B 型利钠肽与临床判断在运动诱发心肌缺血检测中的应用。
B-type natriuretic peptide and clinical judgment in the detection of exercise-induced myocardial ischemia.
机构信息
Department of Cardiology, University Hospital Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland.
Department of Cardiology, University Hospital Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland; Department of Internal Medicine, University Hospital Basel, Switzerland.
出版信息
Am J Med. 2014 May;127(5):427-35. doi: 10.1016/j.amjmed.2014.01.009. Epub 2014 Jan 28.
BACKGROUND
Myocardial ischemia has been shown to be associated with increased levels of B-type natriuretic peptide (BNP). However, it remains unclear whether and how BNP levels could be used clinically in patients with suspected exercise-induced myocardial ischemia.
METHODS
We enrolled 274 consecutive patients with suspected exercise-induced myocardial ischemia referred for evaluation by rest/bicycle myocardial perfusion single-photon emission computed tomography (SPECT). All clinical information available to the treating cardiologist was used to quantify the clinical judgment regarding the presence of myocardial ischemia using a visual analogue scale twice: once before and once after bicycle exercise stress testing. BNP measurements were obtained before, immediately after, and 2 hours after stress testing in a blinded manner. The presence of myocardial ischemia was adjudicated on the basis of perfusion SPECT combined with coronary angiography findings.
RESULTS
Exercise-induced myocardial ischemia was adjudicated to be present in 103 patients (38%). BNP levels were significantly higher at all time points in patients with myocardial ischemia compared with those without (P < .01 for all). The accuracy of BNP levels as quantified by the area under the receiver operating characteristic curve (AUC) was similar among the time points evaluated (AUC, 0.677-0.697). Combining clinical judgment before exercise testing with BNP levels at rest increased diagnostic accuracy from AUC 0.708 to 0.754 (P = .018). When combining clinical judgment after exercise testing with BNP levels, AUC increased from 0.741 to 0.771 (P = .055).
CONCLUSIONS
Combining clinical judgment with BNP levels increased the diagnostic accuracy regarding the presence of myocardial ischemia.
背景
已有研究表明，心肌缺血与 B 型利钠肽（BNP）水平升高有关。然而，目前尚不清楚 BNP 水平是否以及如何在疑似运动诱发心肌缺血的患者中临床应用。
方法
我们纳入了 274 例连续疑似运动诱发心肌缺血的患者，这些患者因评估而行静息/踏车心肌灌注单光子发射计算机断层扫描（SPECT）检查。根据治疗心脏病专家提供的所有临床信息，使用视觉模拟量表两次对心肌缺血的存在进行定量评估：一次在踏车运动负荷试验之前，一次在运动后。以盲法方式在负荷试验前、负荷试验后即刻和 2 小时后采集 BNP 测量值。根据 SPECT 灌注和冠状动脉造影结果判断是否存在心肌缺血。
结果
根据 SPECT 灌注和冠状动脉造影结果，103 例（38%）患者被判定为存在运动诱发的心肌缺血。与无心肌缺血患者相比，存在心肌缺血患者的 BNP 水平在所有时间点均显著升高（所有 P <.01）。通过受试者工作特征曲线下面积（AUC）评估，各时间点的 BNP 水平的准确性相似（AUC 为 0.677-0.697）。将负荷试验前的临床判断与静息时的 BNP 水平相结合，可将诊断准确性从 AUC 0.708 提高到 0.754（P =.018）。将运动后临床判断与 BNP 水平相结合时，AUC 从 0.741 提高到 0.771（P =.055）。
结论
将临床判断与 BNP 水平相结合可提高对心肌缺血存在的诊断准确性。
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