Bahrmann Philipp, Bahrmann Anke, Hofner Benjamin, Christ Michael, Achenbach Stephan, Sieber Cornel Christian, Bertsch Thomas
Institute for Biomedicine of Aging, Friedrich-Alexander-University, Nuremberg, Germany
Department of Cardiology, Friedrich-Alexander-University, Erlangen, Germany.
Eur Heart J Acute Cardiovasc Care. 2015 Apr;4(2):137-47. doi: 10.1177/2048872614541904. Epub 2014 Jul 7.
Biomarkers can help to identity acute heart failure (AHF) as the cause of symptoms in patients presenting to the emergency department (ED). Older patients may prove a diagnostic challenge due to co-morbidities. Therefore we prospectively investigated the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone or in combination with other biomarkers for AHF upon admission at the ED.
302 non-surgical patients aged ≥ 70 years were consecutively enrolled upon admission to the ED. In addition to NT-proBNP, mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), C-terminal pro-endothelin-1 (CT-proET-1) and ultra-sensitive C-terminal pro-vasopressin (Copeptin-us) were measured at admission. Two cardiologists independently adjudicated the final diagnosis of AHF after reviewing all available baseline data excluding the biomarkers. We assessed changes in C-index, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) for the multimarker approach.
AHF was diagnosed in 120 (40%) patients (age 81±6 years, 64 men, 56 women). Adding MR-ADM to NT-proBNP levels improved C-index (0.84 versus 0.81; p=0.045), and yielded IDI (3.3%; p=0.002), NRI (17%, p<0.001) and continuous NRI (33.3%; p=0.002). Adding CT-proET-1 to NT-proBNP levels improved C index (0.86 versus 0.81, p=0.031), and yielded robust IDI (12.4%; p<0.001), NRI (31.3%, p<0.001) and continuous NRI (69.9%; p<0.001). No other dual or triple biomarker combination showed a significant improvement of both C-index and IDI.
In older patients presenting to the ED, the addition of CT-proET-1 or MR-proADM to NT-proBNP improves diagnostic accuracy of AHF. Both dual biomarker approaches offer significant risk reclassification improvement over NT-proBNP.
生物标志物有助于确定急性心力衰竭（AHF）是急诊科（ED）就诊患者症状的病因。由于存在合并症，老年患者可能是一个诊断挑战。因此，我们前瞻性地研究了单独使用N端前脑钠肽（NT-proBNP）或与其他生物标志物联合使用对急诊入院时AHF的诊断性能。
302名年龄≥70岁的非手术患者在急诊入院时连续入组。除NT-proBNP外，入院时还检测了中段肾上腺髓质素原（MR-proADM）、中段心房利钠肽原（MR-proANP）、C端内皮素-1原（CT-proET-1）和超敏C端抗利尿激素原（Copeptin-us）。两名心脏病专家在审查所有排除生物标志物的可用基线数据后，独立判定AHF的最终诊断。我们评估了多标志物方法的C指数、综合判别改善（IDI）和净重新分类改善（NRI）的变化。
120名（40%）患者被诊断为AHF（年龄81±6岁，男性64名，女性56名）。将MR-ADM添加到NT-proBNP水平可提高C指数（0.84对0.81；p=0.045），并产生IDI（3.3%；p=0.002）、NRI（17%，p<0.001）和连续NRI（33.3%；p=0.002）。将CT-proET-1添加到NT-proBNP水平可提高C指数（0.86对0.81，p=0.031），并产生显著的IDI（12.4%；p<0.001）、NRI（31.3%，p<0.001）和连续NRI（69.9%；p<0.001）。没有其他双重或三重生物标志物组合显示C指数和IDI均有显著改善。
在急诊就诊的老年患者中，将CT-proET-1或MR-proADM添加到NT-proBNP可提高AHF的诊断准确性。两种双重生物标志物方法在风险重新分类方面均比NT-proBNP有显著改善。
