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.
Bibliographical noteFunding Information:
Dr. Rodseth is supported by a Canadian Institutes of Health Research Scholarship (the Canada-HOPE Scholarship) , Ottawa, Canada; the College of Medicine of South Africa (the Phyllis Kocker/Bradlow Award) , Cape Town, South Africa; and the University of KwaZulu-Natal (competitive research grant) , Durban, South Africa. Dr. Biccard is supported by the South African Society of Anaesthesiologists (The Jan Pretorius Research Fund) , Johannesburg, South Africa; and the University of KwaZulu-Natal (competitive research grant) , Durban, South Africa. Dr. Chong is a recipient of a National Health and Medical Research Council (Australia postgraduate research scholarship), Canberra, Australia, and has received research stipends from The University of Melbourne, Melbourne, Australia, and the Northern Clinical Research, Melbourne, Australia. Dr. Mahla has received NT-proBNP kits from Roche Diagnostics GmbH, Mannheim, Germany; and study grants from Novo Nordisk Pharma GmbH, Vienna, Austria, and CSL Behring Biotherapies for Life, Vienna , Austria. Dr. Radović was supported by the Ministry of Science , Belgrade, Republic of Serbia, Research Grant No. 175089 . Dr. Devereaux is supported by a Heart and Stroke Foundation of Ontario Career Investigator Award, Ottawa, Canada. All other support was provided solely from institutional and/or departmental sources. Dr. Di Somma consults for Alere, San Diego, California. Dr. Mahla has received speaker honoraria and consulting fees from CLS Behring Biotherapies for Life, Vienna, Austria, Germany, and Boehringer Ingelheim RCV, GmbH & Co. KG. Dr. Devereaux has received a grant-in-kind from Roche Diagnostics , Basel, Switzerland, to evaluate NT-proBNP and troponin T among patients undergoing noncardiac surgery. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- myocardial infarction
- natriuretic peptides
- risk factors