Clinical Research
Biomarkers
The Predictive Ability of Pre-Operative B-Type Natriuretic Peptide in Vascular Patients for Major Adverse Cardiac Events: An Individual Patient Data Meta-Analysis

https://doi.org/10.1016/j.jacc.2011.04.018Get rights and content
Under an Elsevier user license
open archive

Objectives

The aims of this study were to perform an individual patient data meta-analysis of studies using B-type natriuretic peptides (BNPs) to predict the primary composite endpoint of cardiac death and nonfatal myocardial infarction (MI) within 30 days of vascular surgery and to determine: 1) the cut points for a natriuretic peptide (NP) diagnostic, optimal, and screening test; and 2) if pre-operative NPs improve the predictive accuracy of the revised cardiac risk index (RCRI).

Background

NPs are independent predictors of cardiovascular events in noncardiac and vascular surgery. Their addition to clinical risk indexes may improve pre-operative risk stratification.

Methods

Studies reporting the association of pre-operative NP concentrations and the primary study endpoint, post-operative major adverse cardiovascular events (defined as cardiovascular death and nonfatal MI) in vascular surgery, were identified by electronic database search. Secondary study endpoints included all-cause mortality, cardiac death, and nonfatal MI.

Results

Six data sets were obtained, 5 for BNP (n = 632) and 1 for N-terminal pro-BNP (n = 218). An NP level higher than the optimal cut point was an independent predictor for the primary composite endpoint (odds ratio: 7.9; 95% confidence interval: 4.7 to 13.3). BNP cut points were 30 pg/ml for screening (95% sensitivity, 44% specificity), 116 pg/ml for optimal (highest accuracy point; 66% sensitivity, 82% specificity), and 372 pg/ml for diagnostic (32% sensitivity, 95% specificity). Subsequent to revised cardiac risk index stratification, reclassification using the optimal cut point significantly improved risk prediction in all groups (net reclassification improvement 58%, p < 0.000001), particularly in the intermediate-risk group (net reclassification improvement 84%, p < 0.001).

Conclusions

Pre-operative NP levels can be used to independently predict cardiovascular events in the first 30 days after vascular surgery and to significantly improve the predictive performance of the revised cardiac risk index.

Key Words

BNP
N-terminal pro-B-type natriuretic peptide
perioperative myocardial infarction
perioperative risk

Abbreviations and Acronyms

AUC
area under the receiver-operating characteristic curve
BNP
B-type natriuretic peptide
CI
confidence interval
MACE
major adverse cardiac event(s)
MI
myocardial infarction
NP
natriuretic peptide
NRI
net reclassification improvement
NT-proBNP
N-terminal pro-B-type natriuretic peptide
OR
odds ratio
RCRI
revised cardiac risk index
ROC
receiver-operating characteristic

Cited by (0)

Dr. Rodseth is supported by a CIHR Scholarship (the Canada-HOPE Scholarship). Dr. Lurati Buse is supported by a scholarship by the Swiss National Science Foundation. Dr. Bolliger has received an unrestricted research grant from CSL Behring (Berne, Switzerland). Dr. Mahla has received N-terminal pro-B-type natriuretic peptide kits from Roche Diagnostics GmbH (Mannheim, Germany), study grants from Novo Nordisk Pharma GmbH (Vienna, Austria) and CSL Behring Biotherapies for Life (Vienna, Austria), and speaker honoraria and consulting fees from CSL Behring Biotherapies for Life. Dr. Biccard is supported by a self-initiated research grant from the Medical Research Council. All other authors have reported that they have no relationships to disclose.