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

doi:10.7326/M19-2501

Multicenter Study

. 2020 Jan 21;172(2):96-104.

doi: 10.7326/M19-2501. Epub 2019 Dec 24.

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

Emmanuelle Duceppe¹, Ameen Patel², Matthew T V Chan³, Otavio Berwanger⁴, Gareth Ackland⁵, Peter A Kavsak², Reitze Rodseth⁶, Bruce Biccard⁷, Clara K Chow⁸, Flavia K Borges⁹, Gordon Guyatt², Rupert Pearse⁵, Daniel I Sessler¹⁰, Diane Heels-Ansdell², Andrea Kurz¹⁰, Chew Yin Wang¹¹, Wojciech Szczeklik¹², Sadeesh Srinathan¹³, Amit X Garg¹⁴, Shirley Pettit¹⁵, Erin N Sloan¹⁶, James L Januzzi Jr¹⁷, Matthew McQueen⁹, Giovanna Lurati Buse¹⁸, Nicholas L Mills¹⁹, Lin Zhang³, Robert Sapsford²⁰, Guillaume Paré⁹, Michael Walsh⁹, Richard Whitlock⁹, Andre Lamy⁹, Stephen Hill², Lehana Thabane², Salim Yusuf⁹, P J Devereaux⁹

Affiliations

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, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.).
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.).

PMID: 31869834
DOI: 10.7326/M19-2501

Multicenter Study

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

Emmanuelle Duceppe et al. Ann Intern Med. 2020.

. 2020 Jan 21;172(2):96-104.

doi: 10.7326/M19-2501. Epub 2019 Dec 24.

Authors

Affiliations

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, Hamilton, Ontario, Canada (F.K.B., M.M., G.P., M.W., R.W., A.L., S.Y., P.D.).
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.).

PMID: 31869834
DOI: 10.7326/M19-2501

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.

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Comment in

Biomarkers to Personalize Preoperative Cardiovascular Risk Stratification: Ready for Prime Time?
Qamar A, Bangalore S. Qamar A, et al. Ann Intern Med. 2020 Jan 21;172(2):149-150. doi: 10.7326/M19-3718. Epub 2019 Dec 24. Ann Intern Med. 2020. PMID: 31869831 No abstract available.
Adding NT-proBNP to the Revised Cardiac Risk Index improved prediction of CV events after noncardiac surgery.
Paladugu S, Donato AA. Paladugu S, et al. Ann Intern Med. 2020 May 19;172(10):JC59. doi: 10.7326/ACPJ202005190-059. Ann Intern Med. 2020. PMID: 32422088
Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery.
Bhudia N, Bakhai A, Baumber R. Bhudia N, et al. Ann Intern Med. 2020 Jun 16;172(12):842-843. doi: 10.7326/L20-0268. Ann Intern Med. 2020. PMID: 32539497 No abstract available.
Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery.
Gupta N, Doshi R, Meghrajani V. Gupta N, et al. Ann Intern Med. 2020 Jun 16;172(12):842. doi: 10.7326/L20-0267. Ann Intern Med. 2020. PMID: 32539498 No abstract available.
Preoperative N-Terminal Pro-B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery.
Duceppe E, Heels-Ansdell D, Devereaux PJ. Duceppe E, et al. Ann Intern Med. 2020 Jun 16;172(12):843. doi: 10.7326/L20-0269. Ann Intern Med. 2020. PMID: 32539503 No abstract available.

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

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

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