盧紅艷,寧偉明,蘇新養(yǎng)
(肇慶市廣寧人民醫(yī)院內(nèi)科二區(qū),廣東肇慶526300)
血清CRP、Fib及NT-proBNP對(duì)慢性房顫并發(fā)早期心衰的診斷價(jià)值
盧紅艷,寧偉明,蘇新養(yǎng)
(肇慶市廣寧人民醫(yī)院內(nèi)科二區(qū),廣東肇慶526300)
目的觀察慢性房顫合并早期心力衰竭患者血清C反應(yīng)蛋白(CRP)、纖維蛋白原(Fib)、氨基末端B型鈉尿肽前體(NT-proBNP)水平的變化,并探討其臨床意義。方法選取2014年12月至2016年5月間廣寧人民醫(yī)院房顫患者120例,其中以NYHA心功能分級(jí)Ⅲ~Ⅳ級(jí)35例為A組,Ⅰ~Ⅱ級(jí)48例為B組,單純慢性房顫37例為C組,選取同期進(jìn)行門診體檢的健康正常人群50例作為對(duì)照組,比較四組受檢者的血清CRP、Fib及NT-proBNP水平。結(jié)果四組受檢者的CRP、Filb、NT-proBNP比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.01),其中A組患者的CRP[(118.52± 20.43)mg/L]、Fib[(278.27±41.22)mg/L]、NT-proBNP[(1102.08±186.54)ng/L]均明顯高于其他三組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);B組患者的CRP[(51.42±14.81)mg/L]、Fib[(38.72±10.20)mg/L]、NT-proBNP[(685.29±94.08)ng/L]均明顯高于C組和對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);NT-pro BNP對(duì)慢性房顫并發(fā)早期心衰患診斷敏感性(98.2%)和特異度(90.4%)均明顯高于CRP(91.3%、50.2%)和Fib(89.4%、65.2%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05);NT-pro BNP曲線下面積為0.922,明顯高于CRP的0.816和Fib的0.802,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論血清CRP、Fib及NT-proBNP可作為慢性房顫并發(fā)早期心衰的預(yù)測(cè)指標(biāo),其中NT-proBNP診斷價(jià)值最高。
心力衰竭;慢性房顫;C反應(yīng)蛋白;纖維蛋白原
心房顫動(dòng)(簡(jiǎn)稱房顫)是常見(jiàn)的心律失常,常見(jiàn)于有器質(zhì)性心臟疾病患者中。此外,房顫同樣是誘發(fā)患者出現(xiàn)心力衰竭的常見(jiàn)原因[1],特別是長(zhǎng)期慢性房顫患者,長(zhǎng)期的房顫不僅導(dǎo)致心衰的發(fā)生和發(fā)展,并且房顫作為心衰的危險(xiǎn)因素,不及時(shí)進(jìn)行干預(yù)容易導(dǎo)致嚴(yán)重并發(fā)癥[2]。研究認(rèn)為,心衰患者血清氨基末端B型鈉尿肽前體水平明顯高于非心衰患者,并且其水平與心衰嚴(yán)重程度呈正相關(guān),認(rèn)為通過(guò)對(duì)氨基末端B型鈉尿肽前體進(jìn)行檢測(cè)能夠幫助對(duì)心衰以及心衰嚴(yán)重程度進(jìn)行預(yù)判[3]。本研究通過(guò)對(duì)慢性房顫合并早期心力衰竭患者血液中C反應(yīng)蛋白(CRP)、纖維蛋白原(Fib)、氨基末端B型鈉尿肽前體(NT-proBNP)進(jìn)行檢測(cè),探討三種指標(biāo)的特點(diǎn),為慢性房顫患者預(yù)測(cè)早期心衰提供依據(jù)。
1.1 一般資料選取2014年12月至2016年5月在我院心內(nèi)科住院治療的120例房顫患者,其中男性69例,女性51例;年齡46~78歲,平均(58.52±8.17)歲。以慢性、持續(xù)性房顫合并重度心衰,NYHA心功能分級(jí)Ⅲ~Ⅳ級(jí)的35例患者為A組,其中男性19例,女性16例;年齡48~78歲,平均(60.05±9.24)歲。以慢性房顫伴明顯心衰前期癥狀,NYHA心功能分級(jí)Ⅰ~Ⅱ級(jí)的48例患者作為B組,其中男性26例,女性22例;年齡46~72歲,平均(58.92±8.72)歲。以單純慢性房顫的37例患者作為C組,其中男性24例,女性13例;年齡45~78歲,平均(58.44±8.05)歲。排除標(biāo)準(zhǔn):①患者在半年內(nèi)有急性冠脈綜合征發(fā)作史、腦栓塞史、肺栓塞史、主動(dòng)脈夾層史;②3個(gè)月內(nèi)有大手術(shù)或者嚴(yán)重創(chuàng)傷史;③患者并發(fā)內(nèi)分泌疾病、自身免疫系統(tǒng)疾病、繼發(fā)性高血壓、慢性腎臟疾病等。選取同期進(jìn)行門診體檢的健康正常人群50例作為對(duì)照組,其中男性28例,女性22例;年齡45~70歲,平均(58.27±8.13)歲。四組受檢者的性別、年齡等一般資料比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2 觀察指標(biāo)與檢測(cè)方法抽取受檢者空腹靜脈血9 mL,置于3抗凝試管中,以1 000 r/min離心10 min后取上清對(duì)相關(guān)指標(biāo)進(jìn)行檢測(cè)。其中C反應(yīng)蛋白檢測(cè)采用免疫比濁法,儀器為日立7070s自動(dòng)生化分析儀,試劑由上海申能德賽有限公司提供;纖維蛋白原檢測(cè)采用Clouse法,儀器為日立7070s自動(dòng)生化分析儀,試劑由上??迫A東菱公司提供。氨基末端B型鈉尿肽前體檢測(cè)采用爽抗體夾心法,儀器為Roche公司產(chǎn)的電化學(xué)全自動(dòng)免疫分析儀,試劑購(gòu)自匹基生物公司。
1.3 統(tǒng)計(jì)學(xué)方法應(yīng)用SPSS20.0統(tǒng)計(jì)軟件包進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差()表示,多組間數(shù)值比較采用方差分析,兩組間比較采用t檢驗(yàn),相關(guān)性分析采用Pearson相關(guān)分析,診斷價(jià)值分析通過(guò)繪制ROC曲線,計(jì)算曲線下面積,以P<0.05為差異具有統(tǒng)計(jì)學(xué)意義。
2.1 四組受檢者血液中CRP、Fib、NT-proBNP比較四組受檢者CRP、Fib、NT-proBNP差異均有統(tǒng)計(jì)學(xué)意義(P<0.01),A組CRP、Fib、NT-proBNP明顯高于其他三組(P<0.05)。B組CRP、Fib、NT-proBNP顯著高于C組和對(duì)照組,C組和對(duì)照組差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),表1。
表1 四組受檢者血液中CRP、Fib、NT-proBNP比較()
表1 四組受檢者血液中CRP、Fib、NT-proBNP比較()
注:與A組比較,aP<0.05;與B組比較,bP<0.05。
組別例數(shù)CRP(mg/L)Filb(mg/L)NT-proBNP(ng/L) A組B組C組對(duì)照組F值P值35 48 37 50 118.52±20.43 51.42±14.81a5.14±1.25ab3.74±1.18ab747.229 0.000 278.27±41.22 38.72±10.20a5.44±0.78ab2.68±0.22ab1 717.778 0.000 1 102.08±186.54 685.29±94.08a402.51±48.08ab168.52±30.13ab628.627 0.000
2.2 CRP、Fib、NT-proBNP在慢性房顫并發(fā)早期心衰患者中的ROC曲線和臨界值NT-pro BNP敏感性和特異度均明顯高于CRP和Fib,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。Fib和CRP兩者差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。此外,NT-pro BNP曲線下面積明顯高于CRP和Fib,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。Fib和CRP兩者差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表2及圖1。
表2 CRP、Fib、NT-proBNP在慢性房顫并發(fā)早期心衰患者
圖1 CRP、Fib、NT-proBNP對(duì)慢性房顫并發(fā)早期心衰患者的ROC曲線
若慢性房顫患者病情得不到有效控制,長(zhǎng)期房顫會(huì)引起泵血能力不足,導(dǎo)致容量負(fù)荷增大,容易引起心房擴(kuò)張,右心室壓增高,最終引起心力衰竭[4]。另一方面,房顫引起的不規(guī)律心室率能夠?qū)е律窠?jīng)內(nèi)分泌系統(tǒng)激活,兒茶酚胺釋放增加,進(jìn)一步加重心衰發(fā)生[5]。而心衰時(shí)心房壓增加,容量負(fù)荷增大,心房進(jìn)一步發(fā)生形態(tài)學(xué)改變,出現(xiàn)不應(yīng)期縮短,進(jìn)一步加重房顫的發(fā)生[6]。因此及時(shí)對(duì)慢性房顫患者早期心衰進(jìn)行診斷并采取積極的治療能夠有效的緩解由房顫進(jìn)展為心衰的進(jìn)程。
BNP是心臟分泌的一種多肽,其具有擴(kuò)血管、利尿以及抑制腎素分泌等功效。研究認(rèn)為,當(dāng)血流動(dòng)力學(xué)出現(xiàn)異常導(dǎo)致心室受壓增高時(shí),心肌細(xì)胞就會(huì)大量分泌BNP,故認(rèn)為BNP可以用于心衰的診斷[7]。近年研究顯示BNP前體——NT-proBNP對(duì)心衰診斷更為敏感,并且能夠反應(yīng)映心衰的嚴(yán)重程度[8]。本研究發(fā)現(xiàn),慢性房顫伴嚴(yán)重心衰患者NT-proBNP明顯高于早期心衰患者,說(shuō)明心衰越嚴(yán)重,NT-proBNP水平越高。并且房顫合并早期心衰NT-proBNP同樣高于單純房顫患者,說(shuō)明在心衰早期就有NT-proBNP增高的現(xiàn)象,因此對(duì)慢性心衰患者定時(shí)測(cè)定NT-proBNP有助于其早期診斷及對(duì)心衰發(fā)展的評(píng)估。
CRP和心衰同樣具有相關(guān)性。研究發(fā)現(xiàn),CRP能夠促進(jìn)細(xì)胞因子的產(chǎn)生,導(dǎo)致血管內(nèi)皮細(xì)胞受損,血管收縮,血液供應(yīng)不足,從而引起心肌缺血壞死[9]。另外,研究發(fā)現(xiàn),慢性心衰患者CRP水平明顯高于非心衰患者,且心功能分級(jí)為Ⅲ、Ⅳ級(jí)患者CRP水平明顯高于Ⅱ級(jí)者[10]。本研究同樣發(fā)現(xiàn),在慢性房顫并早期心衰患者中CRP水平明顯高于單純房顫患者,并且Ⅲ、Ⅳ級(jí)心衰患者CRP水平明顯高于Ⅱ級(jí)患者,說(shuō)明CRP同樣與心衰嚴(yán)重程度相關(guān)。另外,本研究發(fā)現(xiàn),慢性房顫并早期心衰患者中Fib水平明顯高于單純房顫患者,說(shuō)明纖維蛋白原同樣可以作為房顫合并早期心衰的檢測(cè)指標(biāo)。此外,對(duì)B組患者進(jìn)行ROC曲線分析所見(jiàn),NT-pro BNP對(duì)慢性房顫患者并發(fā)早期心衰的診斷敏感性和特異度均明顯高于CRP和Fib,說(shuō)明NT-pro BNP在慢性房顫合并早期心衰的診斷中價(jià)值更高。
綜上所述,慢性房顫患者并發(fā)早期心衰會(huì)出現(xiàn)CRP、Fib、NT-proBNP水平升高,這三種指標(biāo)可以作為衡量是否出現(xiàn)心衰的有利指標(biāo)。三種指標(biāo)中NT-proBNP敏感性和特異性最高,對(duì)提示患者可能發(fā)生心衰最有價(jià)值。
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Diagnostic value of serum CRP,Fib and NT-proBNP in patients with chronic atrial fibrillation complicated with early heart failure.
LU Hong-yan,NING Wei-ming,SU Xin-yang.Second Area of Department of Internal Medicine, Guangning People's Hospital of Zhaoqing City,Zhaoqing 526300,Guangdong,CHINA
ObjectiveTo investigate the changes of serum C reactive protein(CRP),fibrinogen(Fib),amino terminal B type natriuretic peptide the precursor(NT-proBNP)in patients with chronic atrial fibrillation complicated with early heart failure,and to explore its clinical significance.MethodsA total of 120 patients with atrial fibrillation, who admitted to Guangning People's Hospital of Zhaoqing City from Dec 2014 to May 2016,were selected and divided into A group(gradeⅢ-Ⅳ,n=35),B group(gradeⅠ-Ⅱ,n=48)and C group(simple chronic atrial fibrillation,n=37)according to the New York Heart Association(NYHA)Functional Classification.At the same time,50 subjects undergoing healthy physical examination were selected as the control group.The serum levels of CRP,Fib and NT-proBNP in thefour groups were observed and compared.ResultsThere were significant differences in CRP,Fib and NT-proBNP between the four groups(P<0.01).The levels of CRP,Fib,NT-proBNP in A group were respectively(118.52±20.43)mg/L, (278.27±41.22)mg/L,(1 102.08±186.54)ng/L,which were significantly higher than those in the other three groups(P<0.05).The levels of CRP,Fib,NT-proBNP in B group were respectively(51.42±14.81)mg/L,(38.72±10.20)mg/L, (685.29±94.08)ng/L,which were significantly higher than those in C group and the control group(P<0.05).The diagnostic sensitivity and specificity of NT-proBNP(98.2%,90.4%,respectively)for chronic atrial fibrillation complicated with early heart failure were significantly higher than CRP(91.3%,50.2%,respectively)and Fib(89.4%,65.2%,respectively) (P<0.05).The area under NT-proBNP curve(0.922)was significantly higher than that of CRP(0.816)and Fib(0.802) (P<0.05).ConclusionSerum CRP,Fib and NT-proBNP can be used as predictors of early heart failure in patients with chronic atrial fibrillation,among which,NT-proBNP has the highest diagnostic value.
Congestive heart failure;Chronic atrial fibrillation;C reactive protein(CRP);Fibrinogen(Fib)
10.3969/j.issn.1003-6350.2017.08.023
R 541.6
A
1003—6350(2017)08—1271—03
2016-09-21)
廣東省肇慶市科技創(chuàng)新計(jì)劃項(xiàng)目(編號(hào):2014E1118)
盧紅艷。E-mail:lhyanon@163.com