A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

Abstract

SummaryWe conducted a meta-analysis of the utility of pre-operative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide in predicting early (< 30 days) and intermediate (< 180 days) term mortality and major adverse cardiac events (cardiac death and nonfatal myocardial infarction) in patients following vascular surgery. A Pubmed Central and EMBASE search was conducted up to January 2008. Of 81 studies identified, seven prospective observational studies were included in the meta-analysis representing five patient cohorts: early outcomes (504 patients) and intermediate-term outcomes (623 patients). A B-type natriuretic peptide or N-terminal-pro B-type natriuretic peptide above the optimal discriminatory threshold determined by receiver operating characteristic curve analysis was associated with 30-day cardiac death (OR 7.6, 95% CI 1.33-43.4, p = 0.02), nonfatal myocardial infarction (OR 6.24, 95% CI 1.82-21.4, p = 0.004) and major adverse cardiac events (OR 17.37, 95% CI 3.31-91.15, p = 0.0007), and intermediate-term, all-cause mortality (OR 3.1, 95% CI 1.85-5.2, p < 0.0001), nonfatal myocardial infarction (OR 2.95, 95% CI 1.17-7.46, p = 0.02) and major adverse cardiac events (OR 3.31, 95% CI 2.1-5.24, p < 0.00001). B-type natriuretic peptide and N-terminal-pro B-type natriuretic peptide are potentially useful pre-operative prognostic tests in vascular surgical patients. Vascular surgery is associated with major adverse perioperative cardiac events. Unfortunately, the currently used pre-operative diagnostic tests for these patients are not statistically robust enough to accurately predict these events [1]. This was recently confirmed in a meta-analysis of six pre-operative tests for vascular surgical patients, which included: ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy, dipyridamole stress echocardiography and dobutamine stress echocardiography [2]. Dobutamine stress echocardiography had a trend to the best performance of the six tests for the prediction of major adverse cardiac events (defined as peri-operative cardiac death and nonfatal myocardial infarction (MI)) within 30 days of surgery [2], with a positive likelihood ratio (LR) and negative LR of 2.8 and 0.21 respectively. As statistically good discrimination requires a LR of < 0.2 and > 10, there are clearly clinical limitations to the utility of these pre-operative tests for vascular surgical patients [1].There has been recent interest in brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) as prognostic biomarkers of death and major cardiovascular events, even after control for other cardiovascular risk factors [3]. BNP is an

National priorities for perioperative research in South Africa

“…[9] The current data on BNP for preoperative risk assessment fulfil proof of concept for cardiovascular complications, [10,11] validation in prospective studies, [12,13] incremental value by significantly improving the revised cardiac risk index's prediction of major adverse cardiac events, [14] and clinical utility through a significant improvement in preoperative risk classification. [15] Importantly, the fifth stage of integration of a biomarker into clinical practice demands demonstration that biomarker-directed therapy improves clinical outcome.…”

Sleep Apnea in Total Joint Arthroplasty Patients and the Role for Cardiac Biomarkers for Risk Stratification: an Exploration of Feasibility

“…This finding was similar to a study by Schutt et al, who observed increased preoperative NT-proBNP but not postoperative NT-proBNP levels were associated with postoperative cardiac events; however, increased postoperative levels of NT-proBNP were common in all patients [43]. There are several meta-analyses and systematic reviews of studies evaluating BNPs in the surgical population; and they consistently demonstrate that BNPs, in particular when drawn preoperation compared with postoperation, are independent predictors of both short-and long-term adverse cardiac events, including cardiac deaths and all-cause mortality [143,144]. In addition, BNPs were found to be useful as a stratification tool to assess risk for postoperative cardiovascular complications [145].…”

“…In addition, BNPs were found to be useful as a stratification tool to assess risk for postoperative cardiovascular complications [145]. A meta-analysis of vascular surgery patients found that increased preoperative BNP levels (including NT-proBNP) were associated with increased risk of 30-day postoperative cardiac events, cardiac-related mortality and all-cause deaths up to 180 days [144]. Using preoperative BNPs significantly improved the preoperative predictive risk classification of the traditionally utilized RCRI [145].…”

Preoperative B-type natriuretic peptides in patients undergoing noncardiac surgery: a cumulative meta-analysis

“…Almost uniformly every study conducted in non-cardiac surgical populations has reported that preoperative NP measurement elevations are predictive of short (≤ 30 day), intermediate (>30-180 day) and long-term (>180 day) postoperative mortality, 4 as well as major adverse cardiac events such as myocardial infarction, troponin elevation, cardiac failure, and atrial fibrillation. This signal has been repeatedly demonstrated in multiple meta-analyses.…”