Redefining Pre-Heart Failure With Cardiac Biomarkers: Clinical and Research Implications.
Redefining Pre-Heart Failure With Cardiac Biomarkers: Clinical and Research Implications.
复制标题
用心脏生物标志物重新定义心力衰竭前期：临床和研究意义。
DOI：
10.1016/j.jchf.2023.01.015
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
deFilippi,ChristopherR
中科院分区：
文献类型：
--
作者：
Shah,Palak;Arias,Rafael;deFilippi,ChristopherR
- Kelvin勋爵1随着人口老龄化，美国心力衰竭（HF）人口的总百分比约为2%-3%，个人一生中患HF的估计风险约为30%。随着预防和治疗症状性HF的机会越来越多，必须对HF的通用定义进行验证和标准化，该定义侧重于诊断特征，广泛适用，并具有临床相关性。2最近，2022年美国心脏协会（AHA）/美国心脏病学会（ACC）/美国心力衰竭学会（HFSA）心力衰竭管理指南修订了HF的分期，强调A期为“处于风险中”，B期为“HF前”。3最值得注意的是，指南现在指出，心脏生物标志物升高的无症状个体，包括利钠肽或心肌肌钙蛋白，有或没有心脏结构/功能异常的证据，应归类为B期或HF前期。根据经验增加心脏生物标志物是基于来自人群队列研究的大量数据，表明心脏生物标志物升高使患者发生HF的风险增加。由于更新了指南以将心脏生物标志物纳入新的通用定义，因此尚不清楚有多少患者将从A期重新分类为B期，也未对重新分类为HF前患者的相关结局进行充分研究。在这一期的JACC中：心力衰竭，Jia等4试图评价结合N-末端前B型利钠肽（NT-proBNP）或高敏心肌肌钙蛋白T（hs-cTnT）联合超声心动图测量对使用新指南重新分类至B期的个体比例以及随后的HF和死亡风险的影响。作者利用了ARIC（社区动脉粥样硬化风险）研究的数据，这是一项近40年前启动的基于人群的纵向队列研究，评估了从4个地理和种族多样化的美国社区招募的成年人的心血管疾病发病率。使用ARIC研究，研究者对5，324名在访视5（2011-2013）时无HF的参与者进行了分析，这些参与者同时测量了NT-proBNP和hs-cTnT。在研究队列中，4例患者的NT-proBNP升高> 125 pg/mL（52%）或hs-cTnT升高> 14 ng/L（33%）。根据既往和新的HF指南，将受试者分为A期或B期：1）有危险因素但无心脏结构/功能异常的受试者（不考虑生物标志物）被定义为分期前（队列的40%）; 2）心脏结构/功能异常的参与者3）没有异常心脏结构/功能或生物标志物升高的参与者被定义为A期（19%）;和4）具有异常心脏结构/功能或升高的生物标志物的参与者，
—Lord Kelvin 1 With the aging population, the total percentage of the US population with heart failure (HF) approximates 2%-3% and the estimated lifetime risk of HF for an individual approximates 30%. With increasing opportunities to prevent and treat symptomatic HF, it is imperative that a universal definition of HF that is focused on diagnostic features, broadly applicable, and clinically relevant be validated and standardized. 2 Recently, the 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) Guideline for the Management of Heart Failure revised the stages of HF to emphasize Stage A as “At Risk” and Stage B as “Pre-HF.” 3 Most notably, the guidelines now state that asymptomatic individuals with elevated cardiac biomarkers, including natriuretic peptides or cardiac troponins with or without evidence of cardiac structural/functional abnormalities, should be categorized as Stage B or as having Pre-HF. The empirical addition of cardiac biomarkers was based on a preponderance of data from population cohort studies suggesting that elevated cardiac biomarkers put patients at increased risk for incident HF. Since the guidelines were updated to incorporate cardiac biomarkers into the new universal definition, it is not known how many patients would be reclassified from Stage A to Stage B, nor have the associated outcomes of those reclassified as Pre-HF been well studied. In this issue of JACC: Heart Failure, Jia et al 4 sought to evaluate the impact of incorporating N-terminal pro–B-type natriuretic peptide (NT-proBNP) or high-sensitivity cardiac troponin T (hs-cTnT) in conjunction with echocardiographic measures on both the proportion of individuals reclassified to Stage B using the new guidelines and subsequent risk of HF and death. The authors leveraged data from the ARIC (Atherosclerosis Risk In Communities) study, a population-based longitudinal cohort study initiated close to 4 decades ago that evaluated the incidence of cardiovascular disease in adults recruited from 4 geographically and racially diverse US communities. Using the ARIC study, the investigators performed an analysis of 5,324 participants without HF at visit 5 (2011-2013) who had contemporaneous measures of NT-proBNP and hs-cTnT. In the study cohort, 4 many patients had either an elevation of NT-proBNP $125 pg/mL (52%) or hs-cTnT $14 ng/L (33%). Participants were classified as Stage A or B based on the former and new HF guidelines: 1) participants with risk factors but without abnormal cardiac structure/function (irrespective of biomarkers) were defined as Stage Aformer (40% of the cohort); 2) participants with cardiac structural/functional abnormalities (irrespective of biomarkers) were defined as Stage Bformer(60%); 3) participants without abnormal cardiac structure/function or biomarker elevations were defined as Stage Anew (19%); and 4) participants with either abnormal cardiac structure/function or elevated biomarkers were