Key result
Elevated BNP or NT-proBNP predicts ~153% higher all-cause mortality in classical low-flow aortic stenosis.
Why the study?
Patients with classical low-flow aortic stenosis have dismal outcomes without aortic valve replacement but high operative mortality, and the utility of BNP/NT-proBNP for risk stratification and clinical decision-making was unknown.
Do baseline BNP or NT-proBNP levels predict mortality and assist in clinical decision-making for early aortic valve replacement in patients with classical low-flow, low-gradient aortic stenosis?
Cohort (n=234)
Yes
Do baseline BNP or NT-proBNP levels predict mortality and assist in clinical decision-making for early aortic valve replacement in patients with classical low-flow, low-gradient aortic stenosis?
Effect estimate: adjusted HR 2.53 (95% CI 1.68-3.81)
p-value: p=<0.001
In patients with classical low-flow, low-gradient aortic stenosis, elevated BNP (>550 pg/ml) or NT-proBNP (>1,600 pg/ml) identifies high-risk individuals who have poor outcomes with conservative management but significantly improved survival with early aortic valve replacement.
Elevated natriuretic peptides identify high-risk low-flow AS; hypothesis-generating for early AVR benefit, pending randomized confirmation.
BackgroundPatients with low left ventricular ejection fraction (LVEF), low-flow, low-gradient (i.e. classical low flow [CLF]) aortic stenosis (AS) have a dismal short-term outcome without aortic valve replacement (AVR) but high operative mortality. We hypothesized that brain natriuretic peptides (BNP/NT-proBNP) can risk stratify patients with CLF AS and may assist in clinical decision-making.MethodsPatients with aortic valve area ≤1.2 cm2, mean transvalvular gradient <40 mmHg, and left ventricular ejection fraction <50%, were prospectively recruited. BNP and/or NT-proBNP were measured at baseline.ResultsAmong 234 patients (77 [68–83] years, 76% male), BNP > 550 pg/ml or NT-proBNP > 1,600 pg/ml (85% and 93% sensitivity, respectively, to correctly classify 1-year death) strongly predicted all-cause mortality (adjusted HR = 2.53 [1.68–3.81], p < 0.001) outperforming flow reserve and baseline LVEF (all likelihood ratio p ≤ 0.02). For both natriuretic peptides, spline curve analysis showed gradual increase in mortality with higher biomarkers levels, which was blunted by AVR. In a head-to-head comparison (n = 104), NT-proBNP appeared to have superior incremental prognostic value than BNP (likelihood-ratio p < 0.001 vs. p = 0.07). Baseline NT-proBNP ≥ 1,600 pg/ml or BNP ≥ 550 pg/ml, identified: i) a high-risk cohort with a dismal outcome under conservative management, but a markedly better survival associated with early AVR (adjusted HR = 0.41 [0.25–0.65], p < 0.001); and ii) a low-risk cohort with an excellent 1-year survival (94 ± 4%) with conservative management or deferred AVR.ConclusionIn patients with CLF AS, BNP/NT-proBNP have the potential to identify high-risk patients who may benefit from early AVR.
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Annabi et al. (2021) conducted a cohort in Low Ejection Fraction, Low-Flow, Low-Gradient Aortic Stenosis (n=234). BNP > 550 pg/ml or NT-proBNP > 1,600 pg/ml vs. BNP ≤ 550 pg/ml or NT-proBNP ≤ 1,600 pg/ml was evaluated on All-cause mortality (adjusted HR 2.53, 95% CI 1.68-3.81, p=<0.001). Elevated baseline BNP (>550 pg/ml) or NT-proBNP (>1,600 pg/ml) strongly predicted all-cause mortality (adjusted HR 2.53; 95% CI 1.68-3.81; p<0.001) in classical low-flow aortic stenosis.
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