Risk Stratification in Patients With Chronic Thromboembolic Pulmonary Hypertension Following Pulmonary Endarterectomy: The Role of Brain Natriuretic Peptide and High-Sensitivity Troponin I

Stefano Ghio; Andrea Rapagnani; Beatrice Pasotti; Alessia Alloni; Bruno Crimi; Catherine Klersy; Riccardo Albertini; Mauro Acquaro; Laura Scelsi; Annalisa Turco; Andrea Maria D'Armini

doi:10.1016/j.chest.2026.04.021

Risk Stratification in Patients With Chronic Thromboembolic Pulmonary Hypertension Following Pulmonary Endarterectomy: The Role of Brain Natriuretic Peptide and High-Sensitivity Troponin I

Chest. 2026 Apr 28:S0012-3692(26)00579-9. doi: 10.1016/j.chest.2026.04.021. Online ahead of print.

Authors

Affiliations

¹ Cardiology Division, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. Electronic address: s.ghio@smatteo.pv.it.
² Cardiac Surgery and Pulmonary Hypertension Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Cardiac Surgery Unit, University of Pavia School of Medicine, Pavia, Italy.
³ Cardiology Division, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Cardiac Surgery and Pulmonary Hypertension Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
⁴ Cardiac Surgery and Pulmonary Hypertension Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
⁵ Cardiac Surgery Unit, University of Pavia School of Medicine, Pavia, Italy.
⁶ Biostatistics and Clinical Trial Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
⁷ Laboratory of Clinical Chemistry, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
⁸ Cardiology Division, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

PMID: 42061699
DOI: 10.1016/j.chest.2026.04.021

Abstract

Background: Natriuretic peptides are a simple, widely accessible, and cost-effective tool for the assessment of disease severity in patients with pulmonary arterial hypertension. The potential prognostic value of these biomarkers has never been assessed to stratify the risk of patients with chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary endarterectomy (PEA).

Research question: Do brain natriuretic peptide (BNP) and high-sensitivity troponin I (hs-TNI) plasma levels predict long-term prognosis following PEA? Also, do they provide prognostic information additional to persistent pulmonary hypertension (PH) following surgery (defined as mean pulmonary artery pressure > 20 mm Hg and pulmonary vascular resistance > 2 Woods unit)?

Study design and methods: The study included a total of 1,176 consecutive patients with CTEPH who underwent PEA from 1994 to 2024. Data on hemodynamics and biomarkers were available in 1,176 patients at baseline and in 867 patients at a first follow-up visit 3 to 6 months after PEA.

Results: At follow-up, 357 patients had normal BNP and 488 had abnormal BNP levels; 22 additionally had abnormal hs-TNI plasma levels. The proportion of patients in World Health Organization functional class III to IV and with compromised exercise capacity increased over the 3 groups (the difference between the abnormal BNP group and the group with abnormality of both biomarkers did not reach statistical significance). During a subsequent median follow-up period of 54 months, 45 cardiac deaths occurred. Abnormal plasma levels of BNP following surgery were associated with a 5-fold increased mortality at multivariable analysis adjusted for the presence of persistent PH.

Interpretation: Plasma levels of BNP are robust prognostic parameters that provide additional information to the assessment of persistent PH in patients with CTEPH who have undergone PEA.

Keywords: BNP; CTEPH; hs-TNI; prognosis; pulmonary endarterectomy.