Medar Shivanand Shankar, Hsu Daphne T, Ushay H Michael, Lamour Jacqueline M, Cohen Hillel W, Killinger James S
1Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY. 2Division of Pediatric Cardiology, Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY. 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
Pediatr Crit Care Med. 2015 Jul;16(6):529-34. doi: 10.1097/PCC.0000000000000408.
In children, elevated amino-terminal pro-B-type natriuretic peptide levels are associated with impaired heart function. The predictive value of serial monitoring of amino-terminal pro-B-type natriuretic peptide levels in acute decompensated heart failure is unclear.
Prospective observational study.
Single, tertiary referral pediatric critical care unit.
Patients aged 0-21 years with primary myocardial dysfunction and acute decompensated heart failure.
Amino-terminal pro-B-type natriuretic peptide levels were obtained on enrollment, day 2, and day 7. Clinical, laboratory, and imaging data were collected on enrollment. Adverse cardiovascular outcome was defined as heart transplant, ventricular assist device placement, extracorporeal membrane oxygenation, or death at 1 year after admission. Aminoterminal pro-B-type natriuretic peptide levels and the percent change from day 0 to day 2 and day 0 to day 7 were calculated and compared between those with and without adverse cardiovascular outcome.
Sixteen consecutive patients were enrolled. Adverse cardiovascular outcome occurred in six patients (37.5%, four heart transplant and two ventricular assist device). In patients with an adverse cardiovascular outcome, median amino-terminal pro-B-type natriuretic peptide levels at day 7 were significantly higher (7,365 vs 1,196 pg/mL; p = 0.02) and the percent decline in amino-terminal pro-B-type natriuretic peptide was significantly smaller (28% vs 73%; p = 0.02) compared with those without an adverse cardiovascular outcome. Receiver operating curve analysis revealed that a less than 55% decline in amino-terminal pro-B-type natriuretic peptide levels at day 7 had a sensitivity and specificity of 83% and 90%, respectively, in predicting an adverse cardiovascular (area under the curve, 0.86; 95% CI, 0.68-1.0; p = 0.02).
In conclusion, children with primary myocardial dysfunction and acute decompensated heart failure, a persistently elevated amino-terminal pro-B-type natriuretic peptide, and/or a lesser degree of decline in amino-terminal pro-B-type natriuretic peptide during the first week of presentation were strongly associated with adverse cardiovascular outcome. Serial amino-terminal pro-B-type natriuretic peptide monitoring may allow the early identification of children at risk for worse outcome.
在儿童中，氨基末端前B型利钠肽水平升高与心脏功能受损有关。急性失代偿性心力衰竭时连续监测氨基末端前B型利钠肽水平的预测价值尚不清楚。
前瞻性观察性研究。
单一的三级转诊儿科重症监护病房。
年龄在0至21岁之间、患有原发性心肌功能障碍和急性失代偿性心力衰竭的患者。
在入组时、第2天和第7天检测氨基末端前B型利钠肽水平。入组时收集临床、实验室和影像学数据。不良心血管结局定义为心脏移植、心室辅助装置置入、体外膜肺氧合或入院后1年死亡。计算并比较有和没有不良心血管结局患者的氨基末端前B型利钠肽水平以及从第0天到第2天和第0天到第7天的变化百分比。
连续纳入16例患者。6例患者出现不良心血管结局（37.5%，4例心脏移植和2例心室辅助装置）。与没有不良心血管结局的患者相比，有不良心血管结局的患者在第7天的氨基末端前B型利钠肽水平中位数显著更高（7365 vs 1196 pg/mL；p = 0.02），氨基末端前B型利钠肽下降百分比显著更小（28% vs 73%；p = 0.02）。受试者工作特征曲线分析显示，第7天氨基末端前B型利钠肽水平下降小于55%在预测不良心血管结局时的敏感性和特异性分别为83%和90%（曲线下面积，0.86；95% CI，0.68 - 1.0；p = 0.02）。
总之，患有原发性心肌功能障碍和急性失代偿性心力衰竭的儿童，在发病第一周氨基末端前B型利钠肽持续升高和/或氨基末端前B型利钠肽下降程度较小与不良心血管结局密切相关。连续监测氨基末端前B型利钠肽可能有助于早期识别预后较差风险的儿童。
