Cavefors Oscar, Einarsson Freyr, Holmqvist Jakob, Bech-Hanssen Odd, Ricksten Sven-Erik, Redfors Björn, Oras Jonatan
Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
ESC Heart Fail. 2024 Dec;11(6):4009-4018. doi: 10.1002/ehf2.14980. Epub 2024 Aug 1.
This study aimed to assess the use of high-sensitivity troponin T (hsTNT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in screening for cardiac dysfunction [left ventricular (LV) systolic or diastolic dysfunction or right ventricular (RV) dysfunction] in mixed intensive care unit (ICU) patients and establish whether these biomarkers are independently associated with an increased risk of death.
We performed a secondary analysis of a single-centre prospective observational study in which consecutive ICU patients were examined with transthoracic echocardiography (TTE) and cardiac biomarkers. Patients with systolic or diastolic LV dysfunction, RV dysfunction or a combination of these were compared with patients with normal cardiac function. Sensitivity and specificity for different cut-off levels were calculated using receiver operating characteristic curves. Regression models were used to evaluate the associations between cardiac biomarkers, sepsis, renal failure and mortality.
A total of 276 patients were included. Most of the patients had cardiac dysfunction on TTE (64%). Combined cardiac dysfunction was most prevalent (71 patients, 26%), followed by isolated diastolic LV dysfunction (40 patients, 15%). Levels of hsTNT and NT-proBNP were higher in all types of cardiac dysfunction versus patients with normal cardiac function. The area under the curve (AUC) for hsTNT to detect any cardiac dysfunction was 0.75. An optimal cut-off at 30.5 ng/L rendered a positive predictive value (PPV) of 80% and a negative predictive value (NPV) of 58%. The AUC for NT-proBNP to detect any cardiac dysfunction was 0.788. Using an optimal cut-off at 1145 ng/L rendered a PPV of 86% and an NPV of 58%. Using a clinically relevant 90% sensitivity for detecting cardiac dysfunction put the cut-offs at 14.1 ng/L for hsTNT and 247 ng/L for NT-proBNP, resulting in a specificity of 48% and 46%, respectively. Levels of NT-proBNP were associated with sepsis and renal failure (P < 0.001), while levels of hsTNT were associated with renal failure only (P < 0.001) after adjustment for cardiac dysfunction. Levels of biomarkers were associated with an increased risk of 90 day mortality after adjustments for age, Simplified Acute Physiology Score 3, cardiac dysfunction and factors independently associated with biomarker increase (sepsis and renal failure) (P = 0.048 for hsTNT and P < 0.006 for NT-proBNP).
Cardiac biomarkers, hsTNT and NT-proBNP, are strongly correlated to cardiac dysfunction in ICU patients and have a robust association with increased mortality. However, the relatively low NPV and the low specificity at relevant sensitivity levels of the biomarkers make them unsuitable for use in screening for cardiac dysfunction.
本研究旨在评估高敏肌钙蛋白T（hsTNT）和N末端脑钠肽前体（NT-proBNP）在混合重症监护病房（ICU）患者心脏功能障碍[左心室（LV）收缩或舒张功能障碍或右心室（RV）功能障碍]筛查中的应用，并确定这些生物标志物是否与死亡风险增加独立相关。
我们对一项单中心前瞻性观察性研究进行了二次分析，在该研究中，连续的ICU患者接受了经胸超声心动图（TTE）和心脏生物标志物检查。将收缩或舒张性LV功能障碍、RV功能障碍或两者兼有的患者与心脏功能正常的患者进行比较。使用受试者工作特征曲线计算不同临界值的敏感性和特异性。回归模型用于评估心脏生物标志物、脓毒症、肾衰竭和死亡率之间的关联。
共纳入276例患者。大多数患者经TTE检查存在心脏功能障碍（64%）。合并心脏功能障碍最为常见（71例，26%），其次是孤立性舒张性LV功能障碍（40例，15%）。与心脏功能正常的患者相比，所有类型心脏功能障碍患者的hsTNT和NT-proBNP水平均较高。hsTNT检测任何心脏功能障碍的曲线下面积（AUC）为0.75。最佳临界值为30.5 ng/L时，阳性预测值（PPV）为80%，阴性预测值（NPV）为58%。NT-proBNP检测任何心脏功能障碍的AUC为0.788。使用最佳临界值1145 ng/L时，PPV为86%，NPV为58%。以检测心脏功能障碍的临床相关敏感性90%计算，hsTNT的临界值为14.1 ng/L，NT-proBNP的临界值为247 ng/L，特异性分别为48%和46%。校正心脏功能障碍后，NT-proBNP水平与脓毒症和肾衰竭相关（P<0.001），而hsTNT水平仅与肾衰竭相关（P<0.001）。校正年龄、简化急性生理学评分3、心脏功能障碍以及与生物标志物升高独立相关的因素（脓毒症和肾衰竭）后，生物标志物水平与90天死亡风险增加相关（hsTNT为P = 0.048，NT-proBNP为P<0.006）。
心脏生物标志物hsTNT和NT-proBNP与ICU患者的心脏功能障碍密切相关，且与死亡率增加密切相关。然而，生物标志物相对较低的NPV以及在相关敏感性水平下较低的特异性使其不适用于心脏功能障碍的筛查。
