NT-proBNP升高，一定是心衰么？

2018-01-18 赵光临医学之声

患者张某某，男，84岁，主因右侧肢体活动不利1天入我院神经内科。主要表现为右侧肢体活动不利，无其他不适。查体：血压：90/60mmHg，心律不齐，左肺呼吸音低，神清，右下肢肌力4级，余未见明显异常。既往低血压病史，眩晕病史。

病例分享

患者张某某，男，84岁，主因右侧肢体活动不利1天入我院神经内科。主要表现为右侧肢体活动不利，无其他不适。查体：血压：90/60mmHg，心律不齐，左肺呼吸音低，神清，右下肢肌力4级，余未见明显异常。既往低血压病史，眩晕病史。

此次入院前查心电图提示：心室率127次/分，心房纤颤。头DWI提示：幕上脑室系统扩张，脑积水表现，脑白质区多发缺血脱髓鞘灶改变，脑萎缩，脑内多发陈旧病变。尿酸541.0umol/l。尿素、肌酐及电解质大致正常。入院后初步诊断为脑梗死？心房纤颤。

入院后完善相关检验检查，心电监护，吸氧，给予美托洛尔25mg每日两次口服，达比加群110mg每日两次口服，瑞舒伐他汀钙片10mg每晚一次口服，佰塞通注射液100ml每日一次经脉滴注，依达拉奉30mg每日两次静脉滴注。

第二天查房：患者监护提示心室率140次/分，查心电图提示：心房扑动。给予西地兰静脉推注，每4-6小时一次，供给予三次西地兰后，患者心室率将至70-99次/分。完善NT-proBNP检查，提示＞25000pg/ml。患者无胸闷及喘憋等不适，双下肢轻度水肿。复查NT-proBNP提示24900pg/ml，肌钙蛋白I正常。查心脏彩超提示：EF46%，FS24%，右心增大，升主动脉内径增宽，三尖瓣反流（中量），主动脉瓣反流（少量），主动脉瓣钙化，肺动脉高压（中度），左心功能减低，心律不齐。复查肾功能及电解质提示：尿酸稍高。给予速尿一支利尿减轻心脏负荷。

第三天查房：复查NT-proBNP将至8000pg/ml，患者出现发热，体温最高达38℃，查血常规+CRP+C反应蛋白，血象偏高，查胸片提示：左肺高密度影，考虑炎症。给予三代头孢抗炎治疗。

那么问题来了，患者NT-proBNP为何如此之高？急性心衰？

BNP（脑那肽）是一种由32个氨基酸残基构成的多肽类激素，是由心肌分泌的，具有利尿和利钠作用的多肽。而NT-proBNP和BNP同为proBNP进一步分解的产物，两者皆由心肌分泌分解而来。NT-proBNP的半衰期更长，更稳定。两者为反映心功能的重要指标。

此患者未出现急性心衰的临床表现，心脏彩超EF46%，由此可见单纯用急性心衰来解释是解释不通的。

思考分析

那么哪些因素会影响NT-proBNP，会使其升高呢？仅仅是心衰吗？

NT-proBNP作为心衰诊断的一项重要指标，但还有很多疾病会使其升高。

1、心肌梗塞：心肌梗塞患者由于心肌缺血坏死亦可出现NT-proBNP升高，本患者无心肌梗塞临床症状，肌钙蛋白I正常，故可除外。

2、心绞痛：心绞痛患者也可出现NT-proBNP升高，本患者无胸痛、胸闷症状，可能性不大。

3、心房纤颤：房颤患者NT-proBNP可升高，本患者入院前房颤律，入院后心率偏快，患者NT-proBNP升高，考虑与此原因有关。

4、心脏瓣膜反流：心脏瓣膜反流亦可引起其升高，本患者存在心脏瓣膜反流，考虑NT-proBNP升高，与此有关。

5、高血压：血压升高可引起其升高，本患者无高血压病史，故考虑与此无关。

6、肾功能异常：NT-proBNP主要经肾脏清除，肾功能异常可引起其显着升高，本患者两次查肾功能，肌酐及尿素未见明显异常，故考虑与此无关。

7、肺动脉高压：其亦会使NT-proBNP升高。本患者心脏彩超提示存在肺动脉高压，故患者NT-proBNP升高考虑与此亦有关。

8、感染：感染患者NT-proBNP亦会升高，本患者存在肺部感染，不能除外与此相关。

9、脑血管病：脑血管病患者可出现NT-proBNP升高，本患者目前暂不能除外脑血管病可能，考虑与此可能亦有关。

10、其他：毒物，贫血，肝硬化，COPD等。

那么本患者NT-proBNP升高，我们目前考虑与多种因素有关，多种因素共同作用，使其彪出检测范围。

大家如果有不同意见可以可以提出，共同探讨，共同进步，谢谢大家的支持

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2018-01-20 天涯183

非常好的文章.学习了

67 0
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2018-01-20 huiwelcome

#BNP#

24 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-20 mjldent

#NT-proBNP#

31 0
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createdTime=Sat Jan 20 13:41:00 CST 2018, time=2018-01-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1290341, encodeId=412e1290341be, content=<a href='/topic/show?id=f6e513111bc' target=_blank style='color:#2F92EE;'>#NT-proBNP#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=13111, encryptionId=f6e513111bc, topicName=NT-proBNP)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5662228, createdName=mjldent, createdTime=Sat Jan 20 13:41:00 CST 2018, time=2018-01-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601965, encodeId=e5f2160196591, content=<a href='/topic/show?id=2f801469e57' target=_blank style='color:#2F92EE;'>#PRO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14697, encryptionId=2f801469e57, 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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-20 sunylz

#PRO#

30 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-19 swfzhanggui

了解各项指标的现实意义

67 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-19 天地飞扬

学习了.谢谢分享!

66 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-19 张新亮1853311252142e2fm

鉴别诊断很重要

75 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-19 忠诚向上

好好学习天天向上

80 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-19 飛歌

学习了很有用不错

23 0
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createdTime=Fri Jan 19 07:10:21 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279868, encodeId=f0212e9868f8, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jan 19 00:29:09 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279853, encodeId=e6a62e98539b, content=不错的文章.值得拥有, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eff51996281, createdName=1e1b8538m79(暂无匿称), createdTime=Thu Jan 18 23:36:25 CST 2018, time=2018-01-18, status=1, ipAttribution=)]
2018-01-18 1e1b8538m79(暂无匿称)

不错的文章.值得拥有

27 0

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