衰竭的诊断新进展.ppt

NT-proBNP检测的合理应用:  肾功能衰竭 Consider: If one peptide is more affected than another by renal dysfunction then with worsening CKD, the uni-variable r value correlations will fall as GFR worsens…. 无论肾功能异常的程度和左心室功能异常的类型，在肾脏疾病患者中NT-proBNP和BNP具有很强的相关性 Characteristic PRIDE Study Renal Analysis BNP Study Renal Analysis Receiver operating characteristic analyses Area under the ROC curve for subjects with eGFR ≥60 Area under the ROC curve for subjects with eGFR 60 0.95 0.88 0.90-0.91 0.81-0.86 Optimal rule in cut points Optimal cut-point for those with eGFR 60 Sensitivity of optimal rule in cut point for eGFR 60 Specificity of optimal rule in cut point for eGFR 60 Optimal rule out cut points NPV of optimal rule out cut point when eGFR 60 NPV of optimal rule out cut point when eGFR ≥ 60 1200 pg/ml 89% 72% 100% 94% “approx 200 pg/ml” N.R. N.R. N.R. N.R. Natriuretic peptides and 60-d mortality risk OR for death by 60 days associated with NT-proBNP OR for death by 60 days in those with eGFR 60 1.57 (p=0.0004) 1.61 (p=0.006) N.R. N.R. *Anwaruddin, et al, JACC, 2006 ?McCullough, et al, AJKD, 2003 N.R.= “Not Reported” 肾功能和钠素肽: ICON 的三重界值无需根据肾功能对 NT-proBNP界值进一步调整 NT-proBNP检测的合理应用 我们不应该担心什么 类型 敏感性* 特异性* 阴性预测值? 男 91% 84% 98% 女 89% 88% 100% *ICON 三重界值 ?ICON “排除” 界值 (300 ng/L) Krauser, et al, JCF, 2006 糖尿病和非糖尿病患者急性心力衰竭的诊断 1 - Specificity (false positives) Sensitivity (true positives) 糖尿病患者: AUC 0.94, P0.001 非糖尿病患者: AUC 0.93, P0.001 糖尿病患者应用ICON 的三重界值: 敏感性 92% 特异性 90% O’Donoghue et al 2007, AJC, In Press 病人因急性呼吸困难来急诊 病史采集, 体格检查, ECG, 胸片 + NTproBNP 充血性心力衰竭 高度不可能 充血性心力衰竭 高度可能 充血性心力衰竭可能, 其他检查 NTproBNP 300pg/mL NTproBNP 灰色区域 NTproBNP 450pg/mL - 病人 50 岁 900pg/mL - 病人 50-75 岁 1800pg/mL – 病人 75岁 Bayes-Genis A. Rev Esp Cardiol 2005 灰色区域… Adapted from Jourdain et al 300 年龄调整的阳性* *450/900/1800 by age ICON中的1256患者, 215 例患者的NT-proBNP水平位于 ‘grey zone’ 。 116 例患者 (54%)诊断为心力衰竭。 计算最终诊断急性HF的预测因素，并评价预后。 如何处理NT-proBNP处于“灰区”的患者 va