Persistently increased NT-pro BNP one year after acute coronary syndrome: insights from the SPUM-ACS registry

Background Temporal biomarker dynamics have been investigated in predicting cardiovascular (CV) outcome after acute coronary syndrome (ACS). However, the value of longitudinal changes in NT-pro BNP levels after the ACS is uncertain. Purpose The aim of the present study was to evaluate outcomes according to NT-pro BNP trajectory throughout 1 year follow-up after ACS. Methods Acute coronary syndrome (ACS) patients admitted to four Swiss University Hospitals and enrolled in the multicenter SPUM registry between 2009 and 2017 were followed prospectively for 1 year. The primary endpoint was a composite of major adverse cardiovascular (MACE); i.e., non-fatal stroke, non-fatal myocardial infarction (MI) or major bleeding) at 1 year. Persistently high NT-pro BNP was defined as >125 pg/ml at baseline as well as at 1 year follow-up. Multivariable-adjusted Cox proportional hazard regression models were fit to estimate MACE risk. Results Out of 4’787 ACS patients, 1704 (35,6%) presented persistently high NT-pro BNP. These patients were older (64.2±12.7 vs 63.2±11.2 years, p=0.011), had similar rate of traditional cardiovascular (CV) risk factors with the exception of a slightly lower prevalence of hypercholesterolemia (60.0% vs 65.2%, p>0.001). Further, they had fewer prior CV events, such as previous MI (9.8% vs 13.9, p<0.001) and previous percutaneous coronary interventions (PCI; 11.2% vs 17.4%, p<0.001). The initial presentation was more frequently NSTEMI (49.1% vs 39.9%, p<=.001) and they were more often pharmacologically undertreated (all p<0.001). Glomerular filtration rate was slightly lower (83.0±22.8 vs 84.3±19.7, p=0.021) in those with persistently high NT-pro BNP and they also had increased inflammation as reflected by plasma levels of high-sensitive C-reactive protein (hs-CRP 16.3±36.3 vs 8.6±22.3 mg/l, p<0.001 and NLR 6.9±1.8 vs 4.9±1.1, p<0.001). Lastly, persistently high NT-pro BNP was associated with a higher rate of MACE at 1 year (7.1% vs 5.2%, p=0.006). This enhanced risk persisted after adjustment for confounding baseline characteristics (adjusted HR 1.39, 95%CI 1.04-1.85, p=0.02, Figure 1, Panel A) and they were linked to the highest risk of MACE (Figure 1, Panel B) compared to all other groups. Conclusions Persistently high NT-pro BNP at 1 year follow-up is associated with increased risk of MACE at 1 year. Patients with persistently high NT-pro BNP coincide with the highest risk of MACE compared to those with persistently low levels or change in NT-pro BNP determination. Thus, these features should alert physicians to implement aggressive secondary prevention in such patients.