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

Duceppe E 1 , Patel A 2 , Chan MTV 3 , Berwanger O 4 , Ackland G 5 , Kavsak PA 2 Show all authors , Rodseth R 6 , Biccard B 7 , Chow CK 8 , Borges FK 9 , Guyatt G 2 , Pearse R 5 , Sessler DI 10 , Heels-Ansdell D 2 , Kurz A 10 , Wang CY 11 , Szczeklik W 12 , Srinathan S 13 , Garg AX 14 , Pettit S 15 , Sloan EN 16 , Januzzi JL 17 , McQueen M 9 , Buse GL 18 , Mills NL 19 , Zhang L 3 , Sapsford R 20 , Paré G 9 , Walsh M 9 , Whitlock R 9 , Lamy A 9 , Hill S 2 , Thabane L 2 , Yusuf S 9 , Devereaux PJ 9

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.)
Ann Intern Med, 2020 01 21;172(2):96-104.
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.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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