1,Company Confidential 2010 Abbott,B-Type Natriuretic Peptide （BNP）,2,Company Confidential 2010 Abbott,3,Company Confidential 2010 Abbott,4,Company Confidential 2010 Abbott,Overview,案例：HF何謂BNPBNP臨床應用,5,Company Confidential 2010 Abbott,Case HF:,男性，65歲，主訴“進行性加重的呼吸困難1天。”查體：BP170/100mmHg，HR100bpm，律齊，無奔馬律，兩肺可及廣泛干濕 羅音，無水腫。輔助檢查：EKG：竇速，多源性早搏，左房、左室肥大，陳舊性Q波胸片（成像差）：未見心臟擴大床邊B超：輕度室壁運動減退（陳舊性），收縮功能未見明顯異常。TNI0.04ng/ml，血常規、電解質正常BNP未做既往史：高血壓、COPD、陳舊性心梗、1年前心臟射血分數正常既往用藥：2種吸入劑、可樂定、斯伐他汀,6,Company Confidential 2010 Abbott,Case HF：,接下來 診斷：COPD急性加重 處理：吸氧、噴霧、糖皮質激素患者自覺好轉，2小時后準予回家,7,Company Confidential 2010 Abbott,Case HF：,接下來 3小時后患者感到嚴重呼吸困難，由急救車再次送至急診室。 查體：BP160/110mmHg，HR140bpm,律絕對不齊（心監提示房 顫），兩肺呼吸運動差。,COPD？心衰？肺栓塞？,8,Company Confidential 2010 Abbott,Case HF：,何種檢查需要進一步檢查？ BNP？ D二聚體？ CKMB、TNI？Order BNPBNP900pg/ml,9,Company Confidential 2010 Abbott,Case HF：,速尿40mg IV地爾硫卓 10 mg/h iv Nesiritide（腦促尿鈉排泄肽（商品名：奈西立肽）2 mcg/kg po 后 0.01 mcg/kg/min 靜脈用 24H后患者癥狀明顯改善，心律恢復竇性，兩肺呼吸音轉清，24H尿量3000ml。復測BNP150 pg/mL,10,Company Confidential 2010 Abbott,Case HF：,最終轉歸：心超檢查提示心臟舒張功能減退，E/A0.7予ACEI、受體阻滯劑治療2天后出院,11,Company Confidential 2010 Abbott,Case HF：,思考,如何正確診斷呼吸困難？肺源性？心源性？,12,Company Confidential 2010 Abbott,35%病人無臨床癥狀35%病人癥狀不典型缺少既往病史往往合并其他疾病常規EKG、X-rays無法特異區分心源性和肺源性疾病心超能夠明確，但在急診室不常規檢查,HF in ED,13,Company Confidential 2010 Abbott,from the BNP Consensus Panel 2004,Consensus Statement 2：Using BNP Levels to Help Triage Patients Presenting to the ED With Dyspnea,14,Company Confidential 2010 Abbott,何謂BNP？,15,Company Confidential 2010 Abbott,Brain natriuretic peptide (BNP),由心室心肌細胞釋放的肽段1988首先由豬腦組織中分離出，但是由心室細胞首先合成生理作用：利尿，促尿鈉排泄，抑制RAAS系統及交感系統，舒張血管平滑肌，以減少容量負荷BNP 是一個心臟激素,16,Company Confidential 2010 Abbott,BNP from Cardiac Myocytes,Blood,Cardiomyocyte,Mair et al. Clin Chem Lab Med 39:571-88.,17,Company Confidential 2010 Abbott,BNP vs NT-proBNP,*當 eGFR 60 mL/min時，截斷值為 1200 pg/mL,18,Company Confidential 2010 Abbott,BNP的臨床應用,19,Company Confidential 2010 Abbott,Clinical Utility of BNP,心衰診斷預后的評價治療監測急性冠脈綜合征預后的評價,20,Company Confidential 2010 Abbott,BNP應用于心衰,21,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,所有BNP供應商建議以 100 pg/mL 作為判定值,Dickstein K.E heart J.2008;29:2388-2422,22,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,from the BNP Consensus Panel Consensus Statement 3, renal disease:3.1. 慢性腎功能衰竭患者的BNP水平會發生變化 (估計 GFR 60 ml/min), 重新定標后所獲得的截斷值約為 200 pg/mL. 然而, 當BNP水平極高或極低時，有助于對呼吸困難進行評估。,23,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Breathing Not Properly (BNP) Study1586位由于急性呼吸困難至急診室就診的患者患者就診時予測定BNP,但急診醫生診斷時沒有提供BNP的值急診醫生結合病史、體格檢查及除BNP外其他相關實驗室檢查（eg. EKG，X-Ray，心超、及其他臨床生化免疫檢查）對病人做出診斷同時用2位心臟科專家各自結合所有的臨床數據（除BNP）做出的診斷為標準心臟科專家做出診斷時未提供BNP值，未參考急診醫師的診斷,24,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Silver MA, et al. Congest Heart Fail. 2004;10:1-30.,N = 1586,Breathing Not Properly Study,BNP提高HF診斷率,25,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,McCullough PA, et al. Circulation. 2002;106:416-422.,N = 1586,Optimal BNP cutoff point determined at 100 pg/mL,在ED，ROC曲線下面積臨床判斷是0.86BNP單獨是0.90兩者結合0.93,26,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Mueller C, et al. N Engl J Med. 2004;350:647-654.,N = 452,至急診就診的急性呼吸困難患者(N = 452),終點出院時間總的治療費用,BNP for Acute Shortness of Breath Evaluation (BASEL) Study,27,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,Mueller C, et al. N Engl J Med. 2004;350:647-654.,N = 452,BASEL Study: BNP組提高診斷率，能減少治療費用,28,Company Confidential 2010 Abbott,BNP同樣可用于心臟舒張功能不全的患者的診斷BNP升高程度不如收縮功能不全的患者，視舒張功能受損情況而定,Breathing Not Properly Multinational Study 447 patients with acute dyspnea in the ED Maisel et al. JACC. 2003;41:2010-2017,34,413,821,Diagnostic Utility of BNP in HF,29,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,合并肺部疾病 from the BNP Consensus Panel Consensus Statement 4：pulmonary disease:4.1. 大約20%肺部疾病患者的BNP會上升, BNP水平的上升意味著心衰結合肺部疾病,肺源性心臟病的發生, 或意味著當呼吸困難,真正的病因是心衰時所發生的誤診 4.2. 當發生肺部栓塞時 (PE),三分之一患者會發生 BNP 上升 ,30,Company Confidential 2010 Abbott,Diagnostic Utility of BNP in HF,合并肺部疾病患者中BNP水平與心衰的關系,McCullough, Wu, et al. Acad Emerg Med 2003;10:198-204,31,Company Confidential 2010 Abbott,Prognostic Utility of BNP in HF,Logeart D, et al. J Am Coll Cardiol. 2004;43:635-641.,*Predischarge BNP level,N = 202,BNP是心衰患者死亡率及再住院率的獨立預測因子,0,25,50,75,100,0,30,60,90,120,150,180,Death or Readmission, %,Follow-up, Days,Hazard Ratios,120天出院前測得的BNP值80% risk,32,Company Confidential 2010 Abbott,Monitoring of Therapy,Patients, %,Hospitalization for Heart Failure or Death Related to Heart Failure,BNP-Guided Therapya (n = 110)Conventional Therapyb (n = 110),p.001,The STARS-BNP Study,aMedical therapy increased with a goal of BNP 80 pg/mL，其死亡的可能性，發生心衰或心衰惡化的可能性，發生心梗及心梗復發的可能性均明顯升高 (p.005),de Lemos JA, et al. N Engl J Med. 2001;345:1014-1021.,Patients, %,At 30 Days,At 10 Months,*p30kg/m2）,36,Company Confidential 2010 Abbott,conclusion,配合多學科實踐指南，BNP檢測已成為評估心衰的標準： National Academy of Clinical Biochemistry(NACB)European Society of Cardiology(ESC)American College of Cardiology(AAC)American Heart AssociationBNP Consensus PanelBNP 能診斷及監控心衰BNP的結果值隨年齡、肥胖度、及腎功能衰竭程度而變化 BNP 是高性價比的檢測項目,37,Company Confidential 2010 Abbott,謝謝,38,Company Confidential 2010 Abbott,39,Company Confidential 2010 Abbott,Prognostic Utility of BNP in ACS TACTICS-TIMI 18,若患者其BNP 80 pg/mL，其7天(2.5% versus 0.7%; p=.