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Association of NT-ProBNP, Blood Pressure, and CV Events
Quick Takes
- Higher levels of NT-proBNP in milder forms of hypertension (e.g., sBP 120-149 mm Hg) could identify who might benefit from the more intensive sBP lowering to <120 mm Hg, as suggested in the SPRINT trial.
- In the ARIC study, as with hs-cTNT, NT-proBNP levels can improve risk estimates of CV events in middle-aged persons at low risk with mild to moderate hypertension that can inform number needed to treat.
- Considering the very low cost and safety of antihypertensive therapy and the high risk of CVD from hypertension, the cost-benefit of avoiding treatment of those with a low NT-proBNP should not be inferred.
Study Questions:
Does N-terminal pro–B-type natriuretic peptide (NT-proBNP) help identify persons at high risk for cardiovascular disease (CVD) events across systolic blood pressure (sBP), diastolic blood pressure (dBP), or pulse pressure (PP) categories?
Methods:
Participants from the ARIC (Atherosclerosis Risk In Communities) study visit 4 were grouped according to sBP, dBP, or PP categories and further stratified by NT-proBNP categories. Cox regression models were used to estimate hazard ratios for incident CVD (coronary heart disease, ischemic stroke, or heart failure hospitalization) and mortality across combined NT-proBNP and/or BP categories, adjusting for CVD risk factors.
Results:
The study included 9,309 participants (ages 62.6 ± 5.6 years; 58.3% women) without CVD at baseline. They experienced 2,416 CVD events (18.6 per 1,000-person years) over a median follow-up of 16.7 years. Approximately 49% of CVD events occurred in subjects with sBP <130 mm Hg and 59% in subjects with NT-proBNP <100 pg/ml. In contrast, 52% of those with baseline NT-proBNP ≥300 pg/ml experienced a CVD event during follow-up. Subjects with higher baseline NT-proBNP were more likely to be older, women, White, and smokers; have diabetes or hypertension; use antihypertensive medications; have higher high-density lipoprotein cholesterol, high-sensitivity C-reactive protein, high-sensitivity cardiac troponin T (hs-cTnT), and left ventricular hypertrophy; and have lower body mass index, total cholesterol, and estimated glomerular filtration rate. Within each sBP, dBP, or PP category, a higher category of NT-proBNP (100 to <300 or ≥300 pg/ ml, compared with NT-proBNP <100 pg/ml) was associated with a graded increased risk for CVD events and mortality. Participants with sBP 130-139 mm Hg but NT-proBNP ≥300 pg/ml had a hazard ratio of 3.4 for CVD (95% confidence interval, 2.44-4.77) compared with a NT-proBNP of <100 pg/ml and sBP of 140-149 mm Hg.
Conclusions:
Elevated NT-proBNP is independently associated with CVD and mortality across sBP, dBP, and PP categories and helps identify subjects at the highest risk. Participants with stage 1 hypertension but elevated NT-proBNP had greater CV risk compared with those with stage 2 sBP but lower NT-proBNP. Future studies are needed to evaluate use of biomarker-based strategies for CVD risk assessment to assist with initiation or intensification of BP treatment.
Perspective:
The ARIC study was conducted in a diverse group of men and women ages 45-64 years, enrolled in 1986-1989, to investigate the causes of atherosclerosis and its clinical outcomes, and variation in CV risk factors and medical care. In this low-risk cohort, subjects with increasing levels of NT-proBNP demonstrated a lower number needed to treat across sBP and pooled cohort equation risk groups.
Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Nonstatins, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Hypertension
Keywords: Antihypertensive Agents, Atherosclerosis, Biomarkers, Blood Pressure, Brain Ischemia, Cardiovascular Diseases, Cholesterol, HDL, Coronary Disease, Diabetes Mellitus, Glomerular Filtration Rate, Heart Failure, Hypertension, Hypertrophy, Left Ventricular, Natriuretic Peptide, Brain, Primary Prevention, Risk Assessment, Risk Factors, Stroke, Troponin T, Vascular Diseases
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