The Prognostic Value of Pre-Operative and Post-Operative B-Type Natriuretic Peptides in Patients Undergoing Noncardiac Surgery
Key result
Elevated post-operative natriuretic peptide predicts ~270% higher 30-day death or MI risk after noncardiac surgery.
- OR 3.7
- 95% CI 2.2 to 6.2
- P<0.001
- n=2,179
Why the study?
Pre-operative natriuretic peptide concentrations predict perioperative cardiovascular complications, but it remained unclear whether measuring post-operative levels provides additional prognostic value when pre-operative measurements exist.
Does adding post-operative NP measurement to pre-operative NP measurement improve risk stratification for death or nonfatal MI in adult patients undergoing noncardiac surgery?
Key Points
- To determine whether measuring postoperative B-type natriuretic peptides (BNP and NT-proBNP) improves risk stratification for death and myocardial infarction in patients undergoing noncardiac surgery who already had preoperative measurements.
- Conducted a systematic review and individual patient data meta-analysis across 18 eligible studies including 2,179 adult patients undergoing noncardiac surgery.
- Evaluated model fit and risk reclassification for the composite endpoint of death and nonfatal myocardial infarction at 30 days and ≥180 days post-surgery.
- Adding postoperative NP to models with preoperative NP significantly improved risk reclassification at 30 days (NRI: 20%; p < 0.001; QIC: 1,280 to 1,204) and ≥180 days (NRI: 11%; p = 0.003; QIC: 1,320 to 1,300).
- Elevated postoperative NP was the strongest independent predictor of the composite outcome at 30 days (OR: 3.7; 95% CI: 2.2 to 6.2; p < 0.001) and ≥180 days (OR: 2.2; 95% CI: 1.9 to 2.7; p < 0.001).
Study Design
Type
Meta-Analysis (n=2,179)
Multicenter
Yes
Structured PICO
Does adding post-operative NP measurement to pre-operative NP measurement improve risk stratification for death or nonfatal MI in adult patients undergoing noncardiac surgery?
P
Population
2,179 adult patients undergoing noncardiac surgery with pre-operative natriuretic peptide measurements, evaluated for post-operative risk stratification.
E
Exposure
Post-operative B-type natriuretic peptide (BNP or NT-proBNP) measurement added to a risk prediction model containing pre-operative NP
C
Comparator
Pre-operative NP measurement alone
O
Outcome
Composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgerycomposite
Main Result
Odds Ratio: 3.7 (95% CI 2.2–6.2)
p-value: p=<0.001
Measuring post-operative natriuretic peptides in addition to pre-operative levels significantly enhances risk stratification for death or nonfatal MI at 30 and ≥180 days after noncardiac surgery.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“the cost of measuring natriuretic peptide levels is much lower than the cost of a stress test. Results can be obtained within minutes with testing at the point of care. [This approach] is thus preferable to stress testing because it is more accurate and convenient, faster, and less expensive. In fact, measurement of natriuretic peptide levels costs less than an internal medicine or cardiology consultation, so the test might be used to decide which patients should be referred for consultation with a specialist.”
“We spend a lot of time and energy right now in trying to do preoperative evaluation to provide people with our ethical obligation to let them understand both the risk and benefit of surgery, and this shows that a very simple, readily available rapid blood test can give you much better risk prediction then the current strategies that we're using.”
AQArman QamarCardiologist, NYU Grossman School of Medicine
“there is unquestionable evidence about the prognostic significance of NT-proBNP in preoperative risk stratification”
Implication
Postoperative NP measurement may enhance risk stratification beyond preoperative values alone; leaves open whether routine use improves outcomes in noncardiac surgery.
Abstract
OBJECTIVES: The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured. BACKGROUND: Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done. METHODS: We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery. RESULTS: Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery. CONCLUSIONS: Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.
Discussion
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Cite This Study
Rodseth et al. (2013) conducted a meta-analysis in Noncardiac surgery (n=2,179). Elevated post-operative B-type natriuretic peptides (NPs) vs. Pre-operative NP measurement alone was evaluated on Composite of death and nonfatal myocardial infarction at 30 days (OR 3.7, 95% CI 2.2 to 6.2, p=<0.001). Elevated post-operative natriuretic peptide was a strong independent predictor of death or nonfatal myocardial infarction at 30 days (OR 3.7; 95% CI 2.2-6.2; P<0.001) after noncardiac surgery.