N 端脑利钠肽前体在疑似急性心肌梗死的早期评估中的应用。

N-terminal pro B-type natriuretic peptide in the early evaluation of suspected acute myocardial infarction.

机构信息

Department of Internal Medicine, University Hospital, Basel, Switzerland.

出版信息

Am J Med. 2011 Aug;124(8):731-9. doi: 10.1016/j.amjmed.2011.02.035.

DOI:10.1016/j.amjmed.2011.02.035

PMID:21787902

Abstract

BACKGROUND

Myocardial ischemia is a strong trigger of N-terminal pro-B-type natriuretic peptide (NT-proBNP) release. As ischemia precedes necrosis in acute myocardial infarction, we hypothesized that NT-proBNP might be useful in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction.

METHODS

In a prospective multicenter study, NT-proBNP was measured at presentation in 658 consecutive patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality.

RESULTS

Acute myocardial infarction was the adjudicated final diagnosis in 117 patients (18%). NT-proBNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other final diagnoses (median 886 pg/mL vs 135 pg/mL, P <.001). The diagnostic accuracy of NT-proBNP for acute myocardial infarction as quantified by the area under the receiver operating characteristic curve (AUC) was 0.79 (95% confidence interval [CI], 0.75-0.83). When added to cardiac troponin T, NT-proBNP significantly increased the AUC from 0.89 (95% CI, 0.84-0.93) to 0.91 (95% CI, 0.88-0.94; P=.033). Cumulative 24-month mortality rates were 0% in the first, 1.3% in the second, 8.3% in the third, and 23.3% in the fourth quartile of NT-proBNP (P <.001). NT-proBNP (AUC 0.85, 95% CI, 0.81-0.89) predicted all-cause mortality independently of and more accurately than both cardiac troponin T (AUC 0.66, 95% CI, 0.58-0.74; P <.001) and the Thrombolysis in Myocardial Infarction risk score (AUC 0.79, 95% CI, 0.74-0.84; P <.001). Net reclassification improvement (Thrombolysis in Myocardial Infarction vs additionally NT-proBNP) was 0.188 (P <.009), and integrated discrimination improvement was 0.100 (P <.001).

CONCLUSIONS

Use of NT-proBNP improves the early diagnosis and risk stratification of patients with suspected acute myocardial infarction.

摘要

背景

心肌缺血是 N 末端脑利钠肽前体（NT-proBNP）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 NT-proBNP 可能有助于急性心肌梗死疑似患者的早期诊断和危险分层。

方法

在一项前瞻性多中心研究中，对 658 例急性胸痛连续患者在就诊时测量 NT-proBNP。最终诊断由 2 位独立的心脏病专家裁定。对患者进行长期死亡率随访。

结果

急性心肌梗死是 117 例（18%）患者的最终裁定诊断。与其他最终诊断相比，急性心肌梗死患者就诊时的 NT-proBNP 水平显著升高（中位数 886 pg/mL 比 135 pg/mL，P<.001）。以受试者工作特征曲线（ROC）下面积（AUC）定量的 NT-proBNP 对急性心肌梗死的诊断准确性为 0.79（95%置信区间[CI]，0.75-0.83）。当添加到心脏肌钙蛋白 T 时，NT-proBNP 使 AUC 从 0.89（95%CI，0.84-0.93）增加至 0.91（95%CI，0.88-0.94；P=.033）。NT-proBNP 第 1 四分位数的 24 个月累积死亡率为 0%，第 2 四分位数为 1.3%，第 3 四分位数为 8.3%，第 4 四分位数为 23.3%（P<.001）。NT-proBNP（AUC 0.85，95%CI，0.81-0.89）独立于心脏肌钙蛋白 T（AUC 0.66，95%CI，0.58-0.74；P<.001）和心肌梗死溶栓风险评分（AUC 0.79，95%CI，0.74-0.84；P<.001）更准确地预测全因死亡率。（AUC 0.79，95%CI，0.74-0.84；P<.001）。净重新分类改善（心肌梗死溶栓治疗与额外 NT-proBNP）为 0.188（P<.009），综合鉴别改善为 0.100（P<.001）。