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Ann Intern Med. 2019 Dec 24. doi: 10.7326/M19-2501. [Epub ahead of print]

Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort Study.

Author information

1
University of Montreal, Montreal, Québec, and McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (E.D.).
2
McMaster University, Hamilton, Ontario, Canada (A.P., P.A.K., G.G., D.H., S.H., L.T.).
3
The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (M.T.C., L.Z.).
4
Hospital Israelita Albert Einstein (Academic Research Organization-ARO), Sao Paulo, Brazil (O.B.).
5
Translational Medicine & Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom (G.A., R.P.).
6
University of KwaZulu-Natal, Glenwood, Durban, South Africa (R.R.).
7
Groote Schuur Hospital and University of Cape Town, Western Cape, South Africa (B.B.).
8
Westmead Applied Research Centre, University of Sydney, Sydney, and Westmead Hospital, Westmead, Australia (C.K.C.).
9
McMaster University and Population Health Research Institute and McMaster University, Hamilton, Ontario, Canada (F.K.B., M.M., R.W., A.L.).
10
Cleveland Clinic, Cleveland, Ohio (D.I.S., A.K.).
11
University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.).
12
Jagiellonian University Medical College, Krakow, Poland (W.S.).
13
University of Manitoba, Winnipeg, Manitoba, Canada (S.S.).
14
Western University, London, Ontario, Canada (A.X.G.).
15
Population Health Research Institute, Hamilton, Ontario, Canada (S.P.).
16
University of British Columbia, Vancouver, British Columbia, Canada (E.N.S.).
17
Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, Massachusetts (J.L.J.).
18
University Hospital of Düsseldorf, Düsseldorf, Germany (G.L.B.).
19
British Heart Foundation Centre for Cardiovascular Sciences and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom (N.L.M.).
20
Leeds General Infirmary, Leeds, United Kingdom (R.S.).
21
Population Health Research Institute and McMaster University, Hamilton, Ontario, Canada (G.P.).
22
McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada (M.W., S.Y., P.D.).

Abstract

Background:

Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery.

Objective:

To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery.

Design:

Prospective cohort study.

Setting:

16 hospitals in 9 countries.

Patients:

10 402 patients aged 45 years or older having inpatient noncardiac surgery.

Measurements:

All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery.

Results:

In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]).

Limitation:

External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings.

Conclusion:

Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI.

Primary Funding Source:

Canadian Institutes of Health Research.

PMID:
31869834
DOI:
10.7326/M19-2501

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