NT-proBNP may predict death, myocardial injury after noncardiac surgery
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N-terminal pro-B-type natriuretic peptide levels before noncardiac surgery was strongly linked to myocardial injury and vascular death within 30 days after the procedure and may improve cardiac risk prediction along with the Revised Cardiac Risk Index, according to a study published in the Annals of Internal Medicine.
“We demonstrate that NT-proBNP is able to improve risk prediction in patients who will and will not suffer a major perioperative cardiac event,” P.J. Devereaux, MD, PhD, director of the division of cardiology at McMaster University in Ontario, Canada, and scientific leader of the anesthesiology, perioperative medicine and surgical research group at the Population Health Research Institute in Ontario, told Healio. “This is a major advance compared to our two prior approaches to risk estimation. Moreover, the tests are faster and cheaper than noninvasive cardiac tests and even medical consults.”
VISION NT-proBNP substudy
Emmanuelle Duceppe, MD, assistant professor at University of Montreal, and colleagues analyzed data from 10,402 patients (mean age, 65 years; 50% men) from the VISION NT-proBNP substudy aged at least 45 years who underwent inpatient noncardiac surgery at 16 centers in nine countries. The Revised Cardiac Risk Index was calculated after the study was completed and included congestive HF, ischemic heart disease, preoperative insulin use, high-risk surgery and preoperative creatinine level greater than 177 µmol/L. NT-proBNP levels were measured before surgery, and troponin T levels were measured 6 to 12 hours after surgery and daily for up to 3 days.
The primary outcome was defined as a composite of vascular death and myocardial injury after noncardiac surgery at 30 days, which included ischemic myocardial injury and MI.
Most surgery included in this study were major orthopedic (25.3%), major general (17.9%) and major gynecology or urology procedures (13.8%). The primary composite outcome occurred in 12.2% of patients within 30 days after surgery.
Compared with a preoperative NT-proBNP level less than 100 pg/mL, the incidence of and the risk for the primary composite outcome increased as preoperative NT-proBNP levels increased:
- 100 pg/mL to less than 200 pg/mL (12.3%; HR = 2.27; 95% CI, 1.9-2.7);
- 200 pg/mL to less than 1,500 pg/mL (20.8%; HR = 3.63; 95% CI, 3.13-4.21); and
- greater than 1,500 pg/mL (37.5%; HR = 5.82; 95% CI, 4.81-7.05).
The addition of NT-proBNP to the Revised Cardiac Risk Index led to a net absolute reclassification improvement of 25.8%. The use of NT-proBNP was also linked to all-cause mortality within 30 days for levels less than 100 pg/mL (0.3%), 100 pg/mL to less than 200 pg/mL (0.7%), 200 pg/mL to less than 1,500 pg/mL (1.4%) and greater than 1,500 pg/mL (4%).
“Although our study demonstrates that NT-proBNP can be used to improve perioperative risk prediction and therefore facilitate more informed decision-making about the appropriateness of surgery, surgical and anesthetic approaches and identification of patients who require enhanced monitoring after surgery, there is a need for more research,” Devereaux said in an interview. “We are using NT-proBNP to identify patients who are eligible for a large international randomized controlled trial that we are currently conducting. Moreover, we plan to undertake trials informed by patients preoperative NT-proBNP level that will target interventions that we believe can influence the NT-proBNP level and potentially improve patient outcomes.”
Further research
In a related editorial, Arman Qamar, MD, MPH, interventional cardiology fellow (coronary and endovascular) at New York University Grossman School of Medicine, and Cardiology Today Editorial Board Member Sripal Bangalore, MD, MHA, professor of medicine at NYU Langone Health, wrote: “Given the well-known limitations of clinical risk indices and noninvasive cardiac diagnostic testing in preoperative risk prediction, evaluation of NT-proBNP in addition to clinical factors offers a readily available, precise, and inexpensive tool for risk stratification. However, whether NT-proBNP-driven perioperative management reduces the risk for cardiovascular events is unknown and should be investigated.” – by Darlene Dobkowski
For more information:
P.J. Devereaux, MD, PhD, can be reached at philipj@mcmaster.ca.
Disclosures: Roche Diagnostics provided the NT-proBNP assays in addition to some funding for the VISION study. Devereaux reports grants from Abbott Diagnostics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Covidien, Octapharma, Philips Healthcare, Roche Diagnostics, Siemens and Stryker. Duceppe reports he received grants, nonfinancial support and personal fees from Roche Diagnostics. The authors of the editorial report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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