Journal Article

B-type natriuretic peptide trumps other prognostic markers in patients assessed for coronary disease

Atar, Dan, Flather, Marcus D., Jenkins, Elizabeth, Eccleston, David, Pepper, John, Reid, Christopher M., Kotecha, Dipak, Collins, Peter

2019

Overview

Background Risk prediction for patients with suspected coronary artery disease is complex due to the common occurrence of prior cardiovascular disease and extensive risk modification in primary care. Numerous markers have the potential to predict prognosis and guide management, but we currently lack robust ‘real-world’ evidence for their use. Methods Prospective, multicentre observational study of consecutive patients referred for elective coronary angiography. Clinicians were blinded to all risk assessments, consisting of conventional factors, radial artery pulse wave analysis, 5-minute heart rate variability, high-sensitivity C-reactive protein and B-type natriuretic peptide (BNP). Blinded, independent adjudication was performed for all-cause mortality and the composite of death, myocardial infarction or stroke, analysed with Cox proportional hazards regression. Results Five hundred twenty-two patients were assessed with median age 66 years and 21% prior revascularization. Median baseline left ventricular ejection fraction was 64%, and 62% had ≥ 50% stenosis on angiography. During 5.0 years median follow-up, 30% underwent percutaneous and 16% surgical revascularization. In multivariate analysis, only age and BNP were independently associated with outcomes. The adjusted hazard ratio per log unit increase in BNP was 2.15 for mortality (95% CI 1.45–3.19; p  = 0.0001) and 1.27 for composite events (1.04–1.54; p  = 0.018). Patients with baseline BNP > 100 pg/mL had substantially higher mortality and composite events (20.9% and 32.2%) than those with BNP ≤ 100 pg/mL (5.6% and 15.5%). BNP improved both classification and discrimination of outcomes ( p  ≤ 0.003), regardless of left ventricular systolic function. Conversely, high-sensitivity C-reactive protein, pulse wave analysis and heart rate variability were unrelated to prognosis at 5 years after risk modification and treatment of coronary disease. Conclusions Conventional risk factors and other markers of arterial compliance, inflammation and autonomic function have limited value for prediction of outcomes in risk-modified patients assessed for coronary disease. BNP can independently identify patients with subtle impairment of cardiac function that might benefit from more intensive management. Trial registration Clinicaltrials.gov, NCT00403351 Registered on 22 November 2006

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Adjudication / Aged / Analysis / Angiography / Australia - epidemiology / Autonomic nervous system / B-type natriuretic peptide / Biomarkers - blood / Biomedicine / Blood pressure / Brain natriuretic peptide / C-reactive protein / C-Reactive Protein - analysis / C-Reactive Protein - metabolism / Cardiac patients / Cardiovascular disease / Cardiovascular diseases / Care and treatment / Cause of Death / Cerebral infarction / Clinical trials / Coronary Angiography / Coronary artery / Coronary artery disease / Coronary Artery Disease - blood / Coronary Artery Disease - complications / Coronary Artery Disease - diagnosis / Coronary Artery Disease - mortality / Coronary heart disease / Coronary vessels / Death / Diabetes / Diagnostic imaging / Female / Hazard assessment / Health care / Health risk assessment / Health risks / Heart / Heart attack / Heart attacks / Heart diseases / Heart failure / Heart rate / Humans / Longitudinal Studies / Male / Markers / Medical imaging / Medical prognosis / Medical research / Medical treatment / Medicine / Medicine & Public Health / Middle Aged / Mortality / Multivariate analysis / Myocardial infarction / Myocardial Infarction - blood / Myocardial Infarction - diagnosis / Myocardial Infarction - etiology / Myocardial Infarction - mortality / Natriuretic Peptide, Brain - analysis / Natriuretic Peptide, Brain - blood / Natriuretic peptides / Observational studies / Patients / Peptides / Predictive Value of Tests / Prognosis / Proteins / Regression analysis / Research Article / Risk / Risk analysis / Risk assessment / Risk factors / Sensitivity / Sensitivity analysis / Stenosis / Stroke - blood / Stroke - complications / Stroke - diagnosis / Stroke - mortality / Surgery / Systematic review / Variability / Ventricle / Wave analysis