VAI TR CA CHT CH IM SINH HC NT-PROBNP TRONG SUY TIM V HI CHNG NG MCH VNH CP

Prof. Phm Nguyn Vinh

Bnh vin Tim Tm c i hc Y Khoa Phm Ngc Thch Vin Tim TP. HCM

Cc ch nh ca NT-proBNP
- Chn on sm suy tim

- Theo di iu tr suy tim

- Tm sot suy tim trn qun th chung - Yu t tin lng ca HCMV cp

Dch t hc ca suy tim

- M: 4.7 triu bnh nhn - Th gii: 23 triu

- 550.000 trng hp mi/mi nm (M)

- 250.000 t vong/nm v suy tim (M) - Chi ph 38 t USD

- Tn sut ngy cng tng

Mann DL, Braunwalds Heart Disease, e. Edition, accessed 14 Ap.2010

Khuyn co ACC/AHA 2005 v Phn suy tim

At Risk of Heart Failure Heart Failure

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Hunt SA, Abraham WT, Chin MH et al. Circulation 2005

Chn on suy tim

- Khng mt trc nghim n c
- Phng tin lm sng (bnh s, khm thc th) khng

- Nhu cu: cht ch im sinh hc (biomarkers)

Ti sao cn chn on sm suy tim

Braunwald & Bristow*: c th o ngc tin trnh suy tim
Cht ch im sinh hc: gip chn on sm suy tim**

* Braunwald E, Bristow MR. Circulation 2000; 102 (20 suppl 4): IV14- IV23 ** Braunwald E, N.Engl J Med 2008; 358: 2148-2159

Cc ch im sinh hc ng dng hin nay trong suy tim

- BNP
- NT-proBNP - Mid-regional proANP

- hs-cTnI, hs-cTnT (Troponin I v T nhy cao)

 BNP, NT- pro BNP:

Chn on suy tim cc giai on A,B,C,D Lng nh tin lng v theo di iu tr

NT-proBNP ph gip chn on ban u suy tim/ bnh nhn c triu chng c nng

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Hildehant P et al. Am J Cardiol 2008; 101 (suppl): 25A-28A

Nhng N/C v gii hn im ct NT- proBNP loi tr suy tim trong chm sc ban u

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Hildehant P et al. Am J Cardiol 2008; 101 (suppl): 25A-28A

Cc im chnh v NT- pro BNP trong chn on ban u suy tim

- NT-proBNP: c gi tr loi tr suy tim - im ct 50-75 ng/L bnh nhn di 50 tui, 75-100 ng/L bnh nhn trung nin (50-75 tui), 250-300 ng/L bnh nhn > 75 tui - Kh th khng do suy tim: im ct di ngng - NT-proBNP trn ngng: c gi tr nh hng, cn kho st k hn v tim mch

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Hildehant P et al. Am J Cardiol 2008; 101 (suppl): 25A-28A

TM SOT SUY TIM: CHNG C LM SNG

(Heart Failure Sereening: Clinical Evidence)

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Cc chng c v gi tr ca tm sot suy tim

- Nghin cu SOLVD: iu tr sm suy tim ci thin tin lng (1) (2)
- Cn pht hin suy tim t giai on tin lm sng (3) - Pht hin c qun th c nguy c, ci thin tin lng tim mch (4)

1. SOLVD Investigators. N Engl J Med. 1992; 327:685 2. Devereux. JAMA. 2004; 292:2350 JAMA. 2005; 293:1609 4. McKie. Hypertension. 2006; 47:874

3. Kistorp.

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Tm sot trn qun th dn chng

- Pht hin sm dy tht tri v ri lon chc nng TT gip: iu tr phng nga t giai on tin lm sng suy tim (1) (2) Xc nh nguy c tt bnh v t vong - NT-proBNP > 655 pg/mL dn n: Tng gp 2 t vong Tng gp 3,2 nguy c bin c tim mch nng

1. SOLVD Investigators. N Engl J Med. 1992; 327:685 2. Devereux. JAMA. 2004; 292:2350

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Screening in healthy populations with suspicion of heart failure

Rosenberg, European Heart Journal. 2009; 30:66-73

Study design
Aim: determine NT-proBNP prognostic value in suspected HF subjects who are at an increased risk for death or CV hospitalization N = 5,875, median age 73 years of age (range 47-88) Inclusion: > 17 years of age without prior diagnosis of HF 15 End points: all-cause mortality, CV hospitalization

Screening in healthy populations with suspicion of heart failure

Rosenberg, European Heart Journal. 2009; 30:66-73 NT-proBNP values in quintiles (pg/mL) Q5
>660 pg/mL 229-660 pg/mL 119-228 pg/mL 59-118 pg/mL <59 pg/mL

Q4
Q3 Q2 Q1

50

100

150

200

Age-adjusted CV hospitalization rate per 1000 patient-years

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Rosenberg. European Heart Journal. 2009; 30:66-73

Screening in healthy populations with suspicion of heart failure

Rosenberg, European Heart Journal. 2009; 30:66-73
30% increase in NT=proBNP was associated with a HR of 1.08 (1.06 =1.10), p = 0.001

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Screening in healthy populations with suspicion of heart failure

Rosenberg, European Heart Journal. 2009; 30:66-73

Kt lun:
- NT-proBNP gip tm sot suy tim bnh nhn nguy c cao cha triu chng c nng nhy 92-99% Gi tr tin on m cao - NT-proBNP < 125 pg/mL: nguy c suy tim thp - NT-proBNP trong khong 200 pg/mL 300 pg/mL: cn lm siu m tim
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Screening of Healthy Populations

Emdin. Clin Chem Lab. 2009; 46(11):1533-1542

Kt lun:
- Suy tim khng triu chng c nng thng gp, dn n ti cu trc khng hi phc - Thy thuc chm sc sc kho ban u c th s dng NT-proBNP tm sot suy tim - NT-proBNP: r v tin dng

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im ct NT-proBNP/ chn on suy tim bnh nhn kh th cp

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Januzzi J L et al. Am J Cardiol 2008; 101 (suppl):29A-38A

XT NGHIM NT-proBNP TRONG THEO DI V HNG DN iU TR NI TR SUY TIM CP MT B

Paulo Bettencourt, MD,a v James L. Januzzi, Jr., MDb
de Medicina Interna, Bnh vin S Jon Alameda Hermani Monteiro, Porto, B o Nha; v bB mn Tim mch, Bnh vin a khoa Massachusetts, Trng Y Khoa Harvard, Boston, Massachusetts, Hoa K
aSevico

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Am J Cardiol 2008; 101 (suppl): 67A-71A

Tng quan gia iu tr thnh cng suy tim mt b cp v NT-proBNP: iu tr thnh cng NT-proBNP gim > 50%

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Bettencourt P et al. Am J Cardiol 2008; 101 (suppl):67A-71A

Suy tim tm trng v NT-proBNP

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Tm quan trng ca suy tim tm trng (STTTr)

- 40-50% bnh nhn suy tim
- STTTr : 1% dn chng tui 50, 10% dn chng tui 80 - Thng xy ra ph n cao tui c THA hoc T

- STTTr t vong thp hn suy tim tm thu; tuy nhin t vong STTTr gp 4 ln so vi qun th chung

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Gary. Heart & Lung 2008; 37: 405-416

Suy tim tm trng v NT-proBNP

- NT-proBNP: tin on t vong mnh hn PXTM*

- NT-proBNP > 600pg/mL: STTTr nng va n nng

- NT-proBNP < 140 pg/mL: gi tr tin on m > 90% ** - Phi hp NT-proBNP v siu m tim: rt hiu qu lng nh nguy c/ mi giai on suy tim

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* Paulus. EHJ 2007; 28: 2539-2553 ** Troughton. JACC 2009; 2 (2): 216-225

Diastolic Heart Failure and NT-proBNP

Paulus. EHJ. 2007; 28:2539-2550

- European Consensus on HF and Echocardiography and Association of European Society of Cardiology (ESC) recommends an echocardiogram if NT-proBNP > 220 pg/mL - NT-proBNP values correlate with early diastolic LV relaxation indices NT-proBNP ROC (0.83), LVEDP ROC (0.84), E/A ratio ROC (0.81) Combining NT-proBNP with E/E ratio increased the ROC to 95%
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NT-proBNP v Hi Chng ng Mch Vnh Cp

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C ch tng NT-proBNP/HCMVC
- Thiu mu cc b cp: hot ho BNP gene

- Tn s tim
- Vim - Cytokines

- Neurohormone

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NT-proBNP v Hi Chng MV cp
- Yu t tin on t vong trong bnh vin, ngay c khi hiu chnh theo tui, PXTM v troponin (1) - Troponin T , NT-proBNP : can thip hiu qu cao (2)

- Troponin T < 0.01 ng/L km NT-proBNP thp: nguy c cao khi iu tr can thip (3)

1. Valente. Int J Cardiol. 2009; 132(1):84-89 2. Drewniak. Kardiol Pol. 2008; 7:750-755 3. James. JACC. 2006; 48:1146

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Nghin cu GUSTO IV : NT-proBNP l yu t tin on nguy c NMCTKST chnh ln

James. Circ. 2003; 108:275-281

30

Gi tr ca NT-proBNP qua hai nghin cu s b HCMVC

Early

No early

Weber. JACC. 2008; 51(12):1188-1195 Levels > 474 pg/mL was associated with an increased mortality rate

revascularization

revascularization

Powerful predictor of mortality, NPV of 99%

NT-proBNP should be strongly considered in routine clinical practice when evaluating low risk ACS subjects
N = 2,614

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Yu t tin lng ca cc ch im sinh hc/ bnh nhn au ngc cp

Mc Cann. Am J Cardiol. 2009; 103:22-28

N = 664

1 year death or myocardial reinfraction

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Tip cn nhiu ch im sinh hc bnh nhn NMCTKSTC

Tello-Monoliu. J Intern Med. 2007; 262:651-658

N = 358

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Kt lun
- NT-proBNP l ch im sinh hc hu ch trong: Chn on sm suy tim Theo di iu tr suy tim nng Tm sot suy tim trn qun th dn chng - NT-proBNP kt hp Troponin T: gi tr tin lng HCMV cp

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