Influence of Renal Function on the Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Cardiac Risk Marker in Patients Undergoing Noncardiac Vascular Surgery

doi:10.1016/j.amjcard.2007.07.058

The American Journal of Cardiology

Volume 101, Issue 1, 1 January 2008, Pages 122-126

https://doi.org/10.1016/j.amjcard.2007.07.058 Get rights and content

N-terminal pro-B-type natriuretic peptide (NT–pro-BNP) is related to stress-induced myocardial ischemia and/or volume overload, both common in patients with renal dysfunction. This might compromise the prognostic usefulness of NT–pro-BNP in patients with renal impairment before vascular surgery. We assessed the prognostic value of NT–pro-BNP in the entire strata of renal function. In 356 patients (median age 69 years, 77% men), cardiac history, glomerular filtration rate (GFR, ml/min/1.73 m²), and NT–pro-BNP level (pg/ml) were assessed preoperatively. Troponin T and electrocardiography were assessed postoperatively on days 1, 3, 7, and 30. The end point was the composite of cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariate analysis was used to evaluate the interaction between GFR, NT–pro-BNP and their association with postoperative outcome. Median GFR was 78 ml/min/1.73 m² and the median concentration of NT–pro-BNP was 197 pg/ml. The end point was reached in 64 patients (18%); cardiac death occurred in 7 (2.0%), Q-wave myocardial infarction in 34 (9.6%), and non–Q-wave myocardial infarction in 23 (6.5%). After adjustment for confounders, NT–pro-BNP levels and GFR remained significantly associated with the end point (p = 0.005). The prognostic value of NT–pro-BNP was most pronounced in patients with GFR ≥90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR <30 ml/min/1.73 m², NT–pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). In conclusion, the discriminative value of NT–pro-BNP is most pronounced in patients with GFR ≥90 ml/min/1.73 m² and has no prognostic value in patients with GFR <30 ml/min/1.73 m².

Section snippets

Methods

The study population consisted of 356 patients who underwent elective noncardiac vascular surgery at the Erasmus Medical Center, Rotterdam, The Netherlands, during June 2004 to February 2007. Before surgery, a detailed cardiac history was obtained and patients were screened for hypertension (blood pressure ≥140/90 mm Hg or medical therapy to control hypertension) and diabetes mellitus (fasting glucose level ≥7.0 mmol/L or medication to control diabetes). The presence of coronary artery disease

Results

Baseline characteristics according to renal function status are listed in Table 1. NT–pro-BNP levels were strongly associated with renal function and ranged from 124 pg/ml (interquartile range 67 to 227) in patients with normal renal function to 2,931 pg/ml (interquartile range 972 to 6,942) in those with severe renal dysfunction.

The study end point occurred in 64 patients (18%); 7 (2.0%) had cardiac death, 34 (9.6%) had a nonfatal Q-wave myocardial infarction, and 23 (6.5%) had a nonfatal

Discussion

The discriminative value of NT–pro-BNP was most pronounced in patients with preserved renal function than in those with impaired renal function. In fact, patients with severe renal dysfunction are at such high risk of postoperative cardiac events that NT–pro-BNP is useless for prognostification purposes.

In this study, NT–pro-BNP (half-life time 60 to 120 minutes) levels were measured, not B-type natriuretic peptide levels (half-life time 20 minutes).6, 7 Given the longer half-life of NT–pro-BNP

References (15)

A.S. Levey et al.
Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO)
Kidney Int
(2005)
Y. Takami et al.
Diagnostic and prognostic value of plasma brain natriuretic peptide in non–dialysis-dependent CRF
Am J Kidney Dis
(2004)
S. Anwaruddin et al.
Renal function, congestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study
J Am Coll Cardiol
(2006)
I.A. Khan et al.
N-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide for identifying coronary artery disease and left ventricular hypertrophy in ambulatory chronic kidney disease patients
Am J Cardiol
(2006)
G. Landesberg et al.
Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery
J Am Coll Cardiol
(2003)
F. Van Lente et al.
Ability of troponins to predict adverse outcomes in patients with renal insufficiency and suspected acute coronary syndromes: a case-matched study
J Am Coll Cardiol
(1999)
C.A. Henrikson et al.
Prognostic usefulness of marginal troponin T elevation
Am J Cardiol
(2004)

There are more references available in the full text version of this article.

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The subjective perception of cardiac symptom severity is considered a main treatment target in the management of transthyretin-related cardiac amyloidosis (CA), as opposed to objective prognostic markers such as N-terminal pro b-type natriuretic peptide (NT-proBNP), which objectively reflects the severity of heart disease. Nevertheless, anxious and depressive symptoms in patients with CA might affect subjects perceptions of disease, creating a potential gap between objective and subjective parameters. We assess the impact of such bias in consecutive patients with CA. A total of 60 patients aged 62 to 88 years with CA were recruited. The level of anxiety and depression was measured by the Hospital Anxiety and Depression Scale and the subjective perception of symptoms severity by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Finally, NT-proBNP plasma levels at rest and glomerular filtration rate were measured. Nearly 1/2 of the patients (48%) reported clinically relevant levels of psychologic symptoms. Higher levels of anxious and depressive symptoms were significantly linked to lower KCCQ scores. Furthermore, the relation between NT-proBNP and KCCQ was significant only when anxious and depressive symptoms were low (β = −0.86, p = 0.002; β = −0.86, p = 0.002, respectively) and medium (β = −0.49, p = 0.004; β = −0.45, p = 0.004, respectively) but was otherwise lost. Depression and anxiety in patients with transthyretin-related CA required assessment and management. In conclusion, patients with depression/anxiety have a clear disconnect between their personal assessment and objective measures of cardiac symptoms, with a major influence on the patients’ wellbeing and on their subjective response to treatments in clinical trials.
The use of preoperative B-type natriuretic peptide as a predictor of atrial fibrillation after thoracic surgery: Systematic review and meta-analysis
2015, Journal of Cardiothoracic and Vascular Anesthesia
To determine whether elevated preoperative B-type natriuretic peptide (NP) measurements are an independent predictor of atrial fibrillation (AF) in patients having thoracic surgery.
Systematic review and meta-analysis.
In-hospital and 30 days after thoracic surgery.
The 742 patients who participated in the 5 observational studies.
None.
EMBASE, OVID Health Star, Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ProQuest Dissertations and Theses A&I databases were searched for all studies of noncardiac thoracic surgery patients in whom a preoperative NP was measured up to 1 month before surgery, and that measured the incidence of postoperative AF. Studies were included regardless of their language, sample size, publication status, or study design. Study quality was evaluated using the Newcastle Ottowa Scale.
The combined incidence of postoperative AF was 14.5% (n = 108/742), and the NP thresholds used to predict AF varied among studies. An elevated preoperative NP measurement was associated with an OR of 3.13 (95% CI 1.38-7.12; I2 = 87%) for postoperative AF, with the sensitivity analysis reporting an OR of 9.51 (95% CI 4.66-19.40; I2 = 0).
Patients with an elevated preoperative NP measurement are at an increased risk of postoperative AF. There may be value in incorporating NP measurement into existing AF risk prediction models.
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American college of cardiology/American heart association task force on practice guidelines
2014, Journal of the American College of Cardiology
Role of N-terminal pro B-type natriuretic peptide in identifying patients at high risk for adverse outcome after emergent non-cardiac surgery
2013, British Journal of Anaesthesia
Citation Excerpt :
Secondly, we measured NT-proBNP rather than BNP because of better in vitro stability, a longer half-life, and less susceptibility to rapid haemodynamic changes. Even though there are data showing that increased circulating NT-proBNP might mainly be related to increased cardiac secretion and not decreased renal clearance,31 severely impaired renal function does reduce the specificity of NT-proBNP.32 This could have influenced our results, as we did not exclude patients with renal dysfunction.
Patients undergoing emergency surgery continue to be at very high risk, but accurate risk identification for the individual patient remains difficult. This study tested the usefulness of perioperative N-terminal pro B-type natriuretic peptide (NT-proBNP) for in-hospital and long-term risk stratification.
We conducted a prospective single-centre observational cohort study in an Austrian university hospital. Two hundred and ninety-seven consecutive patients >50 yr of age undergoing a variety of emergency non-cardiac procedures were included. The primary endpoint was a composite of non-fatal myocardial infarction (MI), acute heart failure, or death between index surgery and 3 yr follow-up. The secondary endpoint was in-hospital major adverse cardiac events (MACE), defined as non-fatal MI, acute heart failure, or cardiac death.
During a median follow-up of 34 months (inter-quartile range: 16–39), 31% of subjects reached the primary endpoint. A preoperative NT-proBNP ≥725 pg ml⁻¹ was associated with a 4.8-fold univariate relative risk [95% confidence interval (CI): 3.1–7.6] and a postoperative NT-proBNP ≥1600 pg ml⁻¹ was associated with a four-fold univariate relative risk (95% CI: 2.7–6.2) for reaching the primary endpoint. Moreover, preoperative NT-proBNP remained a significant and independent (hazards ratio 1.91, 95% CI 1.08–3.37, P=0.027) predictor in a multivariate Cox proportional hazards model. A preoperative NT-proBNP ≥1740 pg ml⁻¹ was associated with a 6.9-fold univariate relative risk (95% CI: 3.5–13.4) for MACE during the index hospital stay, but did not remain significant in a multivariate logistic regression model.
Preoperative NT-proBNP can help identify patients at high risk for adverse long-term outcome after emergency surgery.
The prognostic value of B-type natriuretic peptide after cardiac surgery: A comparative study between coronary artery bypass graft surgery and aortic valve replacement
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Citation Excerpt :
Numerous factors may contribute to the postoperative release of BNP after cardiac surgery such as cardioplegia, myocardial damage, infarction, abrupt changes in heart loading conditions, or the occurrence of a systemic inflammatory response syndrome, so the increase in BNP is equivocal during the postoperative period. Impairment in renal function frequently is observed after cardiac surgery and also may act as a confounder, which has been shown to affect BNP prognostic ability in various clinical conditions.17,18 Previous works suggested that the increase of BNP in coronary patients could reflect the extent of myocardial ischemia19 and that ischemia would be the main secretion stimulus for BNP during cardiac surgery.1
The influence of the cardiac surgical procedure on B-type natriuretic peptide (BNP) for the identification of high-risk patients has not been evaluated. This study aimed to compare the prognostic utility of pre- and postoperative BNP in predicting adverse long-term outcome after coronary artery bypass graft (CABG) surgery and aortic valve replacement (AVR).
A retrospective study.
A university teaching hospital.
One hundred eighty-nine patients.
Preoperative, early postoperative (24 hours), and late postoperative (day 5) BNP levels were measured. Major adverse cardiac events (MACEs) within 12 months after surgery were chosen as study endpoints. The predictive abilities of BNP measurements were compared using receiver operating characteristic (ROC) curves. Patients were stratified by CABG surgery (n = 100) and AVR (n = 89). Thirty-four (18%) patients experienced 44 MACEs over the study period. Preoperative BNP values were significantly different between groups. Postoperative BNP gradually increased by 431% on day 5 after CABG surgery and by 100% after AVR (both p < 0.001 v preoperative values). Pre- and early postoperative BNP values were accurate in predicting MACEs after AVR (areas under the ROC curves: 0.78 [95% confidence interval, 0.66-0.90] and 0.76 [95% confidence interval, 0.62-0.89], respectively) and inaccurate after CABG surgery (0.54 [95% confidence interval, 0.38-0.70] and 0.54 [95% confidence interval, 0.36-0.73], respectively). The late postoperative BNP value was of limited value.
BNP measurements should take into account the type of cardiac surgery. Whatever the time of measurement, BNP accurately predicts long-term adverse outcome in valve surgery patients. A late postoperative BNP measurement is useless after cardiac surgery.
The influence of renal function on the prognostic value of Nt-pro brain natriuretic peptide in St-elevation myocardial infarction
2012, International Journal of Cardiology

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¹: Dr. Schouten is supported by an unrestricted research grant from the Netherlands Organization of Health Research and Development (ZonMW), The Hague, the Netherlands.

²: Dr. Dunkelgrun is supported by an unrestricted research grant from the Netherlands Heart Foundation, The Hague, The Netherlands (#2003B143).

³: Drs. Hoeks and van Gestel are supported by an unrestricted research grant from “Lijf & Leven” Foundation, Rotterdam, The Netherlands.

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MiscellaneousInfluence of Renal Function on the Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Cardiac Risk Marker in Patients Undergoing Noncardiac Vascular Surgery

Section snippets

Methods

Results

Discussion

Kidney Int

Am J Kidney Dis

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Miscellaneous
Influence of Renal Function on the Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Cardiac Risk Marker in Patients Undergoing Noncardiac Vascular Surgery