Clinical Chemistry:评价hs-cTnT和NT-proBNP对老年心衰患者预后的预测价值
发布日期：2011-07-28 14:28 文章来源：互联网
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Prognostic Assessment of Elderly Patients with Symptoms of Heart Failure by Combining High-Sensitivity Troponin T and N-Terminal pro B-Type Natriuretic Peptide Measurements
BACKGROUND: N-terminal pro B-type natriuretic peptide (NT-proBNP) is a useful biomarker in heart failure assessment, whereas measurement of cardiac troponin (cTn) is central in the diagnosis of patients with acute coronary syndromes. This report examined the prognostic use of combining high-sensitivity cardiac troponin T (hs-cTnT) and NT-proBNP measurements in elderly patients presenting to a primary care center with symptoms associated with heart failure.
METHODS: A total of 470 elderly patients (age range 65–86 years) presenting with symptoms of heart failure were recruited from primary healthcare. In addition to clinical examination and echocardiography, hs-cTnT and NT-proBNP plasma concentrations were measured. All patients were followed for 10 years, and cardiovascular mortality was registered.
RESULTS: Using the hs-cTnT assay, 80.4% of the population had plasma concentrations above the lower detection limit of the assay. Of those displaying a plasma concentration of hs-cTnT >99th percentile of a healthy population, 43% also had an NT-proBNP concentration in the fourth quartile (>507 ng/L). In the multivariate analysis, we observed a 2.5-fold increased risk for cardiovascular mortality in individuals with a plasma NT-proBNP concentration >507 ng/L (P < 0.0001). Conversely, patients with hs-cTnT >99th percentile displayed an approximately twofold increased risk for cardiovascular mortality (P = 0.0002). Combining the two biomarkers, NT-proBNP concentrations >507 ng/L with hs-cTnT >99th percentile increased the risk threefold, even after adjustment for clinical variables such as age, sex, impaired estimated glomerular filtration rate, and anemia (P < 0.0001).
CONCLUSIONS: hs-cTnT and NT-proBNP measurements combined provide better prognostic information than using either biomarker separately in elderly patients with symptoms associated with heart failure.
心肌肌钙蛋白（cTnT或cTnI）在急性冠状动脉综合征诊断与预后评估中的价值不容忽视，已经成了了实验室医学在临床应用的典范。高敏肌钙蛋白的出现更是将肌钙蛋白在心血管疾病预防与诊疗中的作用提升到了新的高度。虽然08在NEJM发表的AHERE研究显示肌钙蛋白对于心衰病人的预后具有预测价值，但高敏肌钙蛋白是否也同样具有预测价值还不得而知。
相比之下，在心衰的诊疗领域，BNP和NT-proBNP早已是“座上嘉宾”了。BNP/NT-proBNP的出现，极大地推动了临床一线对心衰的预防、诊断和治疗。
如果把高敏肌钙蛋白和NT-proBNP联合起来，是否能对心衰的预后做出更加准确的判断呢？或者说：在判断心衰预后方面，高敏肌钙蛋白和NT-proBNP是否有重叠，重叠多少呢？CC上的这篇文章正是基于这个研究目的，去评价二者联合对心衰预后的预测价值。
这篇文章的研究对象是470明具有心衰症状的老年个体，随访时间长达10年。作者发现，对于病人预后，高敏肌钙蛋白和NT-proBNP都具有预测价值，且二者的预测价值并不完全重叠：(NT-proBNP>507 ng/L的个体，死亡风险增加2.56倍（与NT-proBNP小于507 ng/L的个体相比）；hs-cTnT >99th percentile 的个体，死亡风险较hs-cTnT 小于99th percentile 的个体增高2.24倍。cTnT >99th percentile 且proBNP>507 ng/L的个体，其死亡风险增高3.09倍（与与NT-proBNP小于507 ng/L，或 hs-cTnT 小于99th percentile 的个体相比）。可见，对于心衰预后的判断，二者虽然有所重叠，但是并不完全重叠，联合检测更有助于判断心衰病人的预后。
当然，这些数字只是纯数学模型的推导，这篇文章的核心意思还是建议对于有心衰症状的老年患者，同时检测高敏肌钙蛋白和NT-proBNP更有助于判断患者预后。
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