Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Melbourne, Australia.
BMC Med. 2019 Apr 3;17(1):72. doi: 10.1186/s12916-019-1306-9.
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.
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.
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.
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.
Clinicaltrials.gov, NCT00403351 Registered on 22 November 2006.
由于在初级保健中常见的心血管疾病和广泛的风险修正，对疑似冠心病患者的风险预测较为复杂。有许多标志物具有预测预后和指导管理的潜力，但我们目前缺乏其使用的强大“真实世界”证据。
对接受选择性冠状动脉造影的连续患者进行前瞻性、多中心观察性研究。临床医生对所有风险评估均处于盲态，包括常规因素、桡动脉脉搏波分析、5 分钟心率变异性、高敏 C 反应蛋白和 B 型利钠肽（BNP）。对所有原因死亡率和死亡、心肌梗死或中风的复合事件进行盲法、独立裁定，并使用 Cox 比例风险回归进行分析。
522 例患者接受评估，中位年龄 66 岁，21%有再血管化治疗史。中位基线左心室射血分数为 64%，血管造影显示 62%有≥50%的狭窄。在中位 5.0 年的随访期间，30%的患者接受了经皮冠状动脉介入治疗，16%的患者接受了冠状动脉旁路移植术。多变量分析中，只有年龄和 BNP 与结局独立相关。BNP 每增加一个对数单位，死亡率的调整风险比为 2.15（95%CI 1.45-3.19；p=0.0001），复合事件的调整风险比为 1.27（1.04-1.54；p=0.018）。基线 BNP>100pg/mL 的患者死亡率和复合事件（20.9%和 32.2%）明显高于 BNP≤100pg/mL 的患者（5.6%和 15.5%）。无论左心室收缩功能如何，BNP 均能改善预后的分类和区分能力（p≤0.003）。相反，高敏 C 反应蛋白、脉搏波分析和心率变异性与冠状动脉疾病风险修正和治疗后 5 年的预后无关。
在接受冠状动脉疾病评估的风险修正患者中，传统危险因素和其他动脉顺应性、炎症和自主功能标志物对预后的预测价值有限。BNP 可独立识别心脏功能轻度受损的患者，这些患者可能受益于更强化的管理。
Clinicaltrials.gov，NCT00403351 于 2006 年 11 月 22 日注册。
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