Nguyen Virginia, Cimadevilla Claire, Arangalage Dimitri, Dehoux Monique, Codogno Isabelle, Duval Xavier, Tubiana Sarah, Vahanian Alec, Messika-Zeitoun David
Department of Cardiology, Bichat Hospital, Paris, France; INSERM U1148, Bichat Hospital, Paris, France; University Paris 7, Paris, France.
Department of Biochemistry, Bichat Hospital, Paris, France.
Int J Cardiol. 2017 Mar 1;230:371-377. doi: 10.1016/j.ijcard.2016.12.100. Epub 2016 Dec 24.
The prognostic value of N-terminal fragment of pro B-type natriuretic peptide (Nt-proBNP) in aortic stenosis (AS) is still being debated. We sought to evaluate the determinants of Nt-proBNP in AS and its prognostic value in asymptomatic patients.
Patients with pure isolated at least mild degenerative AS enrolled in our prospective cohort (2006-2013) constituted our population. Clinical and biological measurements as well as echocardiographic evaluations were performed at study entry for all patients. Severe AS was defined by a valve area <1cm. Asymptomatic patients were contacted every six months and seen every year. The occurrence of AS-related events (sudden death, congestive heart failure or new onset of symptoms) within two years was recorded prospectively.
We enrolled 809 patients. Nt-proBNP increased with AS severity (p<0.0001) and symptomatic status (p<0.0001) but there was a wide overlap between groups of AS severity or symptomatic status. Nt-proBNP was the result of complex interactions between multiple determinants, including AS severity and symptomatic status but also age (p=0.0008), history of coronary artery disease (p=0.03), rhythm (p=0.007) and diastolic function (p<0.0001). Consequently, in asymptomatic patients with moderate/severe AS, normal ejection fraction and in sinus rhythm, Nt-proBNP was associated with AS-related events in univariate analysis (p=0.009) but not after adjustment for AS severity (p=0.12). Repeated Nt-proBNP measurements at one year did not improve their predictive value (p=0.43).
This study highlights the limitations of Nt-proBNP in AS and raises caution regarding its use, at least as a single factor, in the decision-making process regarding asymptomatic patients with AS.
B型利钠肽原N端片段（Nt-proBNP）在主动脉瓣狭窄（AS）中的预后价值仍存在争议。我们试图评估AS中Nt-proBNP的决定因素及其在无症状患者中的预后价值。
纳入我们前瞻性队列研究（2006 - 2013年）中的单纯孤立性至少轻度退行性AS患者构成研究人群。所有患者在研究入组时进行临床和生物学测量以及超声心动图评估。重度AS定义为瓣膜面积<1平方厘米。无症状患者每六个月联系一次，每年进行检查。前瞻性记录两年内AS相关事件（猝死、充血性心力衰竭或新出现症状）的发生情况。
我们纳入了809例患者。Nt-proBNP随AS严重程度（p<0.0001）和症状状态（p<0.0001）升高，但AS严重程度组或症状状态组之间存在广泛重叠。Nt-proBNP是多种决定因素复杂相互作用的结果，包括AS严重程度和症状状态，还包括年龄（p = 0.0008）、冠状动脉疾病史（p = 0.03）、心律（p = 0.007）和舒张功能（p<0.0001）。因此，在无症状的中重度AS、射血分数正常且为窦性心律的患者中，Nt-proBNP在单因素分析中与AS相关事件相关（p = 0.009），但在调整AS严重程度后无相关性（p = 0.12）。一年时重复测量Nt-proBNP并未提高其预测价值（p = 0.43）。
本研究强调了Nt-proBNP在AS中的局限性，并提醒在对无症状AS患者的决策过程中，至少作为单一因素使用时要谨慎。
