The Prognostic Value of Preoperative and Postoperative B-Type Natriuretic Peptides (BNP and NT ProBNP) in Patients Having Noncardiac Surgery: A Systematic Review and Individual Patient Data Meta-Analysis

Study Questions:

What is the prognostic utility of postoperative B-type natriuretic peptides (BNPs) (i.e., BNP and N-terminal fragment of proBNP [NT-proBNP]) for risk stratification in adult patients undergoing noncardiac surgery, in whom a preoperative NP has been measured?

Methods:

The investigators conducted a systematic review and individual patient data meta-analysis to determine if the addition of postoperative NP enhanced the prediction of the composite of death and nonfatal myocardial infarction (MI) at 30 and ≥180 days after surgery. To identify independent predictors of the primary outcome at 30 days and ≥180 days after surgery, investigators used generalized estimating equations (GEEs) with an exchangeable correlation structure to take into account study clustering.

Results:

Eighteen eligible studies provided individual patient data (n = 2,179). Adding postoperative NP to a risk prediction model containing preoperative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion [QICu], 1280-1204; net reclassification index [NRI], 20%; p < 0.001) and at ≥180 days (QICu, 1320-1300; NRI, 11%; p = 0.003). Elevated postoperative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio [OR], 3.7; 95% confidence interval [CI], 2.2-6.2; p < 0.001) and ≥180 days (OR, 2.2; 95% CI, 1.9-2.7; p < 0.001) after surgery.

Conclusions:

The authors concluded that additional postoperative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal MI 30 days and ≥180 days after noncardiac surgery, as compared to a preoperative NP measurement alone.

Perspective:

This systematic review and individual patient-level data analysis demonstrates that adding a postoperative NP measurement to a preoperative risk model, which included preoperative NP measurement, improved the prediction of mortality or nonfatal MI at 30 or ≥180 days after noncardiac surgery. It is possible that postoperative NP elevations may identify patients who will develop major cardiovascular complications, allowing physicians to intervene by administering beta-blockers, aspirin, or statins. However, additional studies are required to ascertain whether interventions in response to NP measurements will actually improve patient outcomes.

Clinical Topics: Anticoagulation Management, Dyslipidemia, Nonstatins, Novel Agents, Statins

Keywords: Myocardial Infarction, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lewis Blood-Group System, Postoperative Period, Heart Diseases, Prognosis, Troponin I, Cardiology, Peptide Fragments, Confidence Intervals, Natriuretic Peptide, Brain


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