血液标志物和心脏彩超检查在慢性阻塞性肺疾病急性加重期相关性肺动脉高压的评估价值

The value of blood markers and echocardiography in the evaluation of COPD-related pulmonary hypertension

目的研究血液标志物和心脏彩超检查早期诊断慢性阻塞性肺疾病(COPD)合并肺动脉高压(PH)及进行病情评估的价值.方法分析2016年10月至2018年2月在南京医科大学附属无锡第二医院住院诊断为慢性阻塞性肺疾病急性发作期(AECOPD)的患者66例.记录患者的一般情况,进行相关血液检查,行心脏彩超检查,测量右心参数,研究各指标与肺动脉压力的关系.以肺动脉收缩压(PASP)≥36 mm Hg为PH的诊断标准,把患者分为肺动脉压力正常组(N组)和肺动脉高压组(PH组),比较两组临床资料的情况.行Logistic回归分析,探讨COPD相关性PH的危险因素.采用受试者工作特征曲线(ROC曲线)比较各危险因素单独或联合预测PH的效果.结果两组年龄、性别、体质量指数、病程、吸烟指数的比较差异无统计学意义(P>0.05).各临床资料中,红细胞分布宽度(RDW,%)、中性粒细胞/淋巴细胞比值(NLR)、N末端脑利钠肽前体(NT-proBNP,pg/mL)、糖类相关抗原125(CA125,U/mL)、右心室心肌做功指数(RMPI)在N组和PH组中分别为13.16±0.91 vs.13.99±2.01,4.01(2.33,6.10)vs.5.55(3.95,8.55),143.80(82.38,284.00)vs.834.00(359.05,1825.00),11.80(6.79,20.15)vs.18.53(12.30,46.05),0.37±0.08 vs.0.51±0.13,两组比较差异有统计学意义(P<0.05).其他血液指标及右心参数在两组中比较差异无统计学意义(P>0.05).以性别、年龄、RDW、NLR、NT-proBNP、CA125、RMPI为自变量,以COPD是否合并PH为因变量,进行Logistic回归分析,结果显示,RMPI增大(OR=1.004,95%CI l.001~1.007)、NT-proBNP升高(OR=1.181,95%CIl.068~1.305)为COPD患者并发PH的独立危险因素.ROC曲线分析显示,NT-proBNP对判断PH的最佳切点值为391.75 pg/mL,ROC曲线下面积(AUC)为0.809,敏感度、特异度分别为0.759和0.838.RMPI对判断PH的最佳切点值为0.485,ROC曲线AUC为0.797,敏感度、特异度分别为0.621和0.919.而NT-proBNP联合RMPI的ROC曲线AUC为0.932,敏感度、特异度分别为0.793和0.919.NT-proBNP和RMPI的AUC比较,Z值为0.151,差异无统计学意义(P>0.05);NT-proBNP联合RMPI的AUC分别与NT-proBNP、RMPI比较,Z值为2.449和2.928,差异均有统计学意义(P<0.05).结果说明,NT-proBNP联合RMPI预测PH的价值优于NT-proBNP和RMPI.结论RDW、NLR、NT-proBNP及CA125的增高可能预示PH.心脏彩超是COPD相关性PH患者评估肺动脉压力重要的无创评估手段,RMPI和NT-proBNP诊断PH较敏感,联合其他右心参数可评估患者的右心功能,RMPI联合NT-proBNP可增强对AECOPD相关性PH的预测能力.

Objective This article aimed at early diagnosis and assessment of chronic obstructive pulmonary disease(COPD)with pulmonary hypertension.Methods A total of 66 inpatients diagnosed with acute exacerbation of chronic obstructive pulmonary disease(AECOPD)were enrolled in the Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University from October 2016 to February 2018.The patient's general conditions were recorded and blood tests were performed.Echocardiography was performed to measure right heart parameters.The relationship between these indexes and pulmonary artery pressure was analyzed.The pulmonary arterial systolic pressure(PASP)was measured by echocardiography,and PASP M 36 mm Hg as the standard of pulmonary hypertension.Patients were divided into two groups according to whether there was pulmonary hypertension or not.The clinical data were compared between normal pulmonary arterial pressure group(N group)and pulmonary hypertension group(PH group).Logistic regression analysis was performed to investigate the risk factors of COPD-related pulmonary hypertension.Receiver operating characteristic curve(ROC curve)was used to compare the effect of each risk factor alone or in combination on the prediction of pulmonary hypertension.Results There was no significant differences in age,gender,body mass index,course of disease,smoking index between the two groups(P>0.05).In group N and group P,the results of red blood cell distribution width(RDW),neutrophil/lymphocyte ratio(NLR),N-terminal pro-brain natriuretic peptide(NT-proBNP),carbohydrate-associated antigen 125(CAI25),and right myocardial performance index(RMPI)were as follows:13.16±0.91 persent,13.99±2.01 persent;4.01(2.33,6.10),5.55(3.95,8.55);143.80(82.38,284.00)pg/mL,834.00(359.05,1825.00)pg/mL;11.80(6.79,20.15)U/mL,l8.53(12.30,46.05)U/mL;0.37±0.08,0.51±0.13.There were significant differences between the two groups in RDW,NLR,NT-proBNP,CA125 and RMPI(P<0.05).There were no significant differences in other blood parameters and right heart parameters between the two groups(P>0.05).Gender,age,RDW,NLR,NT-proBNP,CAI25 and RMPI were selected as independent variables,and whether there was pulmonary hypertension or not was used as the dependent variable.Logistic regression analysis was performed.Results showed that RMPI(OR=1.004,95%CZ 1.001-1.007)and NT-proBNP(OR=1.181,95%C/1.068-1.305)were found being independent risk factors for pulmonary hypertension in patients with COPD.The ROC curve analysis showed that the threshold value of NT-proBNP for determining pulmonary hypertension was 391.75 pg/ml,the area under the ROC curve(AUC)was 0.809,with sensitivity and specificity of 0.759 and 0.838,respectively.The cutoff value of RMPI for judging pulmonary hypertension was 0.485,AUC was 0.797,and the sensitivity and specificity were 0.621 and 0.919,respectively.AUC of NT-proBNP combined with RMPI was 0.932,and the sensitivity and specificity were 0.793 and 0.919,respectively.By comparing with AUC of NT-proBNP and RMPI,there were no significant differences for predicting pulmonary hypertension(Z=0.151,P>0.05).NT-proBNP combined with RMPI did have discriminating power for predicting pulmonary hypertension compared with AUC of NT-proBNP(Z=2.449,P<0.05)and RMPI(Z=2.928,P<0.05).The results showed that NT-proBNP combined with RMPI was superior to NT-proBNP and RMPI in predicting pulmonary hypertension.Conclusion Increases in RDW,NLR,NT-proBNP,and CAI25 may indicate pulmonary hypertension.Echocardiography is an important noninvasive assessment method for pulmonary arterial pressure in patients with COPD-associated pulmonary hypertension.RMPI and NT-proBNP are sensitive in diagnosing pulmonary hypertension and can be used to evaluate right heart function in combination with other right heart parameters.NT-proBNP combined with RMPI can increase predicting capability of AECOPD-associated pulmonary hypertension.