Department of Internal Medicine, University Hospital, Basel, Switzerland.
Am J Med. 2011 May;124(5):444-52. doi: 10.1016/j.amjmed.2010.11.012.
Myocardial ischemia is a strong trigger of B-type natriuretic peptide (BNP) release. As ischemia precedes necrosis in acute myocardial infarction, we hypothesized that BNP might be useful in the early diagnosis and risk stratification of patients with acute chest pain.
In a prospective, international multicenter study, BNP was measured in 1075 unselected patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality.
Acute myocardial infarction was the adjudicated final diagnosis in 168 patients (16%). BNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other diagnoses (median 224 pg/mL vs. 56 pg/mL, P <.001). The diagnostic accuracy of BNP for the diagnosis of acute myocardial infarction as quantified by the area under the receiver operating characteristic curve (AUC) (0.74; 95% confidence interval [CI], 0.70-0.78) was lower compared with cardiac troponin T at presentation (AUC 0.88; 95% CI, 0.84-0.92; P <.001). Cumulative 24-month mortality rates were 0.5% in the first, 2.1% in the second, 7.0% in the third, and 22.9% in the fourth quartile of BNP (P <.001). BNP predicted all-cause mortality independently of and more accurately than cardiac troponin T: AUC 0.81 (95% CI, 0.76-0.86) versus AUC 0.70 (95% CI, 0.62-0.77; P <.001). Net reclassification improvement for BNP was 0.10 (P=.04), and integrated discrimination improvement 0.068 (P=.01).
BNP accurately predicts mortality in unselected patients with acute chest pain independently of and more accurately than cardiac troponin T, but does not seem to help in the early diagnosis of acute myocardial infarction.
心肌缺血是 B 型利钠肽（BNP）释放的强烈触发因素。由于急性心肌梗死中缺血先于坏死，我们假设 BNP 可能有助于急性胸痛患者的早期诊断和风险分层。
在一项前瞻性、国际多中心研究中，对 1075 例急性胸痛的未选择患者进行了 BNP 测量。最终诊断由 2 位独立心脏病专家裁决。对患者进行了长期随访，以了解死亡率。
168 例（16%）患者被判定为急性心肌梗死的最终诊断。与其他诊断相比，急性心肌梗死患者就诊时的 BNP 水平明显升高（中位数 224pg/mL 与 56pg/mL，P<.001）。以受试者工作特征曲线下面积（AUC）（0.74；95%置信区间[CI]，0.70-0.78）衡量，BNP 对急性心肌梗死的诊断准确性低于就诊时的心脏肌钙蛋白 T（AUC 0.88；95%CI，0.84-0.92；P<.001）。BNP 第 1、2、3 和第 4 四分位数的 24 个月累积死亡率分别为 0.5%、2.1%、7.0%和 22.9%（P<.001）。BNP 独立且比心脏肌钙蛋白 T 更准确地预测全因死亡率：AUC 0.81（95%CI，0.76-0.86）与 AUC 0.70（95%CI，0.62-0.77；P<.001）。BNP 的净重新分类改善为 0.10（P=.04），综合判别改善为 0.068（P=.01）。
在未选择的急性胸痛患者中，BNP 独立于心脏肌钙蛋白 T 准确预测死亡率，并且比心脏肌钙蛋白 T 更准确，但似乎无助于急性心肌梗死的早期诊断。
