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B-type natriuretic peptide trumps other prognostic markers in patients assessed for coronary disease

Title: B-type natriuretic peptide trumps other prognostic markers in patients assessed for coronary disease
Authors: Kotecha, D
Flather, MD
Atar, D
Collins, P
Pepper, J
Jenkins, E
Reid, CM
Eccleston, D
Item Type: Journal Article
Abstract: Background 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. Methods 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. Results 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. Conclusions 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. Trial registration Clinicaltrials.gov, NCT00403351 Registered on 22 November 2006
Issue Date: 3-Apr-2019
Date of Acceptance: 13-Mar-2019
URI: http://hdl.handle.net/10044/1/74045
DOI: https://doi.org/10.1186/s12916-019-1306-9
ISSN: 1741-7015
Publisher: BioMed Central
Journal / Book Title: BMC Medicine
Volume: 17
Issue: 1
Copyright Statement: © 2019 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Keywords: Science & Technology
Life Sciences & Biomedicine
Medicine, General & Internal
General & Internal Medicine
Risk
Mortality
Coronary artery disease
Coronary angiography
B-type natriuretic peptide
HEART-RATE-VARIABILITY
CARDIOVASCULAR-DISEASE
MYOCARDIAL-INFARCTION
RISK-FACTORS
MORTALITY
EVENTS
DEATH
PREDICTION
PRESSURE
FAILURE
B-type natriuretic peptide
Coronary angiography
Coronary artery disease
Mortality
Risk
Alternative Risk Markers in Coronary Artery Disease (ARM-CAD) Study
Science & Technology
Life Sciences & Biomedicine
Medicine, General & Internal
General & Internal Medicine
Risk
Mortality
Coronary artery disease
Coronary angiography
B-type natriuretic peptide
HEART-RATE-VARIABILITY
CARDIOVASCULAR-DISEASE
MYOCARDIAL-INFARCTION
RISK-FACTORS
MORTALITY
EVENTS
DEATH
PREDICTION
PRESSURE
FAILURE
General & Internal Medicine
11 Medical and Health Sciences
Publication Status: Published
Article Number: 72
Online Publication Date: 2019-04-03
Appears in Collections:National Heart and Lung Institute