B-Type Natriuretic Peptide Assessment in Patients Undergoing Revascularization for Left Main Coronary Artery Disease:
Björn Redfors1, Shmuel Chen1, Aaron Crowley1
1Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.).
Insights
Elevated B-type natriuretic peptide (BNP) in left main coronary artery disease patients predicts higher mortality after revascularization. Treatment outcomes with percutaneous coronary intervention versus bypass grafting may depend on baseline BNP levels.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Elevated B-type natriuretic peptide (BNP) indicates impaired cardiac function and worse prognosis in coronary artery disease (CAD).
- Left main CAD requires revascularization, with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) as primary options.
Purpose of the Study:
- To assess the association between baseline BNP levels and adverse outcomes in patients with left main CAD.
- To evaluate the relative efficacy of PCI versus CABG based on baseline BNP levels in these patients.
Main Methods:
- Analysis of data from the EXCEL trial, randomizing patients with left main CAD to PCI or CABG.
- Multivariable Cox regression used to assess associations between BNP levels (normal vs. elevated, ≥100 pg/mL) and 3-year adverse events.
- Exploration of treatment interaction between BNP levels and revascularization strategy.
Main Results:
- Elevated baseline BNP was observed in 39.5% of patients and was associated with higher 3-year rates of the primary composite endpoint (death, MI, stroke) and all-cause mortality.
- No significant differences were found in nonfatal ischemic events or bleeding between normal and elevated BNP groups.
- A significant interaction between baseline BNP levels and treatment strategy (PCI vs. CABG) was observed for the primary endpoint, suggesting differential outcomes based on BNP status.
Conclusions:
- Elevated baseline BNP independently predicts long-term mortality in patients with left main CAD undergoing revascularization.
- The choice between PCI and CABG for left main CAD revascularization may need to consider baseline BNP levels due to potential differential long-term outcomes.
Background:
Elevated B-type natriuretic peptide (BNP) is reflective of impaired cardiac function and is associated with worse prognosis among patients with coronary artery disease (CAD). We sought to assess the association between baseline BNP, adverse outcomes, and the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main CAD.
Methods:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and low or intermediate SYNTAX scores (Synergy Between PCI With TAXUS and Cardiac Surgery) to PCI with everolimus-eluting stents versus CABG. The primary end point was the composite of all-cause death, myocardial infarction, or stroke. We used multivariable Cox proportional hazards regression to assess the associations between normal versus elevated BNP (≥100 pg/mL), randomized treatment, and the 3-year risk of adverse events.
Results:
BNP at baseline was elevated in 410 of 1037 (39.5%) patients enrolled in EXCEL. Patients with elevated BNP levels were older and more frequently had additional cardiovascular risk factors and lower left ventricular ejection fraction than those with normal BNP, but had similar SYNTAX scores. Patients with elevated BNP had significantly higher 3-year rates of the primary end point (18.6% versus 11.7%; adjusted hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.16-2.28; P=0.005) and higher mortality (11.5% versus 3.9%; adjusted HR, 2.49; 95% CI, 1.48-4.19; P=0.0006), both from cardiovascular and noncardiovascular causes. In contrast, there were no significant differences in the risks of myocardial infarction, stroke, ischemia-driven revascularization, stent thrombosis, graft occlusion, or major bleeding. A significant interaction ( Pinteraction=0.03) was present between elevated versus normal BNP and treatment with PCI versus CABG for the adjusted risk of the primary composite end point at 3 years among patients with elevated BNP (adjusted HR for PCI versus CABG, 1.54; 95% CI, 0.96-2.47) versus normal BNP (adjusted HR, 0.74; 95% CI, 0.46-1.20). This interaction was stronger when log(BNP) was modeled as a continuous variable ( Pinteraction=0.002).
Conclusions:
In the EXCEL trial, elevated baseline BNP levels in patients with left main CAD undergoing revascularization were independently associated with long-term mortality but not nonfatal adverse ischemic or bleeding events. The relative long-term outcomes after PCI versus CABG for revascularization of left main CAD may be conditioned by the baseline BNP level.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov . Unique identifier: NCT01205776.
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