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

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


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.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Biomarkers / blood
  • Cardiovascular Diseases* / blood
  • Cardiovascular Diseases* / epidemiology
  • Cardiovascular Diseases* / etiology
  • Global Health
  • Humans
  • Incidence
  • Natriuretic Peptide, Brain / blood*
  • Peptide Fragments / blood
  • Postoperative Complications* / blood
  • Postoperative Complications* / epidemiology
  • Postoperative Complications* / etiology
  • Postoperative Period
  • Preoperative Period
  • Prognosis
  • Surgical Procedures, Operative*


  • Biomarkers
  • Peptide Fragments
  • pro-brain natriuretic peptide (1-76)
  • Natriuretic Peptide, Brain