Early discharge after primary percutaneous coronary intervention: the added value of N-terminal pro-brain natriuretic peptide to the Zwolle Risk Score.
BACKGROUND
The Zwolle Risk Score (ZRS) identifies ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) eligible for early discharge. We aimed to investigate whether baseline N-terminal pro-brain natriuretic peptide (NT-proBNP) is also able to identify these patients and could improve future risk strategies.


RESULTS
PPCI patients included in the Ongoing Tirofiban in Myocardial Infarction Evaluation (On-TIME) II study were candidates (N=861). We analyzed whether ZRS and baseline NT-proBNP predicted 30-day mortality and assessed the occurrence of major adverse cardiac events (MACEs) and major bleeding. Receiver operating characteristic curve analysis was used to assess discriminative accuracy for ZRS, NT-pro-BNP, and their combination. After multiple imputation, 845 patients were included. Both ZRS >3 (hazard ratio [HR]=9.42; P<0.001) and log NT-pro-BNP (HR=2.61; P<0.001) values were associated with 30-day mortality. On multivariate analysis, both the ZRS (HR=1.41; 95% confidence interval [CI]=1.27 to 1.56; P<0.001) and log NT-proBNP (HR=2.09; 95% CI=1.59 to 2.74; P<0.001) independently predicted death at 30 days. The area under the curve for 30-day mortality for combined ZRS/NT-proBNP was 0.94 (95% CI=0.90 to 0.99), with optimal predictive values of a ZRS ≥2 and a NT-proBNP value of ≥200 pg/mL. Using these cut-off values, 64% of the study population could be identified as very low risk with zero mortality at 30 days follow-up and low occurrence of MACEs and major bleeding between 48 hours and 10 days (1.3% and 0.6%, respectively).


CONCLUSIONS
Baseline NT-proBNP identifies a large group of low-risk patients who may be eligible for early (48- to 72-hour) discharge, whereas optimal predictive accuracy is reached by the combination of both baseline NT-proBNP and ZRS.
Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.).
Dirk A A M
DA
Schellings
Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.).
Ahmet
A
Adiyaman
Department of Cardiology, Universitäts Klinik, Heidelberg, Germany (E.G.).
Evangelos
E
Giannitsis
Department of Cardiology, Kerckhoff Klinik, Bad Nauheim, Germany (C.H.).
Christian
C
Hamm
Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.) Department of Cardiology, Radboud University, Nijmegen, The Netherlands (H.S.).
Harry
H
Suryapranata
Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands (J.M.B.).
Jurrien M
JM
Ten Berg
Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.).
Jan C A
JC
Hoorntje
Department of Cardiology, Isala Klinieken, Zwolle, The Netherlands (D.M.S., A.A., H.S., J.A.H., A.J.H.).
Arnoud W J
AW
Van't Hof
D000368:Aged; D019540:Area Under Curve; D015415:Biomarkers / Q000097:blood; D003661:Decision Support Techniques; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010351:Patient Discharge; D010446:Peptide Fragments / Q000097:blood*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D000077466:Tirofiban; D016896:Treatment Outcome; D014443:Tyrosine / Q000031:analogs & derivatives / Q000627:therapeutic use
D015415:Biomarkers; D010446:Peptide Fragments; D010975:Platelet Aggregation Inhibitors; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D014443:Tyrosine; D000077466:Tirofiban
NT‐proBNP; PCI; ST‐elevation myocardial infarction; Zwolle Risk Score; discharge; mortality; risk stratification