糖尿病患之心臟衰竭：談腦型利鈉月太胜（BNP）於糖尿病患之臨床運用

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106 280

BNP

1

thiazolidinedione TZD

(BNP)

BNP

TZD BNP (negative predictive value)

BNP TZD

( Heart failure ) ( Diabetes mellitus )

( BNP )

( Microalbuminuria ) ( Thiazolidinedione )

Thiazolidinedione ( TZD )

1

TZD

2

3

( U . S . N a t i o n a l Cholesterol Education Program Adult Treatment Panel III guide-line, NCEP ATP-III guide-line )

2

⁴

(2)

5

3.8%

⁶

F r a m i n g h a m H e a r t Study

6.6% 7.9%

2

5

⁷

Nichols 10,000 2

11.8%

8 9

CONSENSUS 23%

¹⁰

SOLVD 23%

¹¹

ValHeFT study

25.9%

¹²

CHARM study 28.6%

¹³

3~4

A m a t o 1997

30%

¹⁴

15

16

( diabetic cardiomyo- pathy )

17

r e m o d e l - ing

Malmberg 1995 DIGAMI

( 66%)

¹⁸

Liu

19

( microalbuminuria )

( LV mass ) BMI ( Body

Mass Index )

Heart Outcomes Prevention Evaluation ( HOPE ) study

20

21

2 2

B e l l Diabetes Care 2003 editorial

23

24

aspirin

25

26

SOLVD

²⁷

study

ACEI ( Angiotensin converting enzyme inhibitors )

blockers ejection fraction

²⁸

remodeling

(3)

BNP

( gold standard )

1981 de Bold ( Atrial natriuretic pep- tide, ANP )

²⁹

, ANP

( Brain na- triuetic peptide BNP ) ( N ) ( N terminal-proBNP, NT-proBNP )

30

BNP

32 ANP

cystine 17

BNP BNP ANP

1 1

ANP BNP

31

NT-proBNP proBNP

endoprotease furin N 1

7 6

B N P

32

BNP 3 B-

NP NT-proBNP

BNP NT-proBNP

BNP NT-proBNP ejection

fraction

³³

( PCWP ) ( LVEDV )

34

BNP NT-proBNP

NYHA

³⁵

NT-pro BNP BNP

32

BNP NT-proBNP

ejection fraction

36

BNP

37

BNP

B N P

Maisel 1,586 (dyspnea)

B N P

BNP 100 pg/ml

( sensitivity ) 90%

( specificity ) 76% ( posi- tive predictive value ) 78% ( neg- ative predictive value ) 89% ( accu- racy ) 83%

3 8

BASEL

³⁹

study ( time to discharge ) ( total treatment cost ) ( end p o i n t ) 4 5 2

BNP CHF

26% McDonagh

⁴⁰

BNP 1,653 25-74

3 . 2 % B N P

17.9pg/ml

77% 87% 55

( subgroup ) 92%

Vasan 3,177 Framingham Heart

Study BNP

BNP

⁴¹

B N P

42

B N P B N P

( sensitivity )

( study group ) ( prevalence ) ( negative predictive value )

43

BNP

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P S A

40

( cut off value ) B N P

44

BNP

Epshteyn BNP

< 39pg/ml B N P 9 1 %

BNP > 90 pg/ml

( 96% )

⁴⁵

Wu Breathing Not Properly Multinational

Study 1,586 922

( subgroup analysis )

( acute dyspnea ) BNP

46

ANP

47

BNP

Wu

B N P

Yano 2

BNP

⁴⁸

BNP ANP albumin 1-

microglobulin

⁴⁹

Nagai

B N P

50

51

52

Bell

23

Thiazolidinedione

TZD 3-5%

5 3 , 5 4

sulfonylurea met-

formin 6.0-7.5%

^55,56

insulin 15%

^57,58

T Z D

59

T Z D

2

TZD

60

61

TZD

NYHA I II

III IV T Z D

T Z D 3

X B N P

T Z D

BNP Thiazolidinedione

Ogawa

⁶²

2 pioglitazone 15 mg/day 48 pioglitazone

( BNP 100 pg/ml )

( Base-line ) BNP

( 18pg/ml ) BNP

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pioglitazone BNP

buformin BNP

B N P A N P

pioglitazone Ogawa

2 BNP piogli-

tazone 2

B N P pioglitazone BNP

B N P

T Z D

BNP ( negative predictive value )

B N P

Ogawa TZD

B N P

T Z D

BNP BNP

T Z D

BNP TZD

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Diabetes Mellitus and Heart Failure the Potential Implication

of Brain Natriuretic Peptide (BNP)

Ching-Ling Lin, Shinn-Tzong Gong, and Herng-Cheng Chiou

¹

As the use of thiazolidinedione (TZD) becomes more popular, there is a growing concern that fluid reten- tion associated with TZD use may precipitate or induce heart failure in patients with diabetes mellitus. Diabetes mellitus is an independent risk factor of heart failure; more attention must be given to this issue so that the out- come for this group of CAD equivalent patients can be improved. Traditionally echocardiography with dopplar ul- trasound is the gold standard for the diagnosis of heart failure. However, the cost and technical cumbersome pre- clude it from being a full-scale screening tool. Plasma brain natriuretic peptide (BNP) level is closely correlated with both diastolic and systolic cardiac function, however the use of BNP for screening of cardiac dysfunction should be restricted to certain high-risk group. For diabetic patients with TZD associated edema the high nega- tive predictive value of BNP may be useful for identifying patients who need further diagnostic evaluation. For diabetic patients with microalbuminuria and elevated BNP level prior to TZD administration, the risk of heart fail- ure is higher than those without microalbuminuria. For this particular group of patients echocardiographic study should include a complete evaluation of diastolic dysfunction. ( J Intern Med Taiwan 2005; 16: 63-70 )

Endocrinology and Metabolism,

¹