BNP ve NT-BNP'nin acil serviste kalp yetersizligi tanisinda uygun esik degerleri/Cut-off values of BNP and NT-BNP for diagnosis of heart failure in emergency service.Sayin Editor,Nefes darligi sikayetiyle acil servise basvuran hastalarda kalp yetersizligi (KY) tanisinin her zaman kolay konulamadigi bilinmektedir. Acil servislerde bu hastalari sadece belirti ve bulgular ile degerlendirmek KY tanisini koymak icin kismen yararli olmaktadir (1). Son yillarda acil serviste hizli ve dogru bir sekilde KY tanisinin konulabilmesi icin B tipi natriuretik hormon (BNP BNP B-type natriuretic peptide, brain natriuretic peptide Physiology A 32-residue peptide hormone produced predominantly in the ventricles, secreted in response to fluid overload–eg, CHF. See Atrial natriuretic peptide. ) ve N terminal B tipi natriuretik hormon (NT-BNP) kullani-mi gittikce artmaktadir. Ventrikul duvar stresinin artisina bir yanit olarak ventrikul kasi tarafindan kisa surede sentezlenen 32 aminoasitlik BNP ve 76 aminoasitlik NT-BNP, 108 aminoasitlik oncu molekulun 2 parcaya ayrilmasiyla ortaya cikmaktadir (2). Biyolojik etkileri hala tam olarak bilinmeyen NT-BNP'nin yari omru kardiyak bir hormon olan BNP'den daha uzundur (3). Son yillarda acil serviste KY tanisi icin uygun bir belirtec olarak kullanilan bu hormonlar ile ilgili calismalarda oncelikle ozgullugu ve duyarliligi yuksek uygun bir esik deger arastirilmaktadir. Bu amacla yayinlanan calismalar gozden gecirildiginde her iki hormonun farkli birer sinir degere sahip oldugu gorulmustur. Acil servise dispne ile basvuran hastalarda KY tanisinin degerlendirmesi icin BNP'nin yeri hakkinda bir cok calisma bulunmakla beraber ozellikle yapilmis olan uc tane cok merkezli buyuk calismada yaklasik 4000 hasta degerlendirilmis ve BNP icin en iyi esik degerinin 100 pg/ml (duyarligi %90, ozgullugu %73-76) oldugu gorulmustur (4-6). Ayni amacla NT-BNP kullanimi ile yapi lan calismalar nispeten daha kucuk hasta gruplarina sahiptir. Acil servise dispne ile basvuran 100 hasta ile yapilan bir calismada NT-BNP'nin esik degeri 973 pg/ml (duyarligi %91, ozgullugu %93) olarak bulunurken, 599 hasta ile yapilan bir baska calismada, esik degerinin yasa gore farklilik gosterdigi, NT-BNP degerinin 50 yas altinda 450 pg/ml ve 50 yas ustu ise > 900 pg/ml oldu gu gorulmustur (7,8). Yine bu calismada 300 pg/ml altindaki NT-BNP degerlerinde negatif prediktif degerinin %99 oldugu saptanmistir (8). Literaturde bu iki hormonun acil serviste kullaniminin karsilastirildigi calismalar da bulunmaktadir. Lainchbury ve ark. (9) yaptiklari 205 hastalik bir calismada, her hasta icin NT-BNP ve toplam 4 farkli yontem ile BNP degerleri bakilmis, bunlardan Biosite ile incelenen BNP degerinin en iyi esik degeri verdigi gorulmustur. Bu calismada BNP kullanildiginda duyarliginin, NTBNP kullanildiginda ise ozgullugunun arttigi saptanmistir. Yine BNP ve NT-BNP degerlerinin karsilastirildigi benzer bir baska calismada ise KY belirlenmesinde kullanilan her iki yontemin de benzer miktarda yararli oldugu gorulmustur (10). Hastalarda KY olmadigi halde BNP duzeyi (100-500 pg/ml) yuksek bulunan durumlarin incelendigi bir calismada; ileri yas, atriyal fibrilasyon, kardiyomegali, hemoglobin hemoglobin (hē`məglō'bĭn), respiratory protein found in the red blood cells (erythrocytes) of all vertebrates and some invertebrates. konsantrasyonunun ve vucut kitle indeksinin (VKI VKI Variable Keyframe Interval (DivX encoding algorithm) VKI Virtual Keyframe Interval ) dusuk olmasinin serum BNP duzeyini bagimsiz olarak artirdigi gorulmustur (11). Yasla beraber BNP ve NT-BNP duzeyinin arttigi bilindiginden, ileri yaslar icin uygun esik degerinin arastirildigi calismalardan birinde, acil servise dispne ile basvuran 65 yasinin ustundeki 308 hasta degerlendirilmis ve BNP icin uygun esik degeri 250 pg/ml (duyarligi %78, ozgullugu %90) bulunmustur (12). Altmis bes yasinin ustundeki 202 hastanin degerlendirildigi diger calismada ise BNP icin esik degeri 250 pg/ml (duyarligi %73, ozgullugu %91) ve NTBNP icin 1500 pg/ml (duyarligi %75, ozgullugu %76) oldugu gorulmustur (13). Ozellikle obez hastalarda VKI bagli bir sekilde BNP ve NTBNP degerlerinin dustugu, bu hastalarda kilo Thousand (10 to the 3rd power). Abbreviated "K." For technical specifications, it refers to the precise value 1,024 since computer specifications are based on binary numbers. For example, 64K means 65,536 bytes when referring to memory or storage (64x1024), but a 64K salary means $64,000. arttikca esik degerlerinin de bir miktar azaldigi bilinmektedir (14). Yine son yillarda yapilan bir calismada acil servise dispne ile basvuran 1586 hastanin BNP degerleri incelenmis ve oykusunde DM olmasi nin BNP uzerinde degisiklik yaratmadigi gorulmustur (15). Bobrek fonksiyon bozuklugunun da BNP ve NT-BNP uzerinde degisiklik yaptigi bilinmektedir. Bu amacla yapilan bir calismada glomeruler filtrasyon hizi (GFR GFR - Grim File Reaper ) dustukce, BNP ve NTBNP duzeylerinin arttigi gorulmustur (16). Bu iki hormon da bobrekten atilmazken serum duzeylerinde gorulen bu artis, vucut volumunun artmasina bagli olarak yukselen ventrikul geriliminden kaynaklanmaktadir. Yine bu calismada GFR<60 olan ve acil servise dispne sikayetiyle gelen hastalarda uygun esik degerinin BNP icin 480 pg/ml ve NT-BNP icin 1980 pg/ml oldugu gorulmustur. B tipi natriuretik hormon ve NT-BNP'nin acil serviste kullani minin yararlari bilinmekle beraber kesin tani konulurken, klinik degerlendirilmelerin de eklenmesinin ek bir katki sagladigi bilinmektedir. Bu konuda yapilan cok merkezli bir calismada acil servise dispne sikayeti ile basvuran ve ozellikle BNP degeri dusuk saptanan hastalarda akciger grafisi bulgularinin KY tani sini koymada yardimci oldugu gorulmustur (6). Yine Januzzi ve ark. (8) 2005 yilinda yaptiklari bir baska calismada acil servise dispne ile basvuran 599 hastanin akut KY tanisini koymada NT-BNP yuksekliginin klinik taniya gore belirgin derecede guvenilir oldugu, ayrica NT-BNP yuksekligi ve klinik tani beraberli ginin, yalniz NT-BNP ve yalniz klinik tanidan daha ustun oldugu gorulmustur. Maliyet acisindan yapilmis olan prospektif, randomize ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. , kontrollu bir calismada acil servise dispne ile basvuran 452 hasta 2 gruba ayrilarak BNP ile standart yontemlerin KY tanisi degerlendirilmesindeki yeri arastirilmis ve acilde BNP kullaniminin hastalarin taburcu suresini ve toplam maliyetini azalttigi saptanmi stir (17). Sonuc olarak acil serviste kalp yetersizligi tanisinin degerlendirilmesinde BNP icin ortalama 100 pg/ml ve NT-BNP icin ortalama 900 pg/ml esik degerleri kullanilmali, ileri yas, vucut kitle indeksi, anemi ve bobrek fonksiyon bozuklugu gibi BNP degerlerini artiran veya azaltan faktorler goz onune alinarak, kesin tani radyografik ve klinik bulgularla beraber konulmalidir. Kaynaklar (1.) Mueller C, Frana B, Rodriguez D, Laule-Kilian K, Perruchoud AP. Emergency diagnosis of congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. : impact of signs and symptoms. Can J Cardiol 2005; 21: 921-4. (2.) Maeda K, Tsutamoto T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide Brain natriuretic peptide (also known as B-type natriuretic peptide or "GC-B") is a 32 amino acid polypeptide secreted by the ventricles of the heart in response to excessive stretching of myocytes (heart muscles cells) in the ventricles. as a biochemical bi·o·chem·is·try n. 1. The study of the chemical substances and vital processes occurring in living organisms; biological chemistry; physiological chemistry. 2. marker of high left ventricular ven·tric·u·lar adj. Of or relating to a ventricle or ventriculus. ventricular pertaining to a ventricle. ventricular assist device end-diastolic pressure end-diastolic pressure Cardiac pacing Fluid pressure in heart chamber at the end of diastole just before systole in patients with symptomatic left ventricular dysfunction ventricular dysfunction, n an abnormality in contraction and wall motion within the ventricles. . Am Heart J 1998; 135: 825-32. (3.) Sudoh T, Maekawa K, Kojima M, Minamino N, Kangawa K, Matsuo H. Cloning cloning: see clone. To make a product that functions like another. See clone. See also cloning software. and sequence analysis of cDNA encoding See encode. a precursor for human brain natriuretic peptide. Biochem Biophys Res Commun 1989; 159: 1427-34. (4.) McCullough PA, Nowak RM, McCord J, Hollander JE, Herrmann HC, Steg PG, et al. B-type natriuretic peptide B-type natriuretic peptide See BNP. and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study. Circulation 2002; 106: 416-22. (5.) Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al. Breathing Not Properly Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347: 161-7. (6.) Knudsen CW, Omland T, Clopton P, Westheim A, Abraham WT, Storrow AB, et al. Diagnostic value of B-Type natriuretic peptide and chest radiographic radiographic (rā´dēōgraf´ik), adj relating to the process of radiography, the finished product, or its use. findings in patients with acute dyspnea dyspnea /dysp·nea/ (disp-ne´ah) labored or difficult breathing.dyspne´ic paroxysmal nocturnal dyspnea . Am J Med 2004; 116: 363-8. (7.) Bayes-Genis A, Santalo-Bel M, Zapico-Muniz E, Lopez L, Cotes C, Bellido J, et al. N-terminal probrain natriuretic peptide Natriuretic peptide refers to a peptide which induces natriuresis (the discharge of sodium through urine). Types include:
dyspnea. and ventricular dysfunction. Eur J Heart Fail 2004; 6: 301-8. (8.) Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, et al. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005; 95: 948-54. (9.) Lainchbury JG, Campbell E, Frampton CM, Yandle TG, Nicholls MG, Richards AM. Brain natriuretic peptide and N-terminal brain natriuretic peptide in the diagnosis of heart failure in patients with acute shortness of breath Shortness of Breath Definition Shortness of breath, or dyspnea, is a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity. . J Am Coll Cardiol 2003; 42: 728-35. (10.) Mueller T, Gegenhuber A, Poelz W, Haltmayer M. Diagnostic accuracy of B type natriuretic peptide and amino terminal proBNP in the emergency diagnosis of heart failure. Heart 2005; 91: 606-12. (11.) Knudsen CW, Clopton P, Westheim A, Klemsdal TO, Wu AH, Duc P, et al. Predictors of elevated B-type natriuretic peptide concentrations in dyspneic dysp·ne·a n. Difficulty in breathing, often associated with lung or heart disease and resulting in shortness of breath. Also called air hunger. patients without heart failure: an analysis from the breathing not properly multinational study. Ann Emerg Med 2005; 45: 573-80. (12.) Ray P, Arthaud M, Lefort Y, Birolleau S, Beigelman C, Riou B; EPIDASA Study Group. Usefulness of B-type natriuretic peptide in elderly patients with acute dyspnea. Intensive Care Med 2004; 30: 2230-6. (13.) Ray P, Arthaud M, Birolleau S, Isnard R, Lefort Y, Boddaert J, et al. Comparison of brain natriuretic peptide and probrain natriuretic peptide in the diagnosis of cardiogenic cardiogenic /car·dio·gen·ic/ (-jen´ik) 1. originating in the heart; caused by normal or abnormal function of the heart. 2. pertaining to cardiogenesis. car·di·o·gen·ic adj. pulmonary edema Pulmonary Edema Definition Pulmonary edema is a condition in which fluid accumulates in the lungs, usually because the heart's left ventricle does not pump adequately. in patients aged 65 and older. J Am Geriatr Soc 2005; 53: 643-8. (14.) Mehra MR, Uber PA, Park MH, Scott RL, Ventura HO, Harris BC, et al. Obesity and suppressed B-type natriuretic peptide levels in heart failure. J Am Coll Cardiol 2004; 43: 1590-5. (15.) Wu AH, Omland T, Duc P, McCord J, Nowak RM, Hollander JE, et al. The effect of diabetes on B-type natriuretic peptide concentrations in patients with acute dyspnea: an analysis from the Breathing Not Properly Multinational Study. Diabetes Care 2004; 27: 2398-404. (16.) Chenevier-Gobeaux C, Claessens YE, Voyer S, Desmoulins D, Ekindjian OG. Insuence of renal function In medicine (nephrology) renal function is an indication of the state of the kidney and its role in physiology. Indirect markers Most doctors use the plasma concentrations of creatinine, urea, and electrolytes to determine renal function. on N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients admitted for dyspnoea in the Emergency Department: Comparison with brain natriuretic peptide (BNP). Clin Chim Acta 2005; 361: 167-75. (17.) Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004; 350: 647-54. Yazis sma Adresi: Dr. Onur Akpinar, Golcuk Asker Hastanesi, Kardiyoloji Bolumu, Golcuk, Kocaeli, Turkiye Gsm: 0505 668 19 74 E-mail: onurakpinar@yahoo.com Onur Akpinar, Mehmet Kanadasi*, T. Fikret Ilgenli Golcuk Asker Hastanesi, Kardiyoloji Bolumu, Golcuk, Kocaeli, Turkiye * Cukurova Universitesi Tip Fakultesi, Kardiyoloji Bolumu, Adana, Turkiye |
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion