Residual cardiovascular risk after ACS in oncologic patients: the prognostic role of persistently elevated NT proBNP

Background Patients with a history of cancer represent a growing subset of acute coronary syndrome (ACS) survivors and may harbor a high residual cardiovascular risk. NT-proBNP is a well-established biomarker of cardiac stress, but its prognostic value at 1-year follow-up specifically in oncologic ACS patients remains unclear. Purpose To assess whether persistently elevated NT-proBNP at 1 year identifies oncologic ACS patients at higher risk of net adverse clinical events (NACE). 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. NT-proBNP was measured at baseline and at 1-year follow-up in survivors and persistently elevated NT-proBNP at 1 year was defined among patients alive at 1 year. The primary endpoint was a composite of net adverse clinical event (NACE), i.e. death, non-fatal stroke, non-fatal myocardial and major bleedings at 1 year. Multivariable-adjusted Cox proportional hazard regression models were fit to estimate NACE risk. Results Out of 4,787 ACS patients, 372 (7.8%) had a history of cancer. Compared to non-oncologic patients, these patients were older (70.3 ± 10.4 vs 63.1 ± 12.4 years, p < 0.001), more frequently female (25.0% vs 20.0%, p = 0.018), and had a higher prevalence of traditional cardiovascular risk factors (all p < 0.001), except for dyslipidemia. They also had a higher rate of prior percutaneous coronary interventions (PCI; 19.6% vs 14.5%, p = 0.006). NSTEMI was more common at presentation (50.5% vs 42.7%, p = 0.003). Baseline renal function was slightly lower (eGFR 74.0 ± 22.8 vs 84.7 ± 20.7 mL/min/1.73 m², p = 0.021), and these patients exhibited higher inflammatory activity as reflected by hs-CRP (17.1 ± 40.3 vs 11.1 ± 27.7 mg/L, p < 0.001). At 1 year, ACS patients with a history of cancer had a higher incidence of NACE compared to non-oncologic patients (19.6% vs 11.1%, p < 0.001), which remained significant after adjustment for baseline confounders (adjusted HR 1.49, 95% CI 1.07–2.07, p = 0.018; Figure 1, Panel A). Among oncologic patients, those with persistently elevated NT-proBNP at 1 year exhibited an even higher risk of NACE compared to patients with low or normalized NT-proBNP (adjusted HR 1.36, 95% CI 1.02–1.81, p = 0.036; Figure 1, Panel B). Conclusions In ACS patients with a history of cancer, persistently elevated NT-proBNP at 1 year identifies a high-risk biological phenotype. Serial NT-proBNP measurements provide incremental prognostic information beyond baseline clinical characteristics and may support long-term risk stratification in this vulnerable population.KM event rate in oncologic ACS patients.