连续性肾脏替代治疗对急性心肌梗死后心功能不全患者脑钠肽、C反应蛋白及射血分数的影响

Clinical observation on B-type natriuretic peptide, C-reactive protein and left ventricle ejection fraction in acute myocardial infarction patients with acute heart failure after the continuous renal replacement therapy

目的探讨连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)对急性心肌梗死后心功能不全患者脑钠肽(B-type natriuretic peptide,BNP)、C反应蛋白(CRP)及左室射血分数(LVEF)的影响。方法本研究回顾性分析2008年10月～2011年10月在北京安贞医院住院的急性心肌梗死患者181例,其中82例患者在急诊介入治疗、开通罪犯血管后出现急性左心衰,在采用内科药物治疗后,50例患者因心功能无好转而行CRRT治疗。CRRT治疗中严密监测患者生命体征,记录治疗前后血气分析、电解质,测定CRRT后12h、24h、48h血清及超滤液BNP、C反应蛋白,CRRT前行超声心动图检查,记录左室射血分数(LVEF),于1周后再次测量LVEF的变化。结果 50例行CRRT患者中,2例因血小板进行性减少而中止CRRT,1例因收缩压低于90mmHg且有脏器灌注不足临床表现,末梢循环差,肢端皮肤湿冷,少尿,终止透析。47例患者生命体征平稳,心力衰竭症状明显减轻。CRRT治疗后血电解质较治疗前显著改善,BNP、CRP明显降低(P<0.05),LVEF有所改善(P<0.05),超滤液BNP水平极低,且差异无统计学意义(P>0.05)。3例患者于住院1～2月死于心源性猝死,其余44例,均在住院20～59天后出院,随访1年,心功能无恶化,无需长期透析。结论急性心肌梗死后难治性心力衰竭患者应用CRRT是一种相对安全有效的方法。不仅能在较短时间内稳定内环境、显著改善心力衰竭症状、体征、生化指标,并可显著降低患者BNP、CRP水平,改善LVEF,帮助患者渡过危险期,在一定程度上干预心肌梗死后心功能不全患者的预后。

Objective To summarize our experience in the treatment of acute myocardial infarction （AMI） patients complicated with acute heart failure using continuous renal replacement therapy （CRRT）. Method We retrospectively analyzed 181 AMI patients treated in our ward. Eighty-eight of these patients were attacked with acute heart failure after patent blood flow of culprit vessels by primary PTC, and then treated with medications. CRRT was initiated in 50 patients because of the persistence of heart failure. Patient’s vital signs and tolerance to CRRT were closely monitored. Blood gas, electrolytes, plasma B-type natriuretic peptide （BNP） and C-reactive protein （CRP） were measured before and after CRRT. Left ventricle ejection fraction （LVEF） was measured. Patients were followed up for one year. Data were analyzed with SPSS13.0 software. Results CRRT was terminated in 2 patients due to thrombocytopenia, and in one patient due to insufficient perfusion of vital organs. Vital signs and heart failure symptoms improved in 47 patients. After CRRT, electrolytes improved, BNP and CRP decreased （P0.05）, LVEF increased （P0.05）, and BNP in ultrafiltrate became very low （P0.05）. Three cases died of sudden cardiac death. Forty-four patients discharged after 20～59 days, and they were followed up for one year. No deterioration of heart dysfunction was found, and no long-term hemodialysis was required. Conclusions CRRT is a relatively safe and effective strategy for patients with acute heart failure after AMI. It can decrease serum BNP and CRPremarkably, and improve heart failure symptoms and LVEF. It also helps the patients survive the dangerous period. Our patients treated with CRRT experienced a gradual improvement of cardiac function, and dis-charged from the hospital in a stable condition without heart failure recurrence and long-term dialysis during the follow-up period.