NT-proBNP or Self-Reported Functional Capacity in Estimating Risk of Cardiovascular Events After Noncardiac Surgery
Authors: Lurati Buse Giovanna , Larmann Jan , Gillmann Hans-Jörg , Kotfis Katarzyna , Ganter Michael T. , Bolliger Daniel , Filipovic Miodrag , Guzzetti Luca , Chammartin Frédérique , Mauermann Eckhard , Ionescu Daniela , Szczeklik Wojciech , De Hert Stefan , Beck-Schimmer Beatrice , Howell Simon J. ,   METREPAIR NTproBNP Subcohort Investigators, Kemper Johann , Kohaupt Lena , Witzler Jette , Tuzhikov Michael , Roth Sebastian , Stroda Alexandra , MPembele Rene , Schultze Cornelia , Verbarg Nele , Gehrke Christian , Espeter Florian , Russe Benedikt , Weigand Markus A. , Pirzer Raphael , Rach Patric Rene , Neumann Claudia , Sponhol Christoph , Carollo Melissa , Toso Fiorenza , Bacuzzi Alessandro , Servén Marta G. , Artigas Soler Anna , Basso Morena , Peig Font Anna , Torrente-Perez Jara , Fores Maria Isabel , Bubenek-Turconi Serban , Vale Liana , Wanner Patrick , Djurdjevic Mirjana , Nuth Sandra , Seeberger Esther , Kamber Firmin , Gerber Thomas Jan , Schneebeli Daniela , Grape Sina , Bollen Pinto Bernardo , Karolak Igor , Lechowicz Kacper , Drozdzal Sylwester , Kluzik Anna , van Lier Felix , Carrao Andre , Ribeiro Daniela , Santos Nuno , Drummond Andrew , Belskii Vladislav 
Published: November 2023

Importance

Nearly 16 million surgical procedures are conducted in North America yearly, and postoperative cardiovascular events are frequent. Guidelines suggest functional capacity or B-type natriuretic peptides (BNP) to guide perioperative management. Data comparing the performance of these approaches are scarce.

Objective

To compare the addition of either N-terminal pro-BNP (NT-proBNP) or self-reported functional capacity to clinical scores to estimate the risk of major adverse cardiac events (MACE).

Design, Setting, and Participants

This cohort study included patients undergoing inpatient, elective, noncardiac surgery at 25 tertiary care hospitals in Europe between June 2017 and April 2020. Analysis was conducted in January 2023. Eligible patients were either aged 45 years or older with a Revised Cardiac Risk Index (RCRI) of 2 or higher or a National Surgical Quality Improvement Program, Risk Calculator for Myocardial Infarction and Cardiac (NSQIP MICA) above 1%, or they were aged 65 years or older and underwent intermediate or high-risk procedures.

Exposures

Preoperative NT-proBNP and the following self-reported measures of functional capacity were the exposures: (1) questionnaire-estimated metabolic equivalents (METs), (2) ability to climb 1 floor, and (3) level of regular physical activity.

Main Outcome and Measures

MACE was defined as a composite end point of in-hospital cardiovascular mortality, cardiac arrest, myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care.

Results

A total of 3731 eligible patients undergoing noncardiac surgery were analyzed; 3597 patients had complete data (1258 women [35.0%]; 1463 (40.7%) aged 75 years or older; 86 [2.4%] experienced a MACE). Discrimination of NT-proBNP or functional capacity measures added to clinical scores did not significantly differ (Area under the receiver operating curve: RCRI, age, and 4MET, 0.704; 95% CI, 0.646-0.763; RCRI, age, and 4MET plus floor climbing, 0.702; 95% CI, 0.645-0.760; RCRI, age, and 4MET plus physical activity, 0.724; 95% CI, 0.672-0.775; RCRI, age, and 4MET plus NT-proBNP, 0.736; 95% CI, 0.682-0.790). Benefit analysis favored NT-proBNP at a threshold of 5% or below, ie, if true positives were valued 20 times or more compared with false positives. The findings were similar for NSQIP MICA as baseline clinical scores.

Conclusions and relevance

In this cohort study of nearly 3600 patients with elevated cardiovascular risk undergoing noncardiac surgery, there was no conclusive evidence of a difference between a NT-proBNP–based and a self-reported functional capacity–based estimate of MACE risk.

Trial Registration

ClinicalTrials.gov Identifier: NCT03016936