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BNP in high risk major surgery patients
- Brian Cuthbertson (14 August 2007)
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Predictive value of BNP in major non-cardiac surgery
- Elisabeth Mahla, Martin Vicenzi, and Wolfgang Toller (14 August 2007)
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Brian Cuthbertson, Doctor University of Aberdeen
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In reply to the interesting points made by Dr Mahla and colleagues. We agree with many of the statements made in their letter. However, the measurement of BNP in the post-operative period does not add any additional predictive power to pre-operative BNP measurement in the prediction of these short term outcomes such as early post-operative cardiac events (unpublished data from same cohort). Further, our work on the predictive power of BNP for medium term mortality is about to be published in the American Journal of Cardiology in the next two months. I am sure the respondents will find this paper interesting. Although we may have missed some of the post-operative cardiac events occurring in hospital in this cohort due to our timing of measurements we feel that any significant events will be detected in medium term mortality analysis. As they state, other work suggests this is the case and the reader can read our paper in the near future to see our results. Brian H Cuthbertson on behalf of all authors Conflict of Interest:None declared |
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Elisabeth Mahla Department of Anaesthesiology and Intensive Care Medicine, Martin Vicenzi, and Wolfgang Toller
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Editor – We read with great interest the article of Cuthbertson and colleagues1 demonstrating the association of preoperative B-type natriuretic peptide (BNP) levels and adverse cardiac events. In 204 low- to intermediate risk patients (31% patients with a revised cardiac risk score of 2 or greater) scheduled for major non-cardiac surgery, moderately elevated preoperative BNP levels of 40 pg/ml predicted early postoperative death or myocardial injury (area under the receiver operating characteristic curve 0.72; 95% CI interval: 0.59-0.86). This article underlines recent suggestions that the biochemical markers BNP and N- terminal pro-brain natriuretic peptide (NT-proBNP) outperform existing cardiac risk scores regarding prognostic importance.2 3 Unfortunately, the short in-hospital observation period of 72 hours limits the significance and clinical importance of this hitherto largest blinded trial on the prognostic power of preoperative BNP. Although the majority of myocardial infarctions occurs within the first 48 hours after surgery, delayed postoperative myocardial infarction is a well known complication4 and may have been missed in this trial. Furthermore, as mentioned in the editorial5 to this article, postoperative determination of NT-proBNP provides additional prognostic information to preoperative levels regarding in-hospital and long-term cardiac outcome.6 BNP and NT-proBNP are released from cardiac myocytes in response to ischaemia7 or myocardial stretch8 and plasma levels correlate well with the extent of inducible ischaemia.7 Preoperative “stable” levels of natriuretic peptides therefore do not necessarily reflect the variable dynamic consequences of the intra- and postoperative stress response which culminates in adverse in-hospital9 and long-term cardiac outcome.10 Thus, although we recognize that the importance of postoperative NT-proBNP determination in non-cardiac surgery was just very recently published, the significance of the results of Cuthbertson and colleagues1 would have been further improved by a prolonged observation period and by additional postoperative BNP determinations. E. Mahla M. Vicenzi W. Toller Department of Anaesthesiology and Intensive Care Medicine Medical University of Graz Austria e-mail: elisabeth.mahla@meduni-graz.at References: 1. Cuthbertson, B. H., Amiri, A. R., Croal, B. L., et al. Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non-cardiac surgery. Br J Anaesth 2007; 99: 170- 6. 2. Dernellis, J. M., and Panaretou, M. P. Assessment of cardiac risk before noncardiac surgery: Brain Natriuretic Peptide in 1590 patients. Heart 2006; 92: 1645-50. 3. Feringa, H. H., Schouten, O., Dunkelgrun, M., et al. Plasma N-terminal pro-B-type natriuretic peptide as long-term prognostic marker after major vascular surgery. Heart 2007; 93: 226-31. 4. Le Manach, Y., Perel, A., Coriat, P., et al. Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 2005; 102: 885-91. 5. Sear, J. W., and Howard-Alpe, G. Preoperative plasma BNP concentrations: do they improve our care of high-risk non-cardiac surgical patients? Br J Anaesth 2007; 99: 151-4. 6. Mahla, E., Baumann, A., Rehak, P., et al. N-terminal pro-brain natriuretic peptide identifies patients at high risk for adverse cardiac outcome after vascular surgery. Anesthesiology 2007; 106: 1088-95. 7. Bibbins-Domingo, K., Ansari, M., Schiller, N. B., et al. B-type natriuretic peptide and ischemia in patients with stable coronary disease: data from the Heart and Soul study. Circulation 2003; 108: 2987-92. 8. Maisel, A. S., Krishnaswamy, P., Nowak, R. M., et al. Rapid measurement of B-Type Natriuretic Peptide in the emergency diagnosis of heart failure. N Engl J Med 2002; 347: 161-7. 9. Landesberg, G., Mosseri, M., Zahger, D., et al. Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 2001; 37: 1839-45. 10. Bursi, F., Babuin, L., Barbieri, A., et al. Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. Eur Heart J 2005; 26: 2448-56. Conflict of Interest:None declared |
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