急性前壁心肌梗死伴心力衰竭患者急诊经皮冠状动脉介入治疗围手术期应用重组人B型钠尿肽的心肾保护效应

The use of recombinant human B-type natriuretic peptide for the protection of cardiac and renal functions in heart failure patients with acute anterior myocardial infarction in peri-operative period of primary percutaneous coronary intervention

目的 评价急性前壁心肌梗死伴心力衰竭（AAMI-HF）患者急诊经皮冠状动脉介入治疗（pPCI）围手术期应用重组人B型钠尿肽（rhBNP）的心肾保护作用.方法 选择发病24 h内AAMI-HF患者126例,按随机数字表法分为rhBNP组（62例）和对照组（64例）,均行PPCI治疗,并在常规药物治疗的基础上,分别给予持续静脉滴注rhBNP或硝酸甘油至术后24 h,监测治疗前后心率（HR）、收缩压（SBP）、B型钠尿肽（BNP）、肾小球滤过率（eGFR）、心脏功能改变,观察30 d内主要心脏不良事件（MACE）的发生率.结果 pPCI后rhBNP组HR显著下降,对照组降低不明显;两组SBP均显著下降.与给药前比较,两组pPCI后各时间点血浆BNP水平及左室射血分数（LVEF）、左室舒张期末内径（LVEDD）均明显改善,且rhBNP组优于对照组[BNP（ng/L）pPCI后30 h：303.5±128.4比354.0±133.6,pPCI后14 d：157.8±78.6比201.1±91.7;LVEF pPCI后1 d：0.420±0.052比0.378±0.055,pPCI后14 d：0.444±0.050比0.393±0.055,pPCI后30 d：0.469±0.053比0.413±0.052;LVEDD（mm）pPCI后1 d：53.5±4.4比57.6±4.4,pPCI后14 d：49.6±5.1比53.4±4.6,pPCI后30 d：46.5±4.4比50.2±4.8,P＜0.05或P＜0.01].两组pPCI后1 deGFR均出现下降,rhBNP组pPCI后3 d回升至用药前水平,两组pPCI后7 d、14 d eGFR水平显著高于用药前,但两组间无差异.rhBNP组造影剂肾病发生率较对照组有降低趋势[19.4%（12/62）比29.7%（19/64）,P=0.178].pPCI后7 d内rhBNP组室性心律失常发生率显著低于对照组[48.4%（30/62）比75.0%（48/64）,P＜0.01].30 d内rhBNP组MACE发生率显著低于对照组[12.9%（8/62）比26.6%（17/64）,P＜0.05].结论 rhBNP可有效改善AAMI-HF-pPCI围手术期患者的心脏功能,降低30 d内MACE发生率;减少造影剂肾病的发生趋势.

Objective To evaluate the protective effect of recombinant human B-type natriuretic peptide （rhBNP） on cardiac and renal functions in heart failure （HF） patients as a result of acute anterior myocardial infarction （AAMI） in peri-operative period of primary percutaneous coronary intervention （pPCI）.Methods One hundred and twenty-six patients with AAMI-HF were enrolled into this study.All patients undertaken pPCI were randomly assigned to the rhBNP group （n=62） or the control group（n=64）.rhBNP or nitroglycerin was intravenously administered on the basis of conventional treatment from first day of admission to 24 hours after pPCI in both groups.Heart rate （HR）, systolic blood pressure （SBP）, B-type natriuretic peptide （BNP）, estimated lomerular filtration rate （eGFR） and heart function were observed.All patients were followed up for 30 days for the observation of main adverse cardiac events （MACE）.Results The HR was significantly decreased compared with that at admission in rhBNP group, but such condition was not found in the control group.The SBP was reduced obviously in both groups.The plasma level of BNP, left ventricular ejection fraction （LVEF） and left ventricular end-diastolic dimension （LVEDD） were improved significantly at different time points compared with those before administration in both groups.The improvement of above parameters in rhBNP group was more significant than that in the control group[BNP （ng/L） 30 hours after pPCI： 303.5±128.4 vs.354.0± 133.6, 14 days after pPCI：157.8±78.6 vs.201.1±91.7; LVEF 1dayafter pPCI： 0.420±0.052 vs.0.378±0.055, 14 days after pPCI：0.444±0.050 vs.0.393±0.055, 30 days after pPCI： 0.469±0.053 vs.0.413±0.052; LVEDD （mm） 1 day after pPCI： 53.5±4.4 vs.57.6±4.4, 14 days after pPCI： 49.6±5.1 vs.53.4±4.6, 30 days after pPCI： 46.5±4.4 vs.50.2±4.8, P＜0.05 or P＜0.01].The eGFR was reduced obviously 1 day after pPCI than that at admission in both groups, and eGFR recovered to baseline 3 days after pPCI.The level of eGFR was significantly increased 7 days and 14 days after pPCI than that at admission, but there was no difference between rhBNP group and control group.The incidence of contrast-induced nephropathy showed a lowering tendency in the rhBNP group than that in the control group[19.4% （12/62） vs.29.7% （19/64）,P=0.178].The incidence of ventricular arrhythmias was obviously lowered 7 days after pPCI in the rhBNP group than that in the control group[48.4% （30/62） vs.75.0% （48/64）, P＜0.01].The rate of MACE was lower in rhBNP group than that in control group in 30 days[12.9% （8/62） vs.26.6% （17/64）, P＜0.05].Conclusion Administration of rhBNP can effectively improve the heart function in AAMI-HF patients undergoing pPCI, and it lowered the incidence of MACE in 30 days, without influence on renal function, and it can reduce the incidence of contrast-induced nephropathy.