Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
권호 표지

The Role of Plasma B-type Natriuretic Peptide Measurements in the Differential Diagnosis of Acute Dyspnea

급성호흡곤란의 감별진단에서 혈장 B-type Natriuretic Peptide의 역할

  • Moon, Ji Yong (Department of Internal Medicine, Hanyang University) ;
  • Bae, Joong Ho (Department of Internal Medicine, Hanyang University) ;
  • Kim, Tae Hyung (Department of Internal Medicine, Hanyang University) ;
  • Sohn, Jang Won (Department of Internal Medicine, Hanyang University) ;
  • Yoon, Ho Joo (Department of Internal Medicine, Hanyang University) ;
  • Shin, Dong Ho (Department of Internal Medicine, Hanyang University) ;
  • Park, Sung Soo (Department of Internal Medicine, Hanyang University)
  • 문지용 (한양대학교 의과대학 호흡기내과학교실) ;
  • 배중호 (한양대학교 의과대학 호흡기내과학교실) ;
  • 김태형 (한양대학교 의과대학 호흡기내과학교실) ;
  • 손장원 (한양대학교 의과대학 호흡기내과학교실) ;
  • 윤호주 (한양대학교 의과대학 호흡기내과학교실) ;
  • 신동호 (한양대학교 의과대학 호흡기내과학교실) ;
  • 박성수 (한양대학교 의과대학 호흡기내과학교실)
  • Received : 2005.02.14
  • Accepted : 2005.10.04
  • Published : 2005.12.30
Download PDF
⟨ Previous Next ⟩

Abstract

Background : The B-type natriuretic peptide (BNP) is a cardiac neurohormone that is specifically secreted from the ventricles in response to volume expansion and a pressure overload. Differentiating congestive heart failure from the pulmonary causes of dyspnea is very important for patients presenting with acute dyspnea. Methods : A retrospective study was carried out on 261 patients who were admitted to the emergency department of Hanyang University Hospital due to acute dyspnea from March to July 2004. The serum BNP levels of the patients were measured using the ELISA method. Results : The BNP levels were 382, 111-1140 pg/ml (median, interquartile range) in the heart failure group (n=119) and 29, 7-81 pg/ml in the non-heart failure group (n=142). The BNP levels according to the subgroups of heart failure were 820, 354-1620 pg/ml, 1650, 239-1990 pg/ml, and 378, 106-1120 pg/ml for the chronic obstructive pulmonary disease (COPD) with combined left heart failure (n=5), cor pulmonale (n=3), and left heart failure groups (n=111), respectively. The BNP levels according to the subgroups of non-heart failure were 39, 21-101 pg/ml, 59, 10-129 pg/ml, and 15, 6-47 pg/ml for the COPD (n=20), other pulmonary diseases (n=56), and other causes groups (n=66), respectively. The BNP levels were significantly different according to the underlying etiology (p<0.001), and were significantly higher in the COPD patients with left heart failure than in those without (p=0.002). When the patients with no cardiovascular risk factor such as diabetes mellitus, hypertension, smoking or renal failure were analyzed, the BNP levels were also significantly higher in the patients with heart failure than in those without(p<0.001). When 133 pg/ml was designated as the BNP cut-off level the sensitivity for predicting heart failure was 73 percent and the specificity was 87 percent. Conclusion : BNP measurements are useful for determining the presence of heart failure in the patients presenting with acute dyspnea. The possibility of heart failure must be seriously considered in patients with high BNP levels even when they have a pre-existing pulmonary disease such as COPD or no risk factors for heart failure.

배 경 : 급성호흡곤란으로 응급실에 내원한 환자에서 그 원인질환을 감별하는 것은 효율적인 치료에 매우 중요하나 임상양상만으로 감별진단하기는 어려운 경우가 많다. 최근에 쉽게 측정하고 확인이 가능한 생화학적 표지자인 B-type natriuretic peptide에 대해 연구가 이루어지고 있다. 방 법 : 2004년 3월부터 7월까지 한양대학교병원 응급실로 급성호흡곤란을 주소로 내원한 261명의 환자를 대상으로 혈청 BNP를 측정하였고 임상적 소견을 후향적으로 분석하였다. 결 과 : 대상환자를 증상의 원인에 따라 크게 심부전군(n=119, 382, 113-1230 pg/ml)과 비심부전군(n=142, 29, 7-81 pg/ml)으로 나누었고(사람수, 중위수, 백분위수 25-백분위수 75), 하위집단으로 심부전군은 COPD와 좌심부전이 동반된 군(n=5, 820, 354-1620 pg/ml), 폐성심군(n=3, 1650, 239-1990 pg/ml), 좌심부전군(n=111, 378, 106-1120 pg/ml)으로, 비심부전군은 COPD군(n=20, 39, 21-101 pg/ml), 기타 호흡기질환군(n=56, 59, 10-129 pg/ml), 기타 다른 원인군(n=66, 15, 6-47 pg/ml)으로 분류하였다. 혈장 BNP는 원인 질환에 따라 유의한 차이를 보였으며(p<0.001), COPD군과 좌심부전이 동반된 COPD군을 비교했을 때 심부전이 동반될 때 혈장 BNP가 의미있게 높았다(p=0.002). 당뇨병, 고혈압, 흡연 및 신부전 등 심질환의 위험인자가 없는 환자들에서 심부전의 동반 유무와 BNP값을 비교해 보았을 때, 심부전이 동반된 경우 의미있게 BNP값이 증가되어 있었다(p<0.001). 또한, BNP가 133 pg/ml이상일 경우 예민도 0.73, 특이도 0.87로 심부전에 대한 치료에 반응할 수 있는 환자군을 감별할 수 있었다. 결 론 : 혈장 BNP는 급성호흡곤란의 감별진단에서 심부전의 유무를 알아내고 효율적인 치료를 앞당기는데 유용한 검사이다. 특히, 기존의 호흡기 질환을 가지고 있거나 심장질환의 위험요인이 없더라도 BNP가 높은 수치를 보일 경우에는 심부전의 가능성을 고려해서 환자에게 접근해야 한다.

Keywords

References

  1. Levin ER, Gardner DG, Samson WK. Natriuretic peptide. N Engl J Med 1998;339:321-8 https://doi.org/10.1056/NEJM199807303390507
  2. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland T, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 2004;350:655-63 https://doi.org/10.1056/NEJMoa031994
  3. Cowie MR, Jourdain P, Maisel A, Dahlstrom U, Follath F, Isnard R, et al. Clinical applications of B-type natriuretic peptide (BNP) testing. Eur Heart J 2003;24:1710-8 https://doi.org/10.1016/S0195-668X(03)00476-7
  4. Mueller C, Scholer A, Laule-Kilian K, Martina B, Schindler C, Buser P, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647-54 https://doi.org/10.1056/NEJMoa031681
  5. Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:1527-60 https://doi.org/10.1053/euhj.2001.2783
  6. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure. J Am Coll Cardiol 1993;22(Suppl A):6A-13A https://doi.org/10.1016/0735-1097(93)90809-F
  7. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldmanmd AM, Francis GS, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to Revisethe 1995 Guidelines for the Evaluation and Management of Heart Failure). Circulation 2001;104:2996-3007 https://doi.org/10.1161/hc4901.102568
  8. Suttner SW, Boldt J. Natriuretic peptide system: physiology and clinical utility. Curr Opin Crit Care 2004;10:336-41 https://doi.org/10.1097/01.ccx.0000135513.26376.4f
  9. Sudoh T, Kangawa K, Minamino N, Matsuo H. A new natriuretic peptide in porcine brain. Nature 1988;332:78-81 https://doi.org/10.1038/332078a0
  10. Maeda K, Takayoshi T, Wada A, Hisanaga T, Kinoshita M. Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction. Am Heart J 1998;135:825-32 https://doi.org/10.1016/S0002-8703(98)70041-9
  11. Clerico A, Iervasi G, del Chicca MG, Emdin M, Maffei S, Nannipieri M, et al. Circulating levels of cardiac natriuretic peptides (ANP and BNP) measured by highly sensitive and specific immunoradiometric assays in normal subjects and in patients with different degrees of heart failure. J Endocrinol Invest 1998;21:170-9 https://doi.org/10.1007/BF03347297
  12. Silvet H, Young-Xu Y, Walleigh D, Ravid S. Brain natriuretic peptide is elevated in outpatients with atrial fibrillation. Am J Cardiol 2003;92:1124-7 https://doi.org/10.1016/j.amjcard.2003.07.010
  13. Eimer MJ, Ekery DL, Rigolin VH, Bonow RO, Carnethon MR, Cotts WG. Elevated B-type natriuretic peptide in asymptomatic men with chronic aortic regurgitation and preserved left ventricular systolic function. Am J Cardiol 2004;94:676-8 https://doi.org/10.1016/j.amjcard.2004.05.043
  14. Kikuta K, Yasue H, Yoshimura M, Morita E, Sumida H, Kato H, et al. Increased plasma levels of B-type natriuretic peptide in patients with unstable angina. Am Heart J 1996;132:101-7 https://doi.org/10.1016/S0002-8703(96)90396-8
  15. Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161-7 https://doi.org/10.1056/NEJMoa020233
  16. Morrison LK, Harrison A, Krishnaswamy P, Kazanegra R, Clopton P, Maisel AS. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol 2002;39:202-9
  17. Dao Q, Krishnaswamy P, Kazanegra R, Harrison A, Amirnovin R, Lenert L, et al. Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. J Am Coll Cardiol 2001;37:379-85 https://doi.org/10.1016/S0735-1097(00)01156-6
  18. Nagaya N, Nishikimi T, Okano Y, Uematsu M, Satoh T, Kyotani S, et al. Plasma brain natriuretic peptide levels increase in proportion to the extent of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol 1998;31:202-8 https://doi.org/10.1016/S0735-1097(98)81518-0
  19. Nagaya N, Nishikimi T, Uematsu M, Satoh T, Kyotani S, Sakamaki F, et al. Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension. Circulation 2000:102;865-70 https://doi.org/10.1161/01.CIR.102.8.865
  20. Ishii J, Nomura M, Ito M, Naruse H, Mori Y, Wang JH, et al. Plasma concentration of brain natriuretic peptide as a biochemical marker for the evaluation of right ventricular overload and mortality in chronic respiratory disease. Clin Chim Acta 2000;301:19-30 https://doi.org/10.1016/S0009-8981(00)00312-0
  21. Park HH, Kim S, Choi J, Kim KH, Cheon SC, Lee J, et al. The application of B-type natriuretic peptide level of the dyspneic patients: differentiation between for pulmonary and left ventricular dyfunction. Tuberc Respir Dis 2003;54:320-9 https://doi.org/10.4046/trd.2003.54.3.320