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Prognostic Value of NT-proBNP in Elderly With Valvular Heart Disease
Study Questions:
Is the age- and gender-adjusted N-terminal pro–B-type natriuretic peptide (NT-proBNP) ratio associated with outcomes and parameters of cardiac dysfunction in patients with moderate to severe valvular heart disease (VHD)?
Methods:
This study derives its findings from a subset of the China-DVD (China Elderly Valve Disease) prospective cohort, and included 5,983 elderly (age ≥60 years) inpatients with ≥1 valve with at least moderate stenosis or regurgitation and available NT-proBNP data. The primary endpoint was all-cause mortality. Close to three-quarters (72%) of patients had long-term follow-up. Echocardiographic parameters examined included ejection fraction (EF), and left ventricular (LV) and left atrial (LA) volumes. Analyses were stratified by VHD and etiology.
Results:
The mean age was 71 years, and 53% were men. Aortic stenosis (AS) comprised 5% of the population, aortic regurgitation (AR) 10%, mitral stenosis (MS) 3%, mitral regurgitation (MR) 27%, and tricuspid regurgitation (TR) 17%. Over one-third (38%) had multivalvular heart disease (MVHD). The median NT-proBNP ratio was 13.1 (interquartile range, 4.2-40.7), and varied significantly according to diagnostic category, with the highest values seen in MVHD and the lowest in AR. Levels correlated with indexed LV–LA volumes. There were 561 deaths (9.4%) at 1-year follow-up. Except for MS, other VHDs all presented a monotonic increase in hazard ratios (HRs) with greater NT-proBNP ratio. A remarkably sharper increase in HR with the elevation of NT-proBNP ratio was observed for AS compared with other VHDs. The association persisted in the subgroup of patients on medical treatment (n = 4,749), and in those with EF ≥50%. Addition of NT-proBNP to a prognostic model which includes clinical characteristics and LVEF improved risk discrimination indices modestly, an effect more pronounced in AS and AR, modest for TR, and insignificant for MS.
Conclusions:
The authors concluded that NT-proBNP is associated with all-cause death in elderly patients with VHD.
Perspective:
This study reiterates what is already known; NT-proBNP is prognostic in various patient populations, including those with VHD. The correlations with echocardiographic parameters were modest (range r = -0.22 for MS to r = -0.5 for AR). Interestingly, NT-proBNP was not significantly associated with outcomes in patients with MS, which may be due to the overall smaller sample size of this subgroup of patients (3%) and the fact that the left ventricle is typically not affected in MS. Unfortunately, there is little clinical implication to these findings, given the vast majority of patients were treated medically, and no conclusions can be made with using NT-proBNP to time therapeutic interventions.
Clinical Topics: Cardiovascular Care Team, Geriatric Cardiology, Noninvasive Imaging, Valvular Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Aortic Valve Insufficiency, Aortic Valve Stenosis, Constriction, Pathologic, Diagnostic Imaging, Echocardiography, Geriatrics, Heart Valve Diseases, Mitral Valve Insufficiency, Mitral Valve Stenosis, Natriuretic Peptide, Brain, Prognosis, Stroke Volume, Tricuspid Valve Insufficiency
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