Clinical Research
Biomarkers and Cardiac Surgery
Is a Pre-Operative Brain Natriuretic Peptide or N-Terminal Pro–B-Type Natriuretic Peptide Measurement an Independent Predictor of Adverse Cardiovascular Outcomes Within 30 Days of Noncardiac Surgery?: A Systematic Review and Meta-Analysis of Observational Studies

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Objectives

We conducted a systematic review and meta-analysis to determine if pre-operative brain natriuretic peptide (BNP) (i.e., BNP or N-terminal pro–B-type natriuretic peptide [NT-proBNP]) is an independent predictor of 30-day adverse cardiovascular outcomes after noncardiac surgery.

Background

Pre-operative clinical cardiac risk indices have only modest predictive power. BNP predicts adverse cardiovascular outcomes in a variety of nonsurgical settings and may similarly predict these outcomes in the perioperative setting.

Methods

We employed 5 search strategies (e.g., searching bibliographic databases), and we included all studies that assessed the independent prognostic value of pre-operative BNP measurement as a predictor of cardiovascular complications after noncardiac surgery. We determined study eligibility and conducted data abstraction independently and in duplicate. We calculated a pooled odds ratio using a random effects model.

Results

Nine studies met eligibility criteria, and included a total of 3,281 patients, among whom 314 experienced 1 or more perioperative cardiovascular complications. The average proportion of patients with elevated BNP was 24.8% (95% confidence interval [CI]: 20.1 to 30.4%; I2= 89%). All studies showed a statistically significant association between an elevated pre-operative BNP level and various cardiovascular outcomes (e.g., a composite of cardiac death and nonfatal myocardial infarction; atrial fibrillation). Data pooled from 7 studies demonstrated an odds ratio (OR) of 19.3 (95% CI: 8.5 to 43.7; I2= 58%). The pre-operative BNP measurement was an independent predictor of perioperative cardiovascular events among studies that only considered the outcomes of death, cardiovascular death, or myocardial infarction (OR: 44.2, 95% CI: 7.6 to 257.0, I2= 51.6%), and those that included other outcomes (OR: 14.7, 95% CI: 5.7 to 38.2, I2= 62.2%); the p value for interaction was 0.28.

Conclusions

These results suggest that an elevated pre-operative BNP or NT-proBNP measurement is a powerful, independent predictor of cardiovascular events in the first 30 days after noncardiac surgery.

Key Words

perioperative myocardial infarction
brain natriuretic peptide
perioperative risk

Abbreviations and Acronyms

BNP
brain natriuretic peptide
LVEF
left ventricular ejection fraction
MI
myocardial infarction
NT-proBNP
N-terminal pro–B-type natriuretic peptide
OR
odds ratio

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Continuing Medical Education (CME) is available for this article.

Dr. Karthikeyan is supported by a CIHR Scholarship (the Canada-HOPE Scholarship). Dr. Yusuf is supported by a Heart and Stroke Foundation Endowed Chair in Cardiovascular Research. Dr. Devereaux is supported by a Canadian Institutes of Health Research New Investigator Award and has received a grant-in-kind from Roche Diagnostics to evaluate NT-proBNP among patients undergoing noncardiac surgery.