Preoperative N-terminal pro–B-type natriuretic peptide levels predicted postoperative adverse cardiovascular events. The VISION (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) study is a prospective, international cohort study of cardiovascular complications following noncardiac surgery (NEJM JW Gen Med Jun 1 2017 and JAMA 2017; 317:1642). In this substudy from VISION, investigators measured preoperative N-terminal pro–B-type natriuretic peptide (NT-proBNP) in >10,000 inpatients (age, ≥45) who were undergoing noncardiac surgery. Postoperatively, troponin T levels were measured daily (for as long as 3 days) to detect myocardial injury after noncardiac surgery (MINS). Patients were stratified into four risk groups by preoperative NT-proBNP levels: <100, 100–199, 200–1499, and ≥1500 pg/mL. The overall incidence of MINS was 12%; most cases were asymptomatic elevations in troponin (and not clinical myocardial infarctions). In adjusted analyses, patients with increasingly higher NT-proBNP levels in the four risk groups had progressively — and significantly — higher incidences of MINS (5%, 12%, 21%, and 38%), vascular-related death (0.2%, 0.4%, 0.7%, and 2.9%), and all-cause mortality (0.3%, 0.7%, 1.4%, and 4.0%) within 30 days after surgery. When added to the Revised Cardiac Risk Index (RCRI) score, preoperative NT-proBNP levels improved risk assessment by reclassifying 25% of patients into more-appropriate risk groups. |
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COMMENT: Daniel D. Dressler, MD, MSc, SFHM, FACP
In middle-aged or older adults (age, ≥45) who are scheduled for inpatient noncardiac surgery, adding NT-proBNP to the RCRI score could improve individualized preoperative risk stratification and could help patients decide whether potential risks associated with elective noncardiac surgery are acceptable. In theory, preoperative NT-proBNP levels also could help clinicians adjust preoperative investigations, guide surgical or anesthetic approaches, and more precisely intensify or lessen postoperative monitoring. However, whether additional diagnostic and therapeutic interventions triggered by routine perioperative measurement of NT-proBNP would lower postoperative morbidity and mortality is unclear.