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目的比较监测N末端脑钠肽前体(NT-Pro BNP)水平与临床经验指导β受体阻滞剂治疗危重冠心病心力衰竭患者的临床疗效。方法选取2009年1月至2013年4月沈阳军区总医院收治的危重冠心病心力衰竭患者337例,随机分为临床经验组201例、NT-Pro BNP组136例。所有患者入院后均行冠状动脉介入治疗(PCI)后,分别根据临床症状、患者血浆NTPro BNP变化幅度指导β受体阻滞剂治疗。比较两组患者β受体阻滞剂应用剂量、药物不良反应、随访期间主要不良心脏事件(MACE),包括心血管病死亡、心力衰竭恶化再住院、心绞痛或心肌梗死再次行靶血管重建。结果 (1)冠状动脉病变特点:两组患者病变范围,支架的平均直径、长度以及数目,差异无统计学意义(P>0.05)。(2)药物治疗情况:两组患者β受体阻滞剂的使用剂量比较,差异无统计学意义(P>0.05)。临床经验组利尿剂及醛固酮受体拮抗剂的应用较NT-Pro BNP组高,差异有统计学意义(P<0.01)。(3)住院期间药物不良反应:两组患者低血压及心动过缓的发生率比较,差异无统计学意义(P>0.05)。(4)MACE:两组患者心绞痛或心肌梗死再次行靶血管重建方面,差异有统计学意义(P<0.05)。NT-Pro BNP组心源性病死率预计值较临床经验组低,差异有统计学意义(P<0.01)。年龄<70岁,体质量指数>24.5 kg/m2具有更好的获益性(OR值0.377,95%可信区间0.175~0.813,P<0.05;OR值0.384,95%可信区间0.169~0.871,P<0.05)。临床经验组较NT-Pro BNP组更易发生MACE(OR值3.622,95%可信区间1.455~9.017,P<0.01)。结论监测NT-Pro BNP水平有利于指导β受体阻滞剂治疗危重冠心病心力衰竭,是危重冠心病心力衰竭治疗的重要评估指标及临床药物疗效评估的常用方法。
Objective To compare the clinical efficacy of monitoring N-terminal pro-brain natriuretic peptide (NT-Pro BNP) levels with clinical experience in guiding β-blockers in the treatment of critically ill patients with coronary heart disease and heart failure. Methods 337 cases of CHD patients with heart failure admitted to Shenyang Military Region General Hospital from January 2009 to April 2013 were randomly divided into clinical experience group (201 cases) and NT-Pro BNP group (136 cases). All patients were admitted to hospital after coronary intervention (PCI), respectively, according to clinical symptoms, patients with plasma NTPro BNP amplitude-guided changes in β-blocker therapy. The application doses of beta-blockers, adverse drug reactions, major adverse cardiac events (MACE) during follow-up, including cardiovascular death, worsening heart failure, readmission, angina pectoris, or myocardial infarction were compared again for target revascularization. Results (1) The characteristics of coronary lesions: The range of lesions, the average diameter, length and the number of scaffolds in the two groups were not statistically significant (P> 0.05). (2) drug treatment: two groups of patients with β-blockers dose comparison, the difference was not statistically significant (P> 0.05). Clinical experience group of diuretics and aldosterone receptor antagonist application of NT-Pro BNP group, the difference was statistically significant (P <0.01). (3) adverse drug reactions during hospitalization: the two groups of patients with hypotension and bradycardia compared the incidence, the difference was not statistically significant (P> 0.05). (4) MACE: angiography or myocardial infarction in two groups of target vascular reconstruction again, the difference was statistically significant (P <0.05). The predictive value of cardiac death in NT-Pro BNP group was lower than that in clinical experience group, with significant difference (P <0.01). Age <70 years, body mass index> 24.5 kg / m2 had better benefit (OR 0.377, 95% confidence interval 0.175-0.813, P <0.05; OR 0.384, 95% confidence interval 0.169-0.871 , P <0.05). The clinical experience group was more likely to develop MACE than the NT-Pro BNP group (OR 3.622, 95% confidence interval 1.455-9.017, P <0.01). Conclusion Monitoring the level of NT-Pro BNP is helpful to guide β-blocker in the treatment of heart failure due to severe coronary heart disease. It is an important evaluation index for the treatment of heart failure due to severe coronary heart disease and a common method to evaluate the clinical efficacy.