Postoperative B-type Natriuretic Peptide for Prediction of Major Cardiac Events in Patients Undergoing Noncardiac Surgery

and Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio. † Honorary Associate Professor, Perioperative Research Group, Department of Anaesthetics, Inkosi Albert Luthuli Central Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal. ‡ Statistician, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, ***** Masters Candidate, Department of Mathematics and Statistics, McMaster University, Hamilton, Ontario, Canada. § Anaesthetic Consultant, ** Assistant Professor, Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland. ‖ Professor, Departments of Clinical Epidemiology and Biostatistics/Anesthesia/Pediatrics, McMaster University
Anesthesiology (Impact Factor: 5.88). 03/2013; 119(2). DOI: 10.1097/ALN.0b013e31829083f1
Source: PubMed


It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery.

The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more.

The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64-0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77-0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74-7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29-7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32-254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55-75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58-4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67-86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05-1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0-9.34; P = 0.022). Patients with BNP values of 0-250, greater than 250-400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0-300, greater than 300-900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively.

Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

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    • "Breidthardt et al. studied patients undergoing “unselected” orthopedic surgery and demonstrated that preoperative BNP levels can predict short-term and long-term postoperative cardiac events, with ROC analysis giving an AUC of 0.86 for preoperative BNP [25]. Moreover, in a recent meta-analysis of pre- and post-operative BNP values, Rodseth et al. found that patients with elevated postoperative BNP concentrations were at increased risk of AMI, cardiac failure and mortality at 30 days and even 180 days after surgery [26]. The usefulness of preoperative BNP measurements as a predictor of perioperative cardiac events was also reported by Cuthbertson and co-workers, who identified a cut-off of preoperative BNP > 40 pg/mL to be associated with a 5-fold increase in the risk of developing either postoperative cTnI elevation > 0.32 ng/mL or new ECG abnormalities [27]. "
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    ABSTRACT: - To determine if measuring postoperative B-type natriuretic peptides (NP, i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification, in adult patients undergoing noncardiac surgery, in whom a preoperative NP has been measured. - Preoperative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated postoperative NP concentrations are independently associated with these complications. It is not clear if there is value in measuring postoperative NP when a preoperative measurement has been done. We conducted a systematic review and individual patient data meta-analysis to determine if the addition of postoperative NP enhanced the prediction of the composite of death and nonfatal myocardial infarction (MI) at 30 and ≥180 days after surgery. 18 eligible studies provided individual patient data (n=2179). Adding postoperative NP to a risk prediction model containing preoperative NP improved model fit and risk classification at both 30 days (QICu 1280 to 1204; NRI 20%; p<0.001) and at ≥180 days (QICu 1320 to 1300; NRI 11%; p=0.003). Elevated postoperative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio [OR] 3.7; 95% CI 2.2-6.2; p<0.001) and ≥180 days (OR 2.2; 95% CI 1.9-2.7; p<0.001) after surgery. Additional postoperative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal MI 30 days and ≥180 days after noncardiac surgery as compared to a preoperative NP measurement alone.a.
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