Prognostic value of brain natriuretic peptide in noncardiac surgery: a meta-analysis

Anesthesiology. 2009 Aug;111(2):311-9. doi: 10.1097/ALN.0b013e3181aaeb11.


Background: The prognostic role of brain natriuretic peptide (BNP) measurement before noncardiac surgery is unclear. The authors therefore performed a meta-analysis of studies in patients undergoing noncardiac surgery to assess the prognostic value of elevated BNP or N-terminal pro-BNP (NT-proBNP) levels in predicting mortality and major adverse cardiovascular events (MACE) (cardiac death or nonfatal myocardial infarction).

Methods: Unrestricted searches of MEDLINE and EMBASE bibliographic databases were performed using the terms "brain natriuretic peptide," "b-type natriuretic peptide," "BNP," "NT-proBNP," and "surgery." In addition, review articles, bibliographies, and abstracts of scientific meetings were manually searched. The meta-analysis included prospective studies that reported on the association of BNP or NT-proBNP and postoperative major adverse cardiovascular event (MACE) or mortality. The study endpoints were MACE, all-cause mortality, and cardiac mortality at short-term (less than 43 days after surgery) and longer-term (more than 6 months) follow-up. A random-effects model was used to pool study results; funnel-plot inspection was done to evaluate publication bias; Cochrane chi-square test and I testing was used to test for heterogeneity.

Results: Data from 15 publications (4,856 patients) were included in the analysis. Preoperative BNP elevation was associated with an increased risk of short-term MACE (OR 19.77; 95% confidence interval [CI] 13.18-29.65; P < 0.0001), all-cause mortality (OR 9.28; 95% CI 3.51-24.56; P < 0.0001), and cardiac death (OR 23.88; 95% CI 9.43-60.43; P < 0.00001). Results were consistent for both BNP and NT-proBNP. Preoperative BNP elevation was also associated with an increased risk of long-term MACE (OR 17.70; 95% CI 3.11-100.80; P < 0.0001) and all-cause mortality (OR 4.77; 95% CI 2.99-7.46; P < 0.00001).

Conclusions: Elevated BNP and NT-proBNP levels identify patients undergoing major noncardiac surgery at high risk of cardiac mortality, all-cause mortality, and MACE.

Publication types

  • Meta-Analysis
  • Review

MeSH terms

  • Aged
  • Brain-Derived Neurotrophic Factor / blood*
  • Cardiovascular Diseases / etiology*
  • Cardiovascular Diseases / mortality*
  • Female
  • Follow-Up Studies
  • Heart Diseases / etiology
  • Heart Diseases / mortality
  • Humans
  • Male
  • Middle Aged
  • Natriuretic Peptide, Brain / blood
  • Odds Ratio
  • Peptide Fragments / blood
  • Predictive Value of Tests
  • Prognosis*
  • Publication Bias
  • Surgical Procedures, Operative*


  • Brain-Derived Neurotrophic Factor
  • Peptide Fragments
  • pro-brain natriuretic peptide (1-76)
  • Natriuretic Peptide, Brain