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Exploring the Utility of Brain Natriuretic Peptide Measurement in Vascular Surgery
Bill Huang1, Gary K Yang1, Sandra Strandberg2
1Division of Vascular Surgery, Vancouver General Hospital, Vancouver, Vancouver, BC, Canada; Department of Surgery, University of British Columbia, Vancouver, Vancouver, BC, Canada.
Insights
Pre-operative brain natriuretic peptide (BNP) testing may overestimate surgical risk. Elevated BNP correlates with myocardial injury after noncardiac surgery (MINS), but does not significantly alter patient management or predict outcomes.
Area of Science:
- Cardiology
- Vascular Surgery
- Clinical Risk Stratification
Background:
- Canadian Cardiovascular Society guidelines suggest pre-operative brain natriuretic peptide (BNP) measurement for risk-stratifying patients undergoing noncardiac surgery.
- The clinical utility of BNP and myocardial injury after noncardiac surgery (MINS) in affecting patient outcomes remains unclear.
Purpose of the Study:
- To examine the clinical utility of pre-operative brain natriuretic peptide (BNP) testing.
- To assess the association between BNP levels and myocardial injury after noncardiac surgery (MINS) in vascular surgery patients.
Main Methods:
- Analysis of prospectively maintained database of elective open vascular surgery cases (January 2015-December 2018).
- Pre-operative BNP values were collected from June 2018 onward.
- Patients were stratified using the Revised Cardiac Risk Index; composite outcome included 30-day mortality, myocardial infarction, or MINS.
Main Results:
- Elevated pre-operative BNP was associated with an increased odds of the composite outcome (death, myocardial infarction, or MINS) (P=0.04).
- The majority of composite outcomes were due to asymptomatic troponin rise (80%), with unclear clinical implications.
- Detection of MINS did not lead to significant changes in patient management; Revised Cardiac Risk Index was not predictive.
Conclusions:
- Elevated BNP correlates with increased MINS, but may overestimate surgical risk.
- Asymptomatic troponin rises are common in MINS, but their clinical significance is uncertain.
- Further research on long-term outcomes is needed before widespread adoption of BNP testing in vascular surgery.
Background:
The Canadian Cardiovascular Society 2016 guidelines recommend pre-operative measurement of brain natriuretic peptide (BNP) to risk-stratify patients for a 30-day composite outcome of death, myocardial infarction, or asymptomatic myocardial injury after noncardiac surgery (MINS). Whether this practice affects outcomes is unclear. The aim of this study was to examine the clinical utility of brain natriuretic peptide and myocardial injury after noncardiac surgery.
Methods:
Analysis of a prospectively maintained database identified all elective open vascular surgery cases at an academic teaching hospital from January 2015 to December 2018. Pre-operative BNP values were available from June 2018 onward after becoming institutionally mandated. Co-morbidities were also collected to stratify patients using the Revised Cardiac Risk Index. The composite outcome of 30-day mortality, myocardial infarction, or MINS was determined.
Results:
Prior to BNP becoming an institutionally required test, data was available from 1176 open cases. The 30-day mortality was 1.3% (15/1176) and post-operative myocardial infarction rate was 2.3% (27/1176). BNP measurements were collected in 91 consecutive patients. Ten patients (11%) experienced the composite outcome of mortality, myocardial infarction, or MINS. Elevated BNP was associated with increased odds of the composite outcome (P = 0.04), but not with mortality or myocardial infarction. Revised Cardiac Risk Index score was not predictive of outcomes. The majority of patients who qualified for the composite outcome experienced only an asymptomatic troponin rise (80%). Two patients met the universal definition of myocardial infarction, one of whom died. No other deaths occurred within 30 days. Detection of MINS did not result in any significant changes to patient management.
Conclusions:
Elevated BNP correlates with increased MINS. An asymptomatic troponin rise is the most commonly observed event, with unclear clinical implications. BNP may over-estimate surgical risk. Further studies on the long-term outcomes of patients with elevated BNP and MINS are required before widely adopting this strategy in vascular surgery patients.
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