现有儿科心力衰竭诊断标准及脑利钠肽对先天性心脏病合并心力衰竭的诊断价值

Diagnostic value of the currently used criteria and brain natriuretic peptide for diagnosing congestive heart failure in children with congenital heart disease

目的拟评估现有儿科心力衰竭(简称心衰)诊断标准及血浆脑利钠肽(BNP)、无生物活性的氨基末端BNP(NT-proBNP)对先天性心脏病(简称先心病)合并心衰的诊断价值.并通过多因素分析探讨最有价值的诊断指标。方法以先心病患儿118例为研究对象,分别应用改良Ross标准、青岛标准、NYUPHFI、Ross标准以及血浆BNP、NT-proBNP对上述病例进行诊断。以改良Ross评分≥3分作为参考标准,评估各标准及血浆BNP、NT-proBNP的诊断价值。应用logistic回归方法分析各因素对心衰的诊断价值。结果(1)各临床标准诊断心衰的价值:①青岛标准诊断的敏感度为47.9%,特异度为100%,准确率为57.6%。②Ross评分诊断心衰的ROC曲线下面积为0.985,敏感度为88%,特异度为100%。③NYUPHFI评分>2分作为诊断界点时敏感度高而特异度较低,敏感度为100%,特异度为4.5%。(2)血浆BNP及NT-proBNP与改良Ross呈正相关,随着心功能分级严重程度的增加而增加,BNP诊断心衰的ROC曲线下面积为0.880,按照ROC曲线选取的诊断界值为≥349pg/ml。NT-proBNP诊断心衰的ROC曲线下面积为0.981,按照ROC曲线选取的诊断界值为≥499fmol/ml。(3)多因素分析提示,NT-proBNP、呼吸急促、心率增快、呼吸增快、生长发育落后对于心衰的诊断有价值。(4)血浆NT-proBNP与临床标准并联或串联可提高准确率。结论现有临床标准对于先心病合并心衰均具有诊断价值,但青岛标准敏感度低,Ross标准适用范围窄,NYUPHFI>2分特异度低,存在一定的局限性。血浆BNP及NT-proBNP对于小儿先心病导致的心衰具有诊断价值,NT-proBNP是心衰诊断的独立预测因素。

Objective To improve the accuracy of diagnosis of heart failure （HF） has been the focus of research for a long time. The diagnosis for HF with congenital heart disease, however, is more difficult. The aim of the study was to evaluate the diagnostic criteria for HF in children and examine the value of plasma brain natriuretic peptide （BNP） and NT-proBNP for diagnosing HF in podiatric patients with congenital heart disease, and to look for the most valuable index for the diagnosis according to the multifactor analysis. Methods Totally 118 children with congenital heart disease were enrolled. They were diagnosed using modified Ross score, Qingdao criteria, NYU PHFI, and plasma BNP and NT-proBNP. According to modified Ross score as the referent criteria, other diagnostic criteria and plasma BNP and NT-proBNP were studied. The sensitivity, specificity and area of the ROC curve were examined. Logistic regression analysis was used to select the valuable index for diagnosing HF. Results （ 1 ） The value of each clinical criteria ： ① The sensitivity of Qingdao criteria for diagnosing HF was 47.9%. The specificity was 100% and the accuracy was 57. 6%. ② There were 52 patients younger than six months in whom 27 （51.9%） were breast fed. Only 25 children were measured with Ross score. The Ross score was positively correlated with the modified Ross score （r = 0. 948）. The area under the ROC curve of Ross score diagnosing HF was 0. 985, and the sensitivity was 88%, while the specificity was 100%. ③ NYU PHFI score was positively correlated with the modified Ross score. The area under the ROC curve of the NYU PHFI diagnosing HF was 0. 964, and the sum of sensitivity and specificity was favorite when ≥8 was set as the cut-off point. If 〉 2 was set as cut-off point, it had a high sensitivity but a low specificity. The sensitivity of NYU PHFI was 100% 〉 was set 2 as cut-point for diagnosing HF, but the specificity was 4. 5%. （2）Plasma BNP and NT-proBNP were positively correlated with the modified Ross score, and increased with the severity of congestive HF. The area under the ROC curve of BNP was 0. 880, and the cut-off line was ≥ 349 pg/ml. The area under the ROC curve of NT-proBNP was 0. 981, and the cut-off line was ≥499 fmol/ml. （ 3 ） Logistic regression analysis showed that in multifactor analysis, only plasma concentration of NT-proBNP, dyspnea, tachycardia, tachypnea, failure to thrive were the independent predictors for diagnosing HF. （4）Plasma concentration of NT-proBNP incorporated with clinical criteria would improve its accuracy. Conclusion All the clinical criteria commonly used were valuable for diagnosing HF in children with congenital heart disease, but each has its own limits, such as the low sensitivity of Qingdao, the low adaptation of Ross score because of the high breast-feeding rate in our country and the low specificity of NYU PHFI when 〉 2 was set as the cut-off point. Plasma concentrations of BNP and NT-proBNP were valuable for diagnosing HF in children with congenital heart disease, and NT-proBNP was the independent predictor for HF.