title: Combined use of high-sensitivity C-reactive protein and N-terminal pro-B-type natriuretic peptide for risk stratification of vascular surgery patients.
abstract: BACKGROUND
  We sought to assess whether high-sensitivity C-reactive protein (hs-CRP) and pro-B-type natriuretic peptide (NT-proBNP) improve risk prediction when added to an established predictive tool and develop a point-based risk score.
  
  
  METHODS
  Four hundred eleven vascular surgery patients were enrolled. The primary outcome was a composite of death, acute coronary syndromes, pulmonary edema within 30 days of surgery, and postoperative troponin-I elevation. The risk score was developed from a logistic regression model by using an integer-based scoring system.
  
  
  RESULTS
  The rate of the primary outcome was 18%. Adding both hs-CRP and NT-proBNP to the Revised Cardiac Risk Index led to an increase in C statistic from 0.670 to 0.774. The net reclassification improvement was 0.210 (P = 0.004) and the integrated discrimination improvement was 0.112 (P = 0.0001). In the multivariable regression analysis used to develop the risk score, insulin therapy for diabetes (odds ratio [OR]: 2.8; P = 0.003), open surgery (OR: 1.95; P = 0.027), fibrinogen >377 mg/dL (OR: 2.83; P = 0.001), hs-CRP >3.2 mg/L (OR: 3.85; P < 0.0001), and NT-proBNP >221 ng/L (OR: 4.05; P < 0.0001) were associated with the primary outcome. There was no statistical evidence of overfit. The C index was 0.82 and the Hosmer-Lemeshow statistic was 1.61 (P = 0.0447). The observed and predicted rates of the primary outcome across quartiles of risk score were highly correlated.
  
  
  CONCLUSIONS
  Hs-CRP and NT-proBNP substantially improve risk prediction when added to an established predictive tool. The biochemical marker-based risk score may be useful for accurately risk-stratifying vascular surgery patients; nonetheless, further validation studies on external datasets are needed before it can be used in clinical practice.
authors: Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy. Electronic address: domenico.scrutinio@fsm.it.
authors: Domenico
authors: D
authors: Scrutinio
authors: Vascular Surgery Unit, University of Bari, Bari, Italy.
authors: Gloria
authors: G
authors: Guido
authors: Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors: Piero
authors: P
authors: Guida
authors: Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors: Andrea
authors: A
authors: Passantino
authors: Vascular Surgery Unit, University of Bari, Bari, Italy.
authors: Domenico
authors: D
authors: Angiletta
authors: Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors: Daniela
authors: D
authors: Santoro
authors: Vascular Surgery Unit, University of Bari, Bari, Italy.
authors: Davide
authors: D
authors: Marinazzo
authors: Vascular Surgery Unit, University of Bari, Bari, Italy.
authors: Guido
authors: G
authors: Regina
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000209:etiology / Q000401:mortality; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D016017:Odds Ratio; D010446:Peptide Fragments / Q000097:blood*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011654:Pulmonary Edema / Q000097:blood / Q000209:etiology / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D019210:Troponin I / Q000097:blood; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D019210:Troponin I; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D002097:C-Reactive Protein