This resource center is jointly hosted by The American Journal of Medicine,
The American Journal of Cardiology, and the Canadian Journal of Cardiology.

Risk Prediction panel

Key Highlights

  • The authors conducted a systematic review and individual patient meta-analysis to examine the prognostic value of natriuretic peptides (NP) in patients undergoing non-cardiac surgery.
  • The study main objectives were to determine if adding preoperative NP measurement could enhance clinician’s ability to predict a composite of death and non-fatal myocardial infarction at 30 days and ≥180 days after non-cardiac surgery.
  • Individual patient data were obtained from 18 eligible studies for a total of 2179 patients; 10 studies measured NT-proBNP and 8 studies measured BNP. 
  • The authors performed analysis to determine the NP threshold associated with the lowest p value for the composite outcome of death and non-fatal myocardial infarction.
  • A net reclassification approach was used to determine if NP provided additional prognostic information in addition to a clinical model (ie, Revised Cardiac Risk Index) based on risk categories of <5%, 5-10%, >10-15%, and >15%.

Key Findings

  • The overall incidence of the composite of death and non-fatal myocardial infarction at 30 days was 10.8% (235 events).
  • NP threshold values associated with lowest p value for death and myocardial infarction for BNP was 92 ng/L and for NT-proBNP was 300 ng/L.
  • The incidence of death and non-fatal myocardial infarction at 30 days was 21.8% in patients who had a positive preoperative NT-proBNP (≥300 ng/L ) or BNP (≥92 ng/L), compared to 4.9% in patients who had a negative preoperative NT-proBNP (<300 ng/L) or BNP (<92 ng/L).
  • The overall absolute net reclassification showed that in a sample of 1000 patients, a preoperative NP measurement will result in a more appropriate risk estimate in 155 patients compared to a clinical model (ie, Revised Cardiac Risk Index).
  • The 2016 Canadian Cardiology Society Guidelines on perioperative risk prediction and management recommends measuring BNP or NT-proBNP before surgery to enhance perioperative cardiac risk estimation in patients who are ≥65 years of age, are 45 to 64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index (RCRI) score ≥1.

Suggested Readings

Lee TH, Marcantonio ER, Mangione CM, et al. Circulation. 1999;100:1043-1049
Ryding AD, Kumar S, Worthington AM, Burgess D. Anesthesiology. 2009;111:311-319

Featured Study

Sheth T, Chan M, Butler C, et al. BMJ. 2015 Apr 22;350:h1907. doi: 10.1136/bmj.h1907

Key Highlights

  • The objectives were to determine if coronary computed tomographic angiography (CCTA) enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a myocardial infarction after non-cardiac surgery.
  • CCTA was performed preoperatively.  Results were classified as normal, non-obstructive (<50% stenosis), obstructive (one or two vessels with ≥50% stenosis), or extensive obstructive (≥50% stenosis in two vessels including the proximal left anterior descending artery, three vessels, or left main).
  • This prospective cohort study was conducted in 12 centers in eight countries and enrolled 955 patients with, or at risk of, atherosclerotic disease who underwent non-cardiac surgery.
  • The main outcome was the composite of cardiovascular death and non-fatal myocardial infarction within 30 days after surgery.  The independent variables were scores on the revised cardiac risk index and findings on coronary computed tomographic angiography.

Key Findings

  • Compared with the revised cardiac risk index alone, findings on preoperative CCTA appropriately improved risk estimation among patients who will experience perioperative cardiovascular death or a myocardial infarction (adjusted hazard ratio for extensive obstructive coronary artery disease, 3.76; 95% confidence interval [CI], 1.12 to 12.62).
  • CCTA inappropriately resulted in overestimation of risk among patients who will not experience these outcomes within 30 days of non-cardiac surgery.  With 30-day risk categories of <5%, 5-15%, and >15% for the primary outcome, the net absolute effect in a sample of 1000 patients was that CCTA would result in an inappropriate estimate of risk in 81 patients compared with risk estimation based on the revised cardiac risk index alone.
  • While CCTA can improve risk estimation for patients who incur perioperative cardiovascular death or myocardial infarction, results are more than five times as likely to lead to an inappropriate overestimation of risk among those who will not experience these outcomes.

Featured Articles

Devereaux PJ, Sessler DI. N Engl J Med. 2015;373:2258-2269. doi: 10.1056/NEJMra1502824
Duceppe E, Parlow J, MacDonald P, et al. Can J Cardiol. 2016 Oct 4. pii: S0828-282X(16)30980-1. doi: 10.1016/j.cjca.2016.09.008