突破性心衰治療:利用心臟標誌物指導下的療法,顯著改善心臟結構與功能

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最新研究發現,以N末端前腦利鈉肽(NT-proBNP)為指標的心衰治療,相較於傳統治療,能更有效改善心臟結構與功能。研究對象為左心室收縮功能障礙的心衰患者,治療後不僅心臟射血分數提高,心室容量減少,還改善了肺靜脈流速、右心室功能與二尖瓣逆流程度。

在利鈉肽指導下的慢性心衰治療期間,結構和功能超聲心動圖參數的改善:來自利鈉肽門診個性化慢性心衰(PROTECT)研究的機制洞察

Improvement in structural and functional echocardiographic parameters during chronic heart failure therapy guided by natriuretic peptides: mechanistic insights from the ProBNP Outpatient Tailored Chronic Heart Failure (PROTECT) study

Weiner RB, Baggish AL, Chen-Tournoux A, Marshall JE, Gaggin HK, Bhardwaj A, Mohammed AA, Rehman SU, Barajas L, Barajas J, Gregory SA, Moore SA, Semigran MJ, Januzzi JL Jr. Improvement in structural and functional echocardiographic parameters during chronic heart failure therapy guided by natriuretic peptides: mechanistic insights from the ProBNP Outpatient Tailored Chronic Heart Failure (PROTECT) study. Eur J Heart Fail. 2013 Mar;15(3):342-51. doi: 10.1093/eurjhf/hfs180. Epub 2012 Nov 6. PMID: 23132825.

https://pubmed.ncbi.nlm.nih.gov/23132825/

Abstract

Aims

We sought to determine if heart failure (HF) care with a goal to lower N-terminal pro B-type natriuretic peptide (NT-proBNP) concentrations, compared with standard of care (SOC) management, is associated with improvement in echocardiographic parameters of cardiac structure and function.

Methods and results

Of 151 subjects with HF due to left ventricular systolic dysfunction (LVSD) prospectively randomized to NT-proBNP-guided vs. SOC HF care, 116 had serial echocardiographic data. Endpoints in this echocardiographic study included the relationship between change in NT-proBNP and LV reverse remodelling, as well as associations between biomarker-guided therapy and measures of diastolic function, right ventricular (RV) size and function, estimates of LV filling pressure and RV systolic pressure (RVSP), and the degree of mitral regurgitation (MR). After a mean of 10 months of study procedures, in adjusted analyses, final NT-proBNP concentrations predicted risk of remodelling [hazard ratio (HR) ↑LV end-diastolic volume index = 1.43, 95% confidence interval (CI) 1.10-1.86, P = 0.007; HR ↑LV end-systolic volume index = 1.54, 95% CI 1.10-1.91, P = 0.01; HR ↓LV ejection fraction (LVEF) = 1.53, 905% CI 1.12-1.89, P = 0.02]. In addition to greater improvement in LVEF and reductions in LV volume, compared with SOC, NT-proBNP-guided patients showed significant decreases in the ratio of early transmitral peak velocity to early diastolic peak annular velocity (E/E’), pulmonary vein peak S velocity, RV fractional area change, RVSP, and MR severity.

Conclusion

NT-proBNP concentrations may serve as a non-invasive indicator of the state of cardiac structure and function in HF due to LVSD. Multiple, prognostically meaningful echocardiographic variables improved more significantly in patients treated with NT-proBNP-guided care vs. SOC.

摘要

目的

我們旨在確定與標準護理(SOC)管理相比,以降低N末端前B型利鈉肽(NT-proBNP)濃度為目標的心衰(HF)護理是否與心臟結構和功能的超聲心動圖參數改善相關。

方法和結果

在151名因左心室收縮功能障礙(LVSD)導致的HF患者中,前瞻性隨機分配到NT-proBNP指導與SOC HF護理,其中116人有連續的超聲心動圖數據。這項超聲心動圖研究的終點包括NT-proBNP變化與LV逆向重塑之間的關係,以及生物標記指導治療與舒張功能測量、右心室(RV)大小和功能、左心室充盈壓和RV收縮壓(RVSP)估計,以及二尖瓣返流(MR)程度的相關性。經過平均10個月的研究程序,在調整分析後,最終NT-proBNP濃度預測重塑風險[風險比(HR)↑左心室舒張末期容積指數 = 1.43,95%置信區間(CI)1.10-1.86,P = 0.007;HR ↑左心室收縮末期容積指數 = 1.54,95% CI 1.10-1.91,P = 0.01;HR ↓左心室射血分數(LVEF)= 1.53,905% CI 1.12-1.89,P = 0.02]。與SOC相比,NT-proBNP指導的患者除了LVEF的更大改善和左心室容積的減少外,還顯著降低了早期經二尖瓣峰值流速與早期舒張期峰值環速度之比(E/E’)、肺靜脈峰值S速度、RV面積分數變化、RVSP和MR嚴重程度。

結論

NT-proBNP濃度可作為LVSD導致的HF中心臟結構和功能狀態的非侵入性指標。與SOC相比,接受NT-proBNP指導護理的患者在多個具有預後意義的超聲心動圖變量上的改善更為顯著。