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J Am Coll Cardiol. 2014 Jan 21;63(2):170-80. doi: 10.1016/j.jacc.2013.08.1630. Epub 2013 Sep 26.

The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.

Author information

1
Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio. Electronic address: ReitzeRodseth@gmail.com.
2
Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
3
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Anesthesia, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada.
4
Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.
5
Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
6
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Clinical Epidemiology and Biostatistics/Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
7
Department of Internal Medicine, University of Virginia, Charlottesville, Virginia.
8
Department of Surgical Science, University of Perugia, Ospedale S. Maria, Perugia, Italy.
9
Cardioncology Unit, European Institute of Oncology, Milan, Italy.
10
Departments of Aged Care, Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia, and The Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, Victoria, Australia.
11
Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
12
Department of Vascular and General Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland.
13
Department of Medical-Surgery Sciences and Translational Medicine, University La Sapienza, and Emergency Department, Sant'Andrea Hospital, Rome, Italy.
14
Division of General, Visceral and Vascular Surgery, University Hospital, Jena, Germany.
15
Department of Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
16
Departments of Urology, Stepping Hill Hospital, Stockport, United Kingdom, and Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom.
17
Division of Cardiology, Department of Internal Medicine, Ewha Womans University, School of Medicine, Mokdong Hospital, Seoul, Korea.
18
Clinic of Nephrology, University of Belgrade, School of Medicine, Belgrade, Serbia.
19
Department of Vascular Surgery, University Hospital of North Staffordshire, Stoke on Trent, United Kingdom.
20
Department of Vascular Surgery, Ninewells Hospital and Medical School, Dundee, United Kingdom.
21
Department of Mathematics and Statistics, McMaster University, Hamilton, Ontario, Canada.
22
Department of Cardiology, University of Melbourne, Northern Health, Epping, Victoria, Australia.
23
Cardiac Diagnostics Unit, M. Pirogow Provincial Specialist Hospital, Lodz, Poland.
24
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Medicine, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada.

Abstract

OBJECTIVES:

The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (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 pre-operative NP has been measured.

BACKGROUND:

Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done.

METHODS:

We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery.

RESULTS:

Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery.

CONCLUSIONS:

Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.

KEYWORDS:

AUC; B-type natriuretic peptide; BNP; CI; IQR; MI; N-terminal fragment of B-type natriuretic peptide; NP; NRI; NT-proBNP; OR; QICu; RCRI; ROC; Revised Cardiac Risk Index; anesthesia; area under the curve; confidence interval; corrected quasi-likelihood under the independence model criterion; interquartile range; myocardial infarction; natriuretic peptide; natriuretic peptides; net reclassification index; odds ratio; receiver operating characteristic; risk factors; surgery

PMID:
24076282
DOI:
10.1016/j.jacc.2013.08.1630
[Indexed for MEDLINE]
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