Pastormerlo Luigi Emilio, Agazio Assunta, Benelli Eleonora, Gabutti Alessandra, Poletti Roberta, Prontera Concetta, Clerico Aldo, Emdin Michele, Passino Claudio
Division of Cardiology and Cardiovascular Medicine, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
Division of Cardiology and Cardiovascular Medicine, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy.
Am J Cardiol. 2015 Aug 15;116(4):567-72. doi: 10.1016/j.amjcard.2015.05.017. Epub 2015 May 21.
Elevation of resting high-sensitivity troponin (hs-Tn) holds prognostic value in heart failure (HF), but its pathophysiological meaning is unclear. We aimed to investigate hs-Tn elevation after maximal exercise in patients with systolic HF and its neurohormonal and hemodynamic correlates: 30 patients diagnosed with systolic HF (left ventricular ejection fraction 32 ± 8%, mean ± SD), on guideline-directed medical therapy and not recognized inducible ischemia, underwent maximal cardiopulmonary stress test, with assay of plasma N-terminal proB-type natriuretic peptide (NT-proBNP), norepinephrine (NE), and hs-TnT (hs-TnT) at baseline, peak, and 1 and 4 hours after exercise. Cardiac output (CO) was measured during effort, with a rebreathing technique. The natural logarithm of the ratio between percentage (%) increase in CO and NT-proBNP (ln[CO%/NT-proBNP% increase]) was evaluated, as a noninvasive estimate of Frank-Starling adaptation to effort, with NT-proBNP variation considered as a surrogate of end-diastolic left ventricular pressure variation. Hs-TnT increased during exercise with a 4-hour peak (p = 0.001); 10 patients had hs-TnT increase >20%. Patients with Hs-TnT increase >20% were more symptomatic at rest (p = 0.039) and showed greater NE at peak exercise (p = 0.003) and less ln[CO%/NT-proBNP% increase] (p = 0.034). A lower ln[CO%/NT-proBNP% increase] correlated with greater NE at peak exercise (r = -0.430, p = 0.018). In conclusion, acute troponin elevation after maximal exercise was detected in 1/3 of this series. The association of troponin release with NE, CO, and NT-proBNP changes after effort suggests a pathophysiological link among transient hemodynamic overload, adrenergic activation, and myocardial cell damage, likely identifying a clinical subset at greater risk for HF progression.
静息高敏肌钙蛋白（hs-Tn）升高在心力衰竭（HF）中具有预后价值，但其病理生理意义尚不清楚。我们旨在研究收缩性HF患者最大运动后hs-Tn升高情况及其神经激素和血流动力学相关性：30例诊断为收缩性HF的患者（左心室射血分数32±8%，均值±标准差），接受指南指导的药物治疗且未发现可诱导的心肌缺血，进行最大心肺应激试验，在基线、峰值以及运动后1小时和4小时测定血浆N末端B型利钠肽原（NT-proBNP）、去甲肾上腺素（NE）和高敏肌钙蛋白T（hs-TnT）。运动期间采用重呼吸技术测量心输出量（CO）。评估CO增加百分比（%）与NT-proBNP增加百分比之间比值的自然对数（ln[CO%/NT-proBNP%增加]），作为Frank-Starling对运动适应的无创估计，将NT-proBNP变化视为舒张末期左心室压力变化的替代指标。运动期间hs-TnT升高，4小时达到峰值（p = 0.001）；10例患者hs-TnT升高>20%。hs-TnT升高>20%的患者静息时症状更明显（p = 0.039），运动峰值时NE更高（p = 0.003），ln[CO%/NT-proBNP%增加]更低（p = 0.034）。较低的ln[CO%/NT-proBNP%增加]与运动峰值时更高的NE相关（r = -0.430，p = 0.018）。总之，本系列中1/3的患者在最大运动后检测到急性肌钙蛋白升高。肌钙蛋白释放与运动后NE、CO和NT-proBNP变化之间的关联提示短暂血流动力学过载、肾上腺素能激活和心肌细胞损伤之间存在病理生理联系，可能识别出HF进展风险更高的临床亚组。
