Schouten Olaf, Hoeks Sanne E, Goei Dustin, Bax Jeroen J, Verhagen Hence J M, Poldermans Don
Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands.
J Vasc Surg. 2009 Feb;49(2):435-41; discussion 441-2. doi: 10.1016/j.jvs.2008.08.063. Epub 2008 Nov 22.
N-terminal pro-B-type natriuretic peptide (NT-proBNP) is secreted by the heart in response to ventricular wall stress and has prognostic value in patients with heart failure, coronary artery disease, and heart valve abnormalities. Postoperative and long-term outcome is also related to these risk factors. This study assessed the additional prognostic value of NT-proBNP levels as a simple objective risk marker for postoperative cardiac events among vascular surgery patients.
A detailed cardiac history (angina, myocardial infarction, age >70 years, diabetes mellitus, renal failure, stroke, heart failure), resting echocardiography, and NT-proBNP levels were obtained in 400 vascular surgery patients. Postoperative troponin-T levels and an electrocardiogram were obtained on days 1, 3, 7, and 30, and whenever clinically indicated. Patients were monitored every 6 months at the outpatient clinic. Study end points were perioperative cardiac events (ie, composite of cardiac death, myocardial infarction, and troponin release) and long-term all-cause mortality. The additional value of NT-proBNP was assessed with multivariable regression analysis. The optimal cutoff value was assessed by receiver operating characteristic curve analysis.
Postoperative troponin T release occurred in 79 patients (20%). Cardiac risk factors were used to classify patients as low (0 risk factors), intermediate (1 to 2), and high (>3) cardiac risk (event rate of 7%, 15%, and 37%, respectively). The median NT-proBNP level was 206 pg/mL (interquartile range, 80-548 pg/mL). The risk of postoperative cardiac events was augmented with increasing NT-proBNP, irrespective of underlying cardiac risk factors and type of vascular surgery. In addition to cardiac risk factors only (C index, 0.66) or cardiac risk factors and site and type of surgery (C index, 0.81), NT-proBNP was an excellent tool for further risk stratification (C index, 0.86), with an optimal cutoff value of 350 pg/mL. In multivariate analysis, NT-proBNP >350 pg/mL remained significantly associated with perioperative cardiac events (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.1-10.5, P < .001). NT-proBNP >350 pg/mL was also associated with an independent 1.9-fold (95% CI 1.1-3.2) increased risk for long-term mortality during a median follow-up of 2.4 years.
NT-proBNP is an independent prognostic marker for postoperative cardiac events and long-term mortality in patients undergoing different types of vascular surgery and might be used for preoperative cardiac risk stratification.
N 末端 B 型利钠肽原（NT-proBNP）由心脏分泌，以应对心室壁压力，对心力衰竭、冠状动脉疾病和心脏瓣膜异常患者具有预后价值。术后及长期预后也与这些危险因素相关。本研究评估 NT-proBNP 水平作为血管手术患者术后心脏事件简单客观风险标志物的额外预后价值。
收集 400 例血管手术患者的详细心脏病史（心绞痛、心肌梗死、年龄>70 岁、糖尿病、肾衰竭、中风、心力衰竭）、静息超声心动图及 NT-proBNP 水平。术后第 1、3、7 和 30 天以及临床指征时检测肌钙蛋白 T 水平和心电图。在门诊每 6 个月对患者进行一次监测。研究终点为围手术期心脏事件（即心脏死亡、心肌梗死和肌钙蛋白释放的综合指标）和长期全因死亡率。通过多变量回归分析评估 NT-proBNP 的额外价值。通过受试者工作特征曲线分析评估最佳截断值。
79 例患者（20%）术后出现肌钙蛋白 T 释放。根据心脏危险因素将患者分为低（0 个危险因素）、中（1 至 2 个）和高（>3 个）心脏风险组（事件发生率分别为 7%、15%和 37%）。NT-proBNP 水平中位数为 206 pg/mL（四分位间距，80 - 548 pg/mL）。无论潜在心脏危险因素和血管手术类型如何，术后心脏事件风险均随 NT-proBNP 升高而增加。除仅考虑心脏危险因素（C 指数，0.66）或心脏危险因素以及手术部位和类型（C 指数，0.81）外，NT-proBNP 是进一步风险分层的优秀工具（C 指数，0.86），最佳截断值为 350 pg/mL。在多变量分析中，NT-proBNP>350 pg/mL 仍与围手术期心脏事件显著相关（比值比[OR]，4.7；95%置信区间[CI]，2.1 - 10.5，P <.001）。在中位随访 2.4 年期间，NT-proBNP>350 pg/mL 还与长期死亡率独立增加 1.9 倍（95%CI 1.1 - 3.2）相关。
NT-proBNP 是不同类型血管手术患者术后心脏事件和长期死亡率的独立预后标志物，可用于术前心脏风险分层。
