Prognostic power of pre- and postoperative B-type natriuretic peptide levels in patients undergoing abdominal aortic surgery

Therapeutic Assessment of Combination Therapy with a Neprilysin Inhibitor and Angiotensin Type 1 Receptor Antagonist on Angiotensin II-Induced Atherosclerosis, Abdominal Aortic Aneurysms, and Hypertension

Combined neprilysin (NEP) inhibition (sacubitril) and angiotensin type 1 receptor (AT1R) antagonism (valsartan) is used in the treatment of congestive heart failure and is gaining interest for other angiotensin II (AngII)-related cardiovascular diseases. In addition to heart failure, AngII promotes hypertension, atherosclerosis, and abdominal aortic aneurysms (AAAs). Similarly, NEP substrates or products have broad effects on the cardiovascular system. In this study, we examined NEP inhibition (with sacubitril) and AT1R antagonism (with valsartan) alone or in combination on AngII-induced hypertension, atherosclerosis, or AAAs in male low-density lipoprotein receptor-deficient mice. Preliminary studies assessed drug delivery via osmotic minipumps for simultaneous release of sacubitril and/or valsartan with AngII over 28 days. Mice were infused with AngII (1000 ng/kg per minute) in the absence (vehicle) or presence of sacubitril (1, 6, or 9 mg/kg per day), valsartan (0.3, 0.5, 1, 6, or 20 mg/kg per day), or the combination thereof (1 and 0.3, or 9 or 0.5 mg/kg per day of sacubitril and valsartan, respectively). Plasma AngII and renin concentrations increased 4-fold at higher valsartan doses, indicative of removal of AngII negative feedback on renin. Sacubitril doubled plasma AngII concentrations at lower doses (1 mg/kg per day). Valsartan dose-dependently decreased systolic blood pressure, aortic atherosclerosis, and AAAs of AngII-infused mice, whereas sacubitril had no effect on atherosclerosis or AAAs but reduced blood pressure of AngII-infused mice. Combination therapy with sacubitril and valsartan did not provide additive benefits. These results suggest limited effects of combination therapy with NEP inhibition and AT1R antagonism against AngII-induced hypertension, atherosclerosis, or AAAs. SIGNIFICANCE STATEMENT: The combination of valsartan (angiotensin type 1 receptor antagonist) and sacubitril (neprilysin inhibitor) did not provide benefit above valsartan alone on AngII-induced hypertension, atherosclerosis, or abdominal aortic aneurysms in low-density lipoprotein receptor-deficient male mice. These results do not support this drug combination in therapy of these AngII-induced cardiovascular diseases.

Cardiac Biomarkers Predicting MACE in Patients Undergoing Noncardiac Surgery: A Meta-Analysis

Objective: The present meta-analysis was aimed to systematically evaluate the effectiveness and accuracy of brain natriuretic peptide (BNP), cardiac troponin (cTn), high sensitive C reactive protein (hs-CRP) and CRP for predicting postoperative major adverse cardiovascular events (MACE) in patients undergoing noncardiac surgery.

Methods: A total of 26 relevant studies with 7,877 participants were collected from five databases, namely PubMed, Embase, China National Knowledge Infrastructure (CNKI), CQVIP and the Wanfang Database until August 10, 2018. And the Review Manager Version 5.3 and Stata/SE 12 software were used for data syntheses in the meta-analysis.

Results: Strong relationships of BNP/NT-proBNP, cTnI/cTnT and hs-CRP with MACE were detected in patients undergoing noncardiac surgery, and the five biomarkers all increased the risk of MACE. Compared to normal levels, elevated BNP/NT-proBNP could increase the MACE risk by almost 4-fold [RR:3.92, 95%CI: 3.23–4.75, P < 0.001]; elevated BNP corresponded to a 4.5-fold risk [RR:4.57, 95%CI: 3.37–6.20, P < 0.001]; elevated NT-proBNP led to a 3-fold higher risk [RR:3.48, 95%CI: 2.71–4.46, P < 0.001]. Comparing with normal levels of cTnI/cTnT, increased cTnI/cTnT was associated with nearly 5-fold more higher risk of MACE [RR:5.52, 95%CI: 4.62–6.58, P < 0.001]; elevated cTnI faced a 5-fold risk [RR:5.21, 95%CI: 3.96–6.86, P < 0.001]; elevated cTnT resulted in nearly 6-fold higher risk [RR:5.73, 95%CI: 4.55–7.22, P < 0.001]. The elevation of hs-CRP was associated with nearly 4-fold higher risk of MACE in comparison with normal concentration [RR:3.73, 95%CI: 2.63–5.30, P < 0.001].

Conclusion: According to the results of our meta-analysis, the elevations of BNP/NT-proBNP, cTnI/cTnT, and hs-CRP, pre-operation or post-operation immediately, can predict much higher risk of postoperative MACE in patients undergoing noncardiac surgery.

NT-proBNP and diastolic left ventricular function in patients with Marfan syndrome

AIMS

Subclinical diastolic dysfuntion in patients with preclinical heart failure with preserved ejection fraction (HFpEF) has been demonstrated in patients with Marfan syndrome (MFS). We investigated the relationship between diastolic dysfunction and NT-proBNP levels in patients with MFS.

METHODS AND RESULTS

NT-proBNP, C-reactive protein (CRP) and diastolic function were assessed in 217 patients with MFS (31 ± 16 y, 110 f. and in 339 patients referred for suspected MFS in whom the diagnosis was ruled out according to the Ghent nosology (30 ± 15 y, 154 f). Assessment of cardiovascular remodeling, diastolic function in echocardiography, and NT-proBNP was analyzed with univariate analysis and multi-parameter analysis of covariance (MANCOVA). NT-proBNP was 70.6 ± 74.8 pg/ml in patients with Marfan syndrome and 58.4 ± 100.3 pg/ml in controls (p = 0.002, Kolmogorov-Smirnov). There were significant intergroup differences regarding end-diastolic left ventricular volume (p < 0.001), and aortic diameter (p < 0.001). The ratio of early diastolic mitral flow velocity (E) to early relaxation velocity in tissue Doppler (e'), E/e' (p < 0.001) was significantly higher in patients with Marfan syndrome than in controls, whereas e' (p < 0.001) and the ratio of E to inflow velocity during atrial contraction (A), E/A (p = 0.012) was significantly lower. Besides age and gender, diagnosis of MFS, diastolic function (e' and E/e'), Z-Score of aortic diameter, and left ventricular size were identified as significant independent parameters with impact on NT-proBNP levels.

CONCLUSIONS

MFS patients presenting with normal ejection fraction show disturbed diastolic function and higher NT-proBNP levels, which is partly explained by aortic Z-score. Assessment of diastolic function and NT-proBNP levels may therefore detect early abnormalities and guide surveillance and prevention management of patients with MFS.

The effect of anesthesia method on serum level of pro-brain natriuretic Peptide in patients undergoing orthopedic surgery

Background:

Surgical stress response is among the most severe stress tolerated by the patient, which needs suppression by anesthesia.

Objectives:

We assessed the effect of three methods of anesthesia on postoperative levels of pro-brain natriuretic peptide (pro-BNP) to determine the most effective one in preventing surgical stress response.

Patients and Methods:

In a randomized clinical trial, 120 patients who were 18 to 65 years old and met inclusion and exclusion criteria were selected and randomly allocated to three groups of 40:Group A, general anesthesia plus epidural catheter; Group B, general anesthesia and intravenous patient-controlled analgesia; and Group C, spinal anesthesia plus intravenous patient-controlled analgesia.

Results:

There was no difference between three groups for basic characteristics and variables and baseline pro-BNP levels; however, postoperative pro-BNP levels in Groups A, B, and C were respectively63.8 ± 10.1, 83.2 ± 12.3, and 51.5 ± 8.5 ng/L (ANOVA, P = 0.01).

Conclusions:

The results of the current study suggested that spinal anesthesia plus intravenous patient-controlled analgesia have the most favorable cardiac effects regarding postoperative levels of pro-BNP.

Prediction of early postoperative major cardiac events after elective orthopedic surgery: the role of B-type natriuretic peptide, the revised cardiac risk index, and ASA class

BACKGROUND

The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date.

METHODS

The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge.

RESULTS

MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82.

CONCLUSIONS

Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.