The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis.
OBJECTIVE
The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured.


BACKGROUND
Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done.


METHODS
We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery.


RESULTS
Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery.


CONCLUSIONS
Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.
Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio. Electronic address: ReitzeRodseth@gmail.com.
Reitze N
RN
Rodseth
Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
Bruce M
BM
Biccard
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Anesthesia, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada.
Yannick
Y
Le Manach
Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.
Daniel I
DI
Sessler
Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
Giovana A
GA
Lurati Buse
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Clinical Epidemiology and Biostatistics/Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
Lehana
L
Thabane
Department of Internal Medicine, University of Virginia, Charlottesville, Virginia.
Robert C
RC
Schutt
Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
Daniel
D
Bolliger
Department of Surgical Science, University of Perugia, Ospedale S. Maria, Perugia, Italy.
Lucio
L
Cagini
Cardioncology Unit, European Institute of Oncology, Milan, Italy.
Daniela
D
Cardinale
Departments of Aged Care, Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia, and The Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, Victoria, Australia.
Carol P W
CP
Chong
Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
Rong
R
Chu
Department of Vascular and General Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland.
Miłosław
M
Cnotliwy
Department of Medical-Surgery Sciences and Translational Medicine, University La Sapienza, and Emergency Department, Sant'Andrea Hospital, Rome, Italy.
Salvatore
S
Di Somma
Division of General, Visceral and Vascular Surgery, University Hospital, Jena, Germany.
René
R
Fahrner
Departments of Aged Care, Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia, and The Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, Victoria, Australia.
Wen Kwang
WK
Lim
Department of Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
Elisabeth
E
Mahla
Departments of Urology, Stepping Hill Hospital, Stockport, United Kingdom, and Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom.
Ramaswamy
R
Manikandan
Department of Surgical Science, University of Perugia, Ospedale S. Maria, Perugia, Italy.
Francesco
F
Puma
Division of Cardiology, Department of Internal Medicine, Ewha Womans University, School of Medicine, Mokdong Hospital, Seoul, Korea.
Wook B
WB
Pyun
Clinic of Nephrology, University of Belgrade, School of Medicine, Belgrade, Serbia.
Milan
M
Radović
Department of Vascular Surgery, University Hospital of North Staffordshire, Stoke on Trent, United Kingdom.
Sriram
S
Rajagopalan
Department of Vascular Surgery, Ninewells Hospital and Medical School, Dundee, United Kingdom.
Stuart
S
Suttie
Department of Mathematics and Statistics, McMaster University, Hamilton, Ontario, Canada.
Thuvaraha
T
Vanniyasingam
Department of Cardiology, University of Melbourne, Northern Health, Epping, Victoria, Australia.
William J
WJ
van Gaal
Cardiac Diagnostics Unit, M. Pirogow Provincial Specialist Hospital, Lodz, Poland.
Marek
M
Waliszek
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Medicine, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada.
P J
PJ
Devereaux
D015415:Biomarkers / Q000097:blood; D002318:Cardiovascular Diseases / Q000097:blood / Q000453:epidemiology / Q000209:etiology; D014943:Global Health; D006801:Humans; D015994:Incidence; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood; D011183:Postoperative Complications / Q000097:blood / Q000453:epidemiology / Q000209:etiology; D011184:Postoperative Period; D057234:Preoperative Period; D011379:Prognosis; D013514:Surgical Procedures, Operative
D015415:Biomarkers; D010446:Peptide Fragments; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain
AUC; B-type natriuretic peptide; BNP; CI; IQR; MI; N-terminal fragment of B-type natriuretic peptide; NP; NRI; NT-proBNP; OR; QICu; RCRI; ROC; Revised Cardiac Risk Index; anesthesia; area under the curve; confidence interval; corrected quasi-likelihood under the independence model criterion; interquartile range; myocardial infarction; natriuretic peptide; natriuretic peptides; net reclassification index; odds ratio; receiver operating characteristic; risk factors; surgery