| Objective: The aim of this study was to compare the impact onmyocardial ischemia and cardiac function and safety in patients with non-STsegment elevation acute coronary syndrome accompanying with acute heartfailure between recombinant human brain natriuretic peptide (rhBNP) andnitroglycerin (NIT).Methods: Total of80patients(56males and24females, aging from57to81,average68.23±6.20years old)with non-ST segment elevation acutecoronary syndrome(NSTE-ACS)combined with acute heart failure(AHF) ofthe cardiology department in the second hospital of Hebei medical universityfrom December2012to December2013were enrolled into thisstudy.Inclusion criteria:⑴M eet the2011ESC non-ST segment elevation acutecoronary syndrome diagnostic criteria;⑵C ompliance with KillipⅡ-IIIgrade;⑶P lasmaBNP level>400pg/ml at admission.(Reference value<100pg/ml).Exclusion criteria:⑴S Tsegment elevation acute myocardialinfarction;⑵P atients with non-ST-segment elevation acute coronary syndromein need of urgent revascularization;⑶Hypotension (systolic blood pressureless than90mmHg, diastolic blood pressure less than60mmHg);⑷Cardiogenic shock:systolic blood pressure less than90mmHg sustained over30minutes;performance of peripheral vasoconstriction such as pale,sweating,decreased urine output(less than20ml/h),pulse thin,or requiredintra-aortic balloon pump (IABP);⑸V alvular heart disease,constrictivepericarditis,restricted or hypertrophic cardiomyopathy and acute myocarditis;⑹C ontraindications to anticoagulation:There was a history of irregularbleeding or hemorrhagic apoplexy recently,operation or severe injury within6weeks,cardiopulmonary resuscitation(chest compression time was more than 10minutes or treated with tracheal intubation, etc.), gastrointestinal bleedingwithin6months,and infective endocarditis;⑺H igh allergicconstitution;⑻N eed mechanical ventilation;⑼S evere dysfunction of liver or kidney,suchas transaminase was greater than2times of the upper limit of normal, serumcreatinine was over2.5mg/dl;⑽T he presence of autoimmune diseases,severetrauma,bleeding disorders,combined with tumors;⑾Patients or familymembers of patients refused to participate in this study.According to thefigures of the random table all patients were randomly divided into rhBNPgroup and nitroglycerin (NIT) group,which was with40cases of patients ineach group.All patients were given the same anticoagulation,antiplateletaggregation, statins,angiotension converting enzyme inhibitors/AngiotensionⅡ receptorblockers,β-blockers and other drugs.when volume of urine wassignificantly increased compared with the previous,potassium and sodiumwere supplemented in time.Deacetylase lanatoside can be used in the form ofintravenous injection about0.4~0.6mg per day and furosemide20~40mgper day in both of the two groups.In rhBNP group,rhBNP was given with aloading dose of1.5ug/kg(intravenous injection within90seconds),and thenrhBNP was pumped at a speed of0.0075ug/kg·min in the beginning, andgradually increased from0.0075ug/kg.min to the largest dose which was notover0.030ug/kg.min.According to the blood pressure (within the range of130-90/80-60mmHg)and the clinical symptoms of the patients,we controlledthe dose of rhBNP between0.0075~0.030ug/kg.min and maintained it for72hours,and then gradually decreased the dose and stop using within24hours.Nitroglycerin was continuous intravenous pumped with the initial doseat a speed of10ug/min,within the range of blood pressure130-90/80-60mmHgand based on clinical symptoms increased it until reached the maximum dosewhich was not over100ug/min within6hours maintained for72hours,theninduced gradually and stopped within24hours. we compared the efficiency ofintravenous pumping rhBNP and nitroglycerin in treatment of NSTE-ACScombined with AHF through some indexes before and after treatment in thetwo groups,such as systolic blood pressure,diastolic blood pressure,heart rate,breathing rate,arterial partial pressure of oxygen,24-hour urine output,NT-proBNP,Killip classification,left ventricular ejection fraction (LVEF), leftventricular end-diastolic volume (LVEDV),left ventricular end-systolicvolume(LVESV),angina attack frequency and duration,the total number of12-lead ECG ST-segment depression(NST),the sum of the value of STsegment depression.Through these indicators,We observed the effectivenesson myocardial ischemia and cardiac function of intravenous pumping rhBNPin treatment of NSTE-ACS combined with AHF.The security of intravenouspumped rhBNP in treatment of NSTE-ACS combined with AHF wasevaluated through the incidence of adverse reactions such as low bloodpressure,electrolyte disorders (hyponatremia,hypokalemia),kidney damage(theIncreasing of serum creatin-ine)and major adverse cardiac events (MACE)rates.All data were analyzed with the aid of SPSS13.0. P <0.05(2-tailed) wasconsidered statistically significant.Results:1. The basic characteristics of the two groups such as gender, age, pastmedical history such as hypertension, hyperlipidemia, diabetes,old myocardialinfarction,smoking,the level of plasma BNP at admission and Killip classifi-cation had no statistical difference (P>0.05).2. The blood pressure of two groups decreased more significantly thanthat pre-treatment,however,the systolic blood pressure was markedly lower inNIT group than that in rhBNP group at24hours and72hours after treatment(110.62±8.26mmHg vs.120.68±11.09mmHg,P＜0.01),(105.51±8.51mmHg vs.111.31±9.96mmHg,P＜0.05);meanwhile, the diastolic blood pressure waslower in NIT group than that in rhBNP group at24hours and72hours aftertreatment(74.33±6.10mmHg vs.78.77±6.56mmHg,P＜0.01),(63.37±4.26mmHg vs.68.39±5.44mmHg,P＜0.01).Heart rate slowed down significantlyin the two groups,but the heart rate was markedly lower in rhBNP group thanthat in NIT group at24hours and72hours after treatment (80.49±5.20timesper minute vs.85.00±4.51times per minute,P＜0.01),(71.43±4.59times perminute vs.74.78±4.00times per minute,P＜0.01).Compared to the baseline values,breathing rate slowed down greatly after treatment (P<0.05)in bothgroup which was more significant in the rhBNP group at24hours and72hours(19.72±3.50times per minute vs.24.00±4.09times per minute,P＜0.01),(17.47±3.11times per minute vs.19.25±3.74times per minute,P＜0.05).Compared to the baseline values,arterial partial pressure of oxygen wasmarkedly elevated after treatment in both groups(P<0.01)which was moresignificant in the rhBNP group at24hours and72hours (93.57±3.20mmHg vs.82.40±5.43mmHg,P<0.01),(96.06±1.78mmHg vs.93.88±2.92mmHg,P<0.01).3. The level of plasma NT-proBNP was not significantly differentbetween the the rhBNP group and NIT group before treatment (4517.43±896.00pg/ml vs.4580.08±870.11pg/ml,P=0.752).However,compared to thebaseline values, the level of plasma NT-proBNP decreased greatly aftertreatment (P <0.05) in both groups which was more significant in the rhBNPgroup at24hours and72hours (3495.37±542.27pg/ml vs.3736.59±491.83pg/ml, P＜0.05),(2702.91±493.34pg/ml vs.3118.11±486.66pg/ml, P＜0.01).4. Before the treatment, the patients with Killip Ⅱ and Ⅲgrade were21cases and19cases respectively in the rhBNP group, which were24cases and16cases in the nitroglycerin group (P=0.499).After72hours treatment, Killipclass was greatly improved in both of the two groups than that pre-treatment,which was more significant in rhBNP group:29,10and1cases vs.20,11and9cases respectively in KillipⅠ, Ⅱ and Ⅲ grade(P＜0.05).5. The LVEF,LVEDV and LVESV of two groups improved moresignificantly than that pre-treatment(P＜0.05)which were more improvedsignificantly in the rhBNP group (36.60±6.00%vs.33.67±6.11%,P＜0.05），(122.94±10.81ml vs.129.61±13.37ml,P＜0.05),(78.70±13.94ml vs.86.78±16.58ml,P＜0.05).6. The angina attack frequency and duration,the total number of12-leadECG ST-segment depression(NST),the sum of the value of ST segmentdepression of two groups were improved more significantly than thatpre-treatment(P＜0.05)which were more improved significantly in the rhBNP group(2.03±0.45times per day vs.3.00±0.42times per day,P＜0.05),(3.63±0.92minutes/time vs.5.00±0.98minutes/time,P＜0.05),(3.42±0.87vs.5.86±1.16,P＜0.05),(4.15±0.68mm vs.6.32±1.92mm,P＜0.05).7. The serum creatinine concentrations were markedly lower at24hoursand72hours after treatment than that pre-treatment between rhBNPgroup(107.74±14.15umol/L vs.120.27±12.07umol/L,P＜0.05),(101.35±10.39umol/L vs.120.27±12.07umol/L, P<0.05) and NIT group (107.00±14.09umol/L vs.118.00±11.76umol/L,P＜0.05),(105.12±12.30umol/L vs.118.00±11.76umol/L,P＜0.05),however the serum creatinine concentrations were notsignificantly different between the two groups at24hours and72hours aftertreatment(P＞0.05).The24-hour urine output of two groups increased moresignificantly than that pre-treatment,which in the rhBNP group was moresignificant than that in nitroglycerin group (P <0.01).8. In rhBNP group, the average maintenance dose of rhBNP was0.021±0.006ug/kg.min,while it was63.11±19.66ug/min in NIT group.9. There were no allergic reactions in the two groups.There was one casein rhBNP group,while four cases in NIT group suffered from hypotensionwhich did not occur again after adjusting the dose.The NIT group had morehigher incidence of headache than that in the rhBNP group (P <0.05).Therewere seven cases in rhBNP group with hyponatremia within24hours aftertreatment,while eight cases in NIT group,six of them occurred in24hoursafter treatment,the other happened in72hours after treatment;it did not appearagain after supplementing high salt liquid and salty diet.There were five casesin rhBNP group with hypokalemia within24hours after treatment,while sevencases in NIT group,four of them occurred in24hours after treatment, anotherthree happened in72hours after treatment which did not reappear after givingpotassium supplement.There were six cases in NIT group with ventriculararrhythmias,while zero case in rhBNP group.The rhBNP group had lowerincidence of ventricular arrhythmias than that in the NIT group(P＜0.05).Inthe case of maintaining the systolic blood pressure about130-90mmHg anddiastolic blood pressure about80-60mmHg,there was no renal insufficiency occurred or the original renal insufficiency aggravated in both of the twogroups.10. Incidence of MACE within a month which contain recurrent angina,heart failure deterioration, such as the grade of Killip classification wasincreased≥one, and sudden cardiac death was recored.In rhBNP group, therewere two cases of recurrent angina, while five cases in NIT group.There waszero case in rhBNP group with heart failure deterioration, while two cases inNIT group.There was one case of sudden cardiac death in rhBNP group, whiletwo cases in NIT group.Conclusion1. As compared with nitroglycerin, rhBNP can effectively improve thesymptoms of angina and heart failure of the patients.2.Compared with nitroglycerin, rhBNP can more significantly improvemyocardial ischemia，cardiac function and systemic clinical condition inpatients with non-ST segment elevation acute coronary syndrome combinedwith acute heart failure.3. rhBNP has significantly efficacy and better security in treatment ofpatients with non-ST-segment elevation acute coronary syndrome combinedwith acute heart failure. |
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