title: Identification of potential outcome benefit from ACE inhibition after acute coronary syndrome: a biomarker approach using N-terminal proBNP.
abstract: OBJECTIVE
  To consider whether patients most likely to benefit from ACE inhibition in routine practice after acute coronary syndrome (ACS) may be identified from plasma natriuretic peptide concentrations.
  
  
  METHODS
  Observational cohort study.
  
  
  METHODS
  Teaching hospital coronary care unit.
  
  
  METHODS
  1725 patients admitted with acute coronary syndrome (56.3% ST elevation ACS; median age 67, range 24-97 years).
  
  
  METHODS
  Using Cox proportional hazards analysis, we assessed the adjusted predictive value for major adverse cardiac events (MACE) of prescription of an ACE inhibitor, of plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) and for interaction between these factors. To adjust for demographic differences between patients prescribed or not prescribed an ACE inhibitor, a factor correcting for likelihood of ACE inhibitor prescription (propensity score) was included in the analysis.
  
  
  METHODS
  The primary end point was the occurrence of MACE (death, recurrent myocardial infarction or hospitalisation with heart failure).
  
  
  RESULTS
  During the index admission ACE inhibitor was prescribed for 1267/1725 (73.4%) patients. During follow-up (median 528 days, range 0-3873 days), 534/1725 patients experienced MACE. After covariable adjustment, NT-proBNP showed linear association with risk of MACE (p<0.005), strongest for patients with NT-proBNP in the top quartile of observed values (HR=2.768, p<0.001). Only for patients with NT-proBNP in the top quartile was prescription of ACE inhibitor associated with reduction in risk of MACE (HR=0.532, p=0.003). This association was maintained after correction for propensity scores (HR=0.599, p=0.003).
  
  
  CONCLUSIONS
  Prognostic benefit from ACE inhibition was seen only in patients with the most marked elevation of plasma NT-proBNP. Plasma NT-proBNP may be a useful indicator of the appropriateness of individual prescription of ACE inhibitor treatment across the spectrum of ACS.
authors.affiliation: Pharmacology and Therapeutics Group, Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, UK. is11@le.ac.uk
authors.forename: Iain
authors.initials: I
authors.lastname: Squire
authors.forename: Paulene
authors.initials: P
authors.lastname: Quinn
authors.forename: Hafid
authors.initials: H
authors.lastname: Narayan
authors.forename: Sohail
authors.initials: S
authors.lastname: Khan
authors.forename: Onkar
authors.initials: O
authors.lastname: Dhillon
authors.forename: Kuan
authors.initials: K
authors.lastname: Ng
authors.forename: Dominic
authors.initials: D
authors.lastname: Kelly
authors.forename: Joan
authors.initials: J
authors.lastname: Davies
authors.forename: Leong
authors.initials: L
authors.lastname: Ng
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood* / Q000188:drug therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood* / Q000188:drug therapy*; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood*; D055815:Young Adult
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain