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Nt-pro-BNP monitoring in cardiac surgery patients – is there more to consider?

Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany

Preoperative, postoperative and 1-year follow-up N-terminal pro-B-type natriuretic peptide levels in severe chronic aortic regurgitation: correlations with echocardiographic findings

We read with great interest the recent report by Dr. Della Corte and coworkers monitoring the course of nt-pro-BNP levels among patients suffering chronic aortic regurgitation pre- and post-cardiac surgery [1].

Unfortunately, the authors did not comment on other sources of potential nt-pro-BNP production which might have confounded their findings. Recently, a study was published among 135 patients undergoing various cardiac surgery procedures [2]. Pre-operative serum NT-pro-BNP levels were significantly higher in patients with an ICU length of stay of more than 2 days or death prior to postoperative day 28 (3118 ng/l vs. 705 ng/l; P<0.001). Pre-operative serum NT-pro-BNP levels were also significantly higher in patients needing inotropic agents (2628 ng/l vs. 548 ng/l, P<0.001) or IABP insertion (3705 ng/l vs. 935 ng/l; P=0.001) or developing renal failure (2857 ng/l vs. 945 ng/l; P<0.001) postoperatively. The correlation between the serum NT-pro-BNP level and EuroSCORE was good (r=0.658; P<0.001).

Intensive care parameters have an influence on nt-pro-BNP levels [3]. Using multivariate analysis, serum NT-pro-BNP levels at 36 h were associated with increased noradrenaline dose (P=0.001), decreased preoperative ejection fraction (EF) Group (P=0.013) and elevated preoperative NT-pro-BNP (P<0.001). Factors not associated with NT-pro BNP levels at 36 h include the operation type, bypass and cross-clamp times, use of milrinone and troponin-T.

Kidney function is closely related to nt-pro-BNP levels, too [4]. After adjustment for confounders among 356 patients undergoing non-cardiac vascular surgery, NT-pro-BNP levels and glomerular filtration rate (GFR) remained significantly associated with the end point (P=0.005). The prognostic value of NT-pro-BNP was most pronounced in patients with GFR > or = 90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR <30 ml/min/1.73 m(2), NT-pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). The authors concluded that the discriminative value of NT-pro-BNP is most pronounced in patients with GFR > or =90 ml/min/1.73 m(2) and has no prognostic value in patients with GFR <30 ml/min/1.73 m(2).

Besides medication such as Angiotensin-converting enzyme inhibitors, beta-blockers and spironolactone do have an influence on nt-pro-BNP levels which, unfortunately, is not mentioned in the aforementioned institutional report.

	References

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1. Della Corte A, Salerno G, Chiosi E, Iarussi D, Santarpino G, Miraglia M, Naviglio S, De Feo M. Pre-operative, postoperative and 1-year followup N-terminal pro-B-type natriuretic peptide levels in severe chronic aortic regurgitation: correlations with echocardiographic findings. Interact CardioVasc Thorac Surg 2008;7:419–424.[Abstract/Free Full Text]
2. Eliasdottir SB, Klemenzson G, Torfason B, Valsson F. Brain natriuretic peptide is a good predictor for outcome in cardiac surgery. Acta Anaesthesiol Scand 2008;52:182–307.[Medline]
3. Jogia PM, Kalkoff M, Sleigh JW, Bertinelli A, La Pine M, Richards AM, Devlin G. Nt-pro-BNP secretion and clinical endpoints in cardiac surgery intensive care patients. Anaesth Intensive Care 2007;35:363–369.[Medline]
4. Goei D, Schouten O, Boersma E, Welten GM, Dunkelgrun M, Lindemans J, van Gestel YR, Hoeks SE, Bax JJ, Poldermans D. Influence of renal function on the usefulness of n-terminal pro-B-type natriuretic peptide as a progonostic cardiac risk marker in patients undergoing noncardiac vascular surgery. Am J Cardiol 2008;101:122–126.[CrossRef][Medline]

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