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Natriuretic Peptide Levels After TAVR and Outcomes
Quick Takes
- Among patients with severe symptomatic AS treated with TAVR, higher BNP levels at discharge, 30 days, and 1 year were each independently associated with increased mortality and rehospitalization rates.
- These findings suggest that higher residual BNP levels after TAVR despite mechanical unloading of the heart is associated with adverse events and worse quality of life and functional capacity.
- Prospective mechanistic studies are indicated to assess whether strategies to ameliorate the pathobiology of elevated BNP levels such as earlier valve replacement or intensification of medical therapy after TAVR may improve patient outcomes.
Study Questions:
What are the associations of elevated B-type natriuretic peptide (BNP) levels after transcatheter aortic valve replacement (TAVR) and change in BNP levels between follow-up time points with risk of subsequent clinical outcomes?
Methods:
The investigators conducted a cohort study of patients with severe symptomatic aortic stenosis (AS) at intermediate, high, or prohibitive surgical risk for aortic valve replacement who underwent TAVR from the PARTNER IIA cohort, PARTNER IIB cohort, SAPIEN 3 intermediate-risk registry, and SAPIEN 3 high-risk registry. BNP levels were obtained at baseline and discharge as well as 30 days and 1 year after TAVR. For each measurement, a BNP ratio was calculated using measured BNP level divided by the upper limit of normal for the assay used. Outcomes were evaluated in landmark analyses out to 2 years. Data were collected from April 2011 to January 2019. The main outcomes measures were all-cause death, cardiovascular death, rehospitalization, and the combined endpoint of cardiovascular death or rehospitalization. Time to first event curves are displayed using Kaplan-Meier estimates and compared using the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (Cis) are estimated by study-stratified Cox proportional hazards regression models.
Results:
Among 3,391 included patients, 1,969 (58.1%) were male, and the mean (standard deviation) age was 82 (7.5) years. Most patients had a BNP ratio >1 at each follow-up time point, including 2,820 of 3,256 (86.6%) at baseline, 2,652 of 2,995 (88.5%) at discharge, 1,779 of 2,209 (80.5%) at 30 days, and 1,799 of 2,391 (75.2%) at 1 year. After adjustment, every 1-point increase in BNP ratio at 30 days (approximately equivalent to an increase of 100 pg/ml in BNP) was associated with an increased hazard of all-cause death (adjusted HR [aHR], 1.11; 95% CI, 1.07-1.15), cardiovascular death (aHR, 1.16; 95% CI, 1.11-1.21), and rehospitalization (aHR, 1.08; 95% CI, 1.03-1.14) between 30 days and 2 years. Among those with a BNP ratio of ≥2 at discharge, after adjustment, every 1-point decrease in BNP ratio between discharge and 30 days was associated with a decreased hazard of all-cause death (aHR, 0.92; 95% CI, 0.88-0.96) between 30 days and 2 years.
Conclusions:
The authors concluded that elevated BNP levels after TAVR were independently associated with increased subsequent mortality and rehospitalizations.
Perspective:
This cohort study reports that among patients with severe symptomatic AS treated with TAVR, higher BNP levels at discharge, 30 days, and 1 year were each independently associated with increased mortality and rehospitalization rates. Furthermore, every 1-point increase in BNP ratio at 30 days (~ equivalent to an increase of 100 pg/ml in BNP level) was associated with an 11% higher risk of all-cause death, 16% higher risk of cardiovascular death, and 8% higher risk of rehospitalization at 2 years. Overall, these findings suggest that higher residual BNP levels after TAVR despite mechanical unloading of the heart are associated with adverse events and worse quality of life and functional capacity. Additional prospective studies are indicated to assess whether strategies to ameliorate the pathobiology of elevated BNP levels such as earlier valve replacement or intensification of medical therapy after TAVR may improve patient outcomes.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Natriuretic Peptide, Brain, Natriuretic Peptides, Outcome Assessment, Health Care, Patient Discharge, Quality of Life, Risk, Secondary Prevention, Transcatheter Aortic Valve Replacement
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