基于四川南部地区人群血清NT-proBNP、D-二聚体对心源性脑栓塞的诊断效能

Diagnostic efficacy of serum NT-proBNP and D-dimer for cardiogenic cerebral embolism based on population in southern Sichuan

目的基于四川南部地区人群探讨血清N末端B型脑钠肽前体(NT-proBNP)、D-二聚体对心源性脑栓塞(CE)的诊断效能。方法选取2019年6月至2021年4月于西南医科大学附属医院收治的首次发生急性脑梗死(ACI)患者313例及同期单纯房颤(AF)患者34例、健康体检者30例的临床资料,依据急性卒中治疗低分子肝素试验(TOAST)分型将ACI患者分为四个亚组[大动脉粥样硬化型(LAA)、CE、小动脉闭塞型(SAO)、不确定分类型(UT)],比较各组间临床资料的差异,同时比较CE组与单纯AF组、健康组血清NT-proBNP、D-二聚体的差异;采用二元logistic回归分析CE的危险因素,运用受试者工作特征(ROC)曲线评价血清NT-proBNP、D-二聚体对CE的诊断效能。结果ACI各亚组间患者高血压患病率、糖尿病患病率、入院时SBP及DBP、凝血酶原时间(PT)、国际标准化比值(INR)、纤维蛋白原(FIB)、D-二聚体、纤维蛋白原降解产物(FDP)、入院美国国立卫生研究院卒中量表(NIHSS)评分、NT-proBNP、AF患病率差异均有统计学意义(均P<0.05);LAA组与CE组患者的PT、入院NIHSS评分差异均无统计学意义(均P>0.05),CE组患者的D-二聚体、NT-proBNP及AF患病率明显高于其他三组(均P<0.05)。CE组患者的D-二聚体、NT-proBNP、FDP、SBP水平明显高于单纯AF组及健康组(均P<0.05)。二元logistic回归分析表明,D-二聚体及NT-proBNP是CE发生的独立危险因素(均P<0.05)。血清D-二聚体最佳截断值为1.015 mg/L时,ROC曲线下面积(AUC)为0.896(95%CI:0.856~0.935,P<0.01),灵敏度为0.878,特异度为0.833,阳性预测值为0.705,阴性预测值为0.953;血清NT-proBNP最佳截断值为657.145 ng/L时,AUC为0.987(95%CI:0.977~0.998,P<0.01),灵敏度为0.959,特异度为0.963,阳性预测值为0.922,阴性预测值为0.981;血清D-二聚体、NT-proBNP联合检测诊断CE的准确度更高,AUC为0.988(95%CI:0.978~0.998,P<0.01),灵敏度为0.960,特异度为0.977,阳性预测值为0.950,阴性预测值为0.982。结论CE患者血清NT-proBNP及D-二聚体水平明显升高;NT-proBNP及D-二聚体是CE发生的重要预测因子,对CE有较高诊断效能,两者联合诊断特异度更高。

Objective To investigate the diagnostic efficacy of serum N-terminal B-type brain natriuretic peptide(NT-proBNP)and D-dimer for cardiogenic cerebral embolism(CE)based on population in southern Sichuan.Methods We selected the clinical data of 313 patients with acute cerebral infarction(ACI)for the first time,34 patients with simple atrial fibrillation(AF)and 30 healthy people who were admitted to the Affiliated Hospital of Southwest Medical University from June 2019 to April 2021.The patients with ACI were divided into four subgroups according to the Trial of Org 10172 in Acute Stroke Treatment(TOAST)typing:large artery atherosclerosis(LAA),CE,small artery occlusion(SAO),and indeterminate subtype(UT).The differences in clinical data in the groups were compared.At the same time,the differences of NT-proBNP and D-dimer in serum in CE group,AF group and healthy group were compared;The risk factors of CE were analyzed by binary logistic regression,and the diagnostic efficacy of serum NT-proBNP and D-dimer for CE was evaluated by receiver operating characteristic(ROC)curve.Results The prevalence of hypertension,diabetes,systolic blood pressure(SBP)and diastolic blood pressure(DBP)at admission,prothrombin time(PT),international normalized ratio(INR),fibrinogen(FIB),D-dimer,fibrinogen degradation products(FDP),National Institutes of Health Stroke Scale(NIHSS)score at admission,NT-proBNP and AF rate were significantly different among ACI subgroups(all P<0.05);There was no significant difference in PT and NIHSS score at admission between LAA group and CE group(all P>0.05).The prevalence of D-dimer,NT-proBNP and AF rate in CE group was significantly higher than those in other three groups(all P<0.05).The D-dimer,NT-proBNP,FDP and SBP level in CE group were significantly higher than those in AF group and healthy group(all P<0.05).Binary logistic regression analysis showed that D-dimer and NT-proBNP were independent risk factors for CE(both P<0.05).When the optimal cut-off value of serum D-dimer was 1.015 mg/L,the area under the ROC curve(AUC)was 0.896(95%CI:0.856-0.935,P<0.01);the sensitivity and specificity were 0.878 and 0.833,respectively;the positive predictive value and the negative predictive value were 0.705 and 0.953,respectively.When the best cut-off value of serum NT-proBNP was 657.145 ng/L,the AUC was 0.987(95%CI:0.977-0.998,P<0.01);the sensitivity and specificity were 0.959 and 0.963,respectively;the positive predictive value and the negative predictive value were 0.922 and 0.981,respectively.The accuracy of the combined detection of serum D-dimer and NT-proBNP in the diagnosis of CE was higher,and the AUC was 0.988(95%CI:0.978-0.998,P<0.01),sensitivity of 0.960,specificity of 0.977,positive predictive value of 0.950,negative predictive value of 0.982.Conclusions The serum levels of NT-proBNP and D-dimer in CE patients increased significantly;NT-proBNP and D-dimer are important predictors of CE and have higher diagnostic efficacy for CE.The combination of them has a higher specificity for diagnosis.