周莉莎,趙珍珍,李貴星，郭 英,都向陽,黃 俊

(四川大學(xué)華西醫(yī)院 實(shí)驗(yàn)醫(yī)學(xué)科,四川 成都610041)

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hs-cTnT和NT-proBNP在急性心肌梗死患者預(yù)后中的價值研究

周莉莎,趙珍珍,李貴星*，郭 英,都向陽,黃 俊

(四川大學(xué)華西醫(yī)院 實(shí)驗(yàn)醫(yī)學(xué)科,四川 成都610041)

目的 探索hs-cTnT和NT-proBNP在急性心肌梗死患者預(yù)后中的臨床價值。方法 納入2013年1月至2014年12月共347例AMI患者為研究對象，按預(yù)后分為預(yù)后良好組(272例)和預(yù)后不良組(75例)。比較兩組患者h(yuǎn)s-cTnT和NT-proBNP水平，分析預(yù)后良好組和預(yù)后不良組入院及出院hs-cTnT和NT-proBNP水平差異。結(jié)果 在預(yù)后不良組中出院hs-cTnT水平為3127.0(1638.0-6054.0)ng/L，高于入院hs-cTnT的1390.0(291.7-4189.0)ng/L(P<0.05)；出院NT-proBNP水平為4817.0(2585.0-12010.0) pg/ml，高于入院NT-proBNP的1775.0(432.0-5431.0) pg/ml(P<0.05)。預(yù)后良好組入院和出院時hs-cTnT和NT-proBNP變化差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。預(yù)后不良組出院hs-cTnT為3127.0(1638.0-6054.0)ng/L和出院NT-proBNP為4817.0(2585.0-12010.0) pg/ml，高于預(yù)后良好組出院hs-cTnT的1196.5(398.3-2787.0)ng/L和出院NT-proBNP的1329.0(567.8-2592.5)pg/ml，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論 AMI患者出院hs-cTnT和NT-proBNP比入院時增加預(yù)示患者預(yù)后不好。動態(tài)分析AMI患者h(yuǎn)s-cTnT和NT-proBNP水平對患者預(yù)后判斷有價值。

hs-cTnT；NT-proBNP；急性心肌梗死；預(yù)后

(ChinJLabDiagn,2016,20:1859)

急性心肌梗死(acute myocardial infarction,AMI)是冠心病的急重癥，在我國其發(fā)病率、致殘率和死亡率高，是嚴(yán)重危害人類健康的一類心血管疾病，文獻(xiàn)報道在美國AMI的院內(nèi)死亡率高達(dá)5.4%[1-3]。臨床評估AMI患者的預(yù)后非常重要，有助于識別高危人群，制定合理的治療策略，降低死亡率、改善預(yù)后。大量研究已經(jīng)證明高敏肌鈣蛋白T(high sensitivity cardiac troponin T,hs-cTnT)是心肌細(xì)胞損傷的敏感性、特異性標(biāo)志物，在急性冠脈綜合征早期診斷，治療評估，危險分層中具有重要應(yīng)用價值[4-6]。B型利鈉肽(B-type natriuretic peptide,BNP)是由心室肌細(xì)胞分泌的神經(jīng)肽類激素，具有擴(kuò)張血管、抑制交感神經(jīng)系統(tǒng)、促進(jìn)水鈉排泄、維持體液平衡等重要生理功能[7]，BNP 在心力衰竭診斷、治療評價和預(yù)后評估中應(yīng)用廣泛[8]。近年來研究發(fā)現(xiàn)BNP或N-未端利鈉肽前體(NT-proBNP)在急性冠脈綜合征早期診斷、危險分層、預(yù)后評估中具有重要價值[9-13]。本研究應(yīng)用統(tǒng)計(jì)學(xué)方法回顧性分析347例住院急性心肌梗死患者的基本資料、臨床資料、和實(shí)驗(yàn)數(shù)據(jù)，探討hs-cTnT和NT-proBNP在AMI患者中變化趨勢，為臨床評估AMI患者預(yù)后提供循證依據(jù)。

1 材料與方法

1.1 研究對象 納入2013年1月至2014年12月四川大學(xué)華西醫(yī)院心內(nèi)科住院的347例AMI患者，其中：男性280名,女性67名，平均年齡64.5±11.7歲。所有研究對象除外腫瘤和自身免疫性疾病、瓣膜性心臟病、心力衰竭、過度肥胖和擴(kuò)張性心肌病等。所有研究對象均以急診入院，均行冠狀動脈造影檢查診斷為急性心肌梗死，且接受經(jīng)皮冠狀動脈介入治療。入院后行經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention，PCI)，抗凝，抗血小板等相關(guān)積極治療后，病情明顯好轉(zhuǎn)，批準(zhǔn)出院的研究對象納入預(yù)后良好組。入院后行PCI，抗凝，抗血小板等相關(guān)積極治療后，病情仍危重，在院死亡或病情危重自動要求出院的研究對象納入預(yù)后不良組。

1.2 研究方法 hs-cTnT和NT-proBNP檢測原理為電化學(xué)發(fā)光法，由Roche e601分析儀完成檢測，所有研究對象均于入院24小時內(nèi)和出院當(dāng)天檢測hs-cTnT和NT-proBNP水平。回顧性分析患者年齡、性別、高血壓病史、糖尿病病史、吸煙史、肺部感染、入院時收縮壓、入院時舒張壓、入院時心率、入院hs-cTnT和NT-proBNP水平、出院hs-cTnT和NT-proBNP水平等基本資料、臨床資料和實(shí)驗(yàn)數(shù)據(jù)。

2 結(jié)果

2.1 研究對象的基本資料 本研究共納入中國成都地區(qū)347例AMI患者，其中272例為預(yù)后良好組，75例為預(yù)后不良組。預(yù)后良好組和預(yù)后不良組的基本資料比較見表1。表1結(jié)果顯示：預(yù)后不良組年齡、性別、肺部感染、尿素、肌酐、胱抑素-C均高于預(yù)后良好組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。

表1 預(yù)后良好組和預(yù)后不良組AMI患者基本資料比較

2.2 預(yù)后良好組與預(yù)后不良組hs-cTnT和NT-proBNP水平的差異 預(yù)后良好組和預(yù)后不良組入院和出院hs-cTnT和NT-proBNP水平見表2。表2結(jié)果顯示：預(yù)后良好組出院hs-cTnT水平為1196.5(398.3-2787.0)ng/L ，與入院hs-cTnT的1262.0(152.2-3162.8)ng/L，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)(圖1A)；出院時NT-proBNP水平為1329.0(567.8-2592.5)pg/ml，與入院NT-proBNP的1191.0(372.5-3606.0)pg/ml,差異無統(tǒng)計(jì)學(xué)意義(P>0.05)(圖1B)。預(yù)后不良組中出院hs-cTnT水平為3127.0(1638.0-6054.0)ng/L，高于入院hs-cTnT的1390.0(291.7-4189.0)ng/L，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(圖2A)；出院時NT-proBNP水平為4817.0(2 585.0-12 010.0) pg/ml，高于入院NT-proBNP的1775.0(432.0-5431.0) pg/ml，差異有統(tǒng)計(jì)學(xué)意義，P<0.05(圖2B)。研究結(jié)果顯示：出院hs-cTnT和NT-proBNP比入院增加預(yù)示患者預(yù)后不好。進(jìn)一步分析，發(fā)現(xiàn)預(yù)后不良組出院時hs-cTnT NT-proBNP 均明顯高于預(yù)后良好組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。

表2 AMI患者h(yuǎn)s-cTnT(ng/L)和NT-proBNP(pg/ml)水平

圖1 預(yù)后良好組入院及出院hs-cTnT和NT-proBNP水平差異

圖2 預(yù)后不良組入院及出院hs-cTnT和NT-proBNP水平差異

3 討論

本研究回顧性分析347例AMI患者的基本資料、臨床資料和實(shí)驗(yàn)數(shù)據(jù)，探索hs-cTnT和NT-proBNP對AMI患者預(yù)后的預(yù)測價值。NT-proBNP與BNP呈等摩爾分泌，其生物半衰期明顯長于BNP,且受激動神經(jīng)系統(tǒng)和血流動力學(xué)影響較小，經(jīng)科學(xué)研究證明NT-proBNP比BNP生物穩(wěn)定性好，更適用于臨床[14]。近年來大量文獻(xiàn)報道，NT-proBNP與急性冠脈綜合征(acute coronary syndrome,ACS)的早期診斷、危險分層及預(yù)后密切相關(guān)[9-13]。Eren等[12]證明中度危險的ACS患者，NT-proBNP預(yù)測其長期預(yù)后的價值優(yōu)于TIMI評分。本研究結(jié)果顯示出院NT-proBNP較入院顯著增高，預(yù)測AMI患者預(yù)后不良。表明NT-proBNP在AMI預(yù)后中具有重要價值和應(yīng)用前景，動態(tài)NT-proBNP變化趨勢可強(qiáng)烈預(yù)測AMI患者預(yù)后。心肌肌鈣蛋白T(cTnT)是心肌肌鈣蛋白(cTn)的亞單位(cTnI、cTnC、cTnT)之一，是目前國內(nèi)外公認(rèn)的一項(xiàng)心肌損傷的特異性和敏感性標(biāo)志物[15]。在本研究中,發(fā)現(xiàn)預(yù)后不良組出院hs-cTnT水平顯著高于入院時，表明 hs-cTnT動態(tài)變化趨勢對AMI患者預(yù)后的應(yīng)用價值。

近年來大量實(shí)驗(yàn)發(fā)現(xiàn)腎臟功能異常對ACS患者預(yù)后有影響。Marenzi等[16，17]發(fā)現(xiàn)血清肌酐水平，特別是住院期間血肌酐變化模式在ACS患者短期、長期預(yù)后中具有重要應(yīng)用價值。本研究顯示：預(yù)后不良組AMI患者尿素、肌酐、胱抑素C濃度明顯高于預(yù)后良好組，表明腎臟功能與AMI患者預(yù)后密切關(guān)聯(lián)。分析納入患者的基本資料時，發(fā)現(xiàn)預(yù)后不良組以絕經(jīng)后女性為主。女性體內(nèi)雌激素參與多種生理活動，如調(diào)節(jié)脂質(zhì)代謝、保護(hù)血管內(nèi)皮，增加高密度脂蛋白和降低低密度脂蛋白等，絕經(jīng)后，女性喪失雌激素的保護(hù)作用，可能是老年女性AMI患者預(yù)后不良的主要原因[18]。

國外已有研究表明hs-cTnT和NT-proBNP聯(lián)合策略在心血管疾病早期診斷、危險分層和預(yù)后評價中優(yōu)于兩個指標(biāo)的單獨(dú)價值。 Rahul等發(fā)現(xiàn)cTnT和NT-proBNP聯(lián)合策略優(yōu)于兩個指標(biāo)單獨(dú)評估急性心力衰竭患者短期和長期預(yù)后[17，19,20]。本研究表明hs-cTnT和NT-proBNP聯(lián)合動態(tài)觀察可準(zhǔn)確判斷AMI患者預(yù)后。

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Value of hs-cTnT and NT-proBNP in patients with acute myocardial infarction prognosis

ZHOULi-sha,ZHAOZhen-zhen,LIGui-xing,etal.

(DepartmentofLaboratoryMedicine,WestChinaHospital,SichuanUniversity,Chengdu610041,China)

Objective To explore the prognostic significances of high-sensitive troponin T (hs-cTnT) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) for patients with acute myocardial infarction (AMI).Methods A total of 347 AMI patients were enrolled into our study,from January 2013 to December 2014,from West China Hospital of Sichuan University,and then these patients were divided into the good prognosis group with 272 subjects and the poor prognosis group with 75 subjects.hs-cTnT and NT-proBNP concentrations were compared between the two groups,and the differences of the level of hs-cTnT and NT-proBNP between the good prognosis group and the poor prognosis group were analyzed.Results In the poor prognosis group,the hs-cTnT concentrations of hospital discharge were 3127.0(1638.0-6054.0)ng/L,which were higher than those of hospital admission [1390.0(291.7-4189.0)ng/L],and the differences were statistically significant(P<0.05).The levels of NT-proBNP of hospital discharge were 4817.0(2585.0-12010.0) pg/ml,which were higher than those of hospital admission[1775.0(432.0-5431.0) pg/ml],the differences were statistically significant(P<0.05).Hs-cTnT concentrations of hospital discharge were 3127.0(1638.0-6054.0)ng/L,and NT-proBNP concentrations of hospital discharge were 4817.0(2585.0-12010.0) pg/ml in the poor prognosis group,which were higher than those of the good prognosis group[1196.5(398.3-2787.0)ng/L,1329.0(567.8-2592.5)pg/ml,respectively].Conclusion The levels of hs-cTnT and NT-proBNP of hospital discharge increased in comparison with those of hospital admission,predicting the prognosis of AMI patients was poor.

hs-cTnT；NT-proBNP；AMI；Prognosis

四川省科技廳支撐項(xiàng)目(2016SZ0044)

1007-4287(2016)11-1859-05

R542.2

A

周莉莎(1987-)，女，在職碩士研究生，檢驗(yàn)技師，主要從事疾病發(fā)生的生化機(jī)制研究。

2016-05-11)

*通訊作者