Prognostic significance of the admission plasma B-type natriuretic peptide measurement in patients with first ST-elevation myocardial infarction in comparison with C-reactive protein and TIMI risk score

doi:10.1016/j.cca.2007.04.002

Clinica Chimica Acta

Volume 382, Issues 1–2, July 2007, Pages 106-111

https://doi.org/10.1016/j.cca.2007.04.002 Get rights and content

Abstract

Background

In ST-elevation myocardial infarction (STEMI) B-type natriuretic peptide (BNP) holds promise for risk stratification. Aim of this study was to assess prognostic value of plasma BNP measurement and to compare with other powerful prognostic markers — TIMI Risk Score (TRS) and C-reactive protein (CRP) in patients with first STEMI treated with primary PCI (pPCI).

Methods

86 patients, admitted within initial 12 h of the first STEMI. Admission plasma levels of BNP were measured by MEIA method. Serum levels of CRP were measured using immunoturbidimetric assays. Composite end point (CEP) was assessed after 7 months.

Results

Median plasma BNP value was higher in patients with CEP, compared with those without CEP (p < 0.001). Patients with plasma BNP > 99.2 pg/mL were at significantly higher risk for CEP (the highest sensitivity and specificity). CRP level > 10.6 mg/dL was also associated with poor outcome. TRS has not influenced the occurrence of CEP. In the analysis of logistic regression the BNP value > 99.2 pg/mL was the strongest predictor of CEP. ROC analysis identified BNP measurement as significant to estimate adverse outcome 0.950 in the prediction of CEP (95% Confidence interval = 0.878–0.985).

Conclusion

Admission plasma BNP concentrations provide incremental prognostic information in patients with first STEMI treated with pPCI.

Introduction

The studies of the last decade have focused on the evaluation of the diagnostic and prognostic roles of biomarkers in patients with acute coronary syndromes (ACS). Troponins and C-reactive protein (CRP) are good markers in prediction of poor outcome in patients with ACS [1], [2]. Also B-type natriuretic peptide (BNP) holds promise for risk stratification in this group of patients [3], [4], [5]. However prognostic power of BNP and CRP in patients with acute myocardial infarction (AMI) was rarely compared. Additional evidence regarding optimal cut-off values of these two biomarkers is needed.

In the setting of ST-elevation myocardial infarction (STEMI) the Thrombolysis In Myocardial Infarction (TIMI) Risk Score (TRS) is a useful tool for risk stratification [6]. It stratifies patients at presentation using only history and clinical parameters. The value of TRS as a predictor for short- and long-term prognosis has been demonstrated [7]. Nevertheless TRS does not capture some measures of medical co-morbidity that may offer incremental prognostic information. Perhaps it would be useful to combine TRS with baseline biomarkers measurements for more complex and accurate risk evaluation.

The relationship between TRS and biochemical parameters (plasma BNP and serum CRP) in patients with STEMI has not been previously investigated.

The aim of the present study was to assess the prognostic significance of plasma BNP measurement and to compare this value with commonly used CRP and TRS measurement for long-term outcome in patients with first STEMI treated with primary percutaneous coronary intervention (pPCI).

Section snippets

Patients population

Eighty-six patients (63 men, mean age 63.9 ± 11.4 years), admitted to our Department with first STEMI and treated with primary PCI within the first 12 h from the onset of chest pain, were included in the study. According to the inclusion and exclusion criteria patients were selected out of the 187 consecutive STEMI patients. Subjects with any history of previous MI, severe valvular disease, cardiomyopathy, any form of congenital cardiac disease or symptoms of chronic heart failure (CHF) were

Results

Clinical characteristics of the study population is shown in Table 1. Median pain time was 235.0 min. (quartile range 25%–75%: 140.0–300.0), median pain-to-baloon time was 242.5 min. (quartile range 25%–75%: 160.0–350.0). Median procedure time was 50.0 min (quartile range 25%–75%: 40.0–60.0). We did not use thrombus evacuation catheter during procedure. The extent of coronary artery disease was as follows: most of the patients had one-vessel disease (45.3%), in 32.5% we found two-vessel

Discussion

Present analysis strongly suggests the valid prognostic role of plasma BNP measurement with respect to long-term follow-up in patients with first STEMI treated with primary PCI. Because of the strict inclusion criteria, our study population represented a relatively low risk group. For this reason and because of a small sample size we analyzed CEP.

Our work compared the existing models of risk stratification in the population of patients with first STEMI treated with primary PCI. We evaluated the

Conclusions

Increased plasma BNP concentration at initial presentation of patients with first STEMI treated with primary PCI is associated with poor outcome. These findings may justify inclusion of BNP as an important risk factor in STEMI patients. The ability of risk stratification at presentation should be useful to displace patients to the appropriate level of care, according to the current guidelines.

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2018, Revista Portuguesa de Cardiologia
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According to Walsh et al.,9 pPCI can be performed in an elderly population who have a high-risk TIMI score with low mortality and marked symptomatic benefit. The TIMI risk score is based on clinical information that is available at the time of hospital arrival and is suitable for early risk stratification at the bedside, but in the Intravenous nPA for Treatment of Infarcting Myocardium Early (InTIME II) trial, the TIMI score was not the best predictor of poor outcome because of the small sample size.10 Gonzalez-Pacheco et al. found a C-statistic of 0.80 for the predictive value of the TIMI risk score for in-hospital mortality.
The monocyte to high-density lipoprotein cholesterol ratio (MHR) has recently been proposed as a new predictor and prognostic indicator in cardiovascular disease. The TIMI risk score predicts short-term mortality in ST-elevation myocardial infarction (STEMI) patients. However, there have been no studies regarding the association between MHR and TIMI score in patients with STEMI.
A total of 161 patients admitted to our hospital were prospectively enrolled between January 2014 and June 2016. Of these, 111 consecutive patients with a diagnosis of STEMI who underwent primary percutaneous coronary intervention (PCI) were selected as the STEMI group, and the remaining 50 patients, who had angiographically normal coronary arteries, were selected as the control group. The 111 STEMI patients were then divided into two subgroups based on TIMI scores.
MHR was significantly higher in the STEMI group than in the control group (1.71±0.47 vs. 2.21±0.98, p=0.001) and was significantly higher in the high TIMI score group than in the low TIMI score group (1.80±0.59 vs. 2.42±1.09, p=0.001). In multivariate logistic regression analysis, MHR was the only independent predictor of acute STEMI and high TIMI score. In correlation analysis, there was a significant positive correlation between MHR and TIMI score in STEMI patients (r=0.479, p<0.001). The cutoff value of MHR for high TIMI score in patients with STEMI was 2.409, with a sensitivity of 43.06% and a specificity of 87.18% (AUC 0.669; 95% CI 0.569-0.8769; p=0.003) on ROC curve analysis.
This study indicates that MHR is independently and significantly associated with TIMI score in patients with STEMI. MHR is a novel inflammation-based marker and may be an independent predictor of future cardiovascular events in patients with STEMI.
A relação entre a contagem de monócitos e o nível de lipoproteína de alta densidade do colesterol (MHR) foi recentemente apresentada como um novo preditor e indicador prognóstico de doenças cardiovasculares. O score de risco TIMI prediz em curto prazo a mortalidade em doentes com STEMI. Contudo, não há estudo disponível acerca da associação entre o MHR e o score TIMI em doentes com STEMI.
Foram recrutados 161 doentes prospetivamente entre janeiro de 2014 e junho de 2016. Dos 161 doentes, 111 foram admitidos consecutivamente no nosso hospital com o diagnóstico de STEMI e foram submetidos a PCI primária, foram designados como o grupo STEMI, os restantes 50 doentes fizeram angiografia com artérias coronárias normais e foram selecionados como grupo controle. Os 111 doentes com STEMI foram ainda divididos em dois subgrupos, de acordo com o score de risco TIMI.
O MHR foi significativamente mais alto no grupo STEMI quando comparado com o grupo controle (1,71±0,47 versus 2,21±0,98, p=0,001) e foi significativamente mais alto no subgrupo de alto risco TIMI, quando comparado com o subgrupo de baixo risco TIMI (1,80±0,59 versus 2,42±1,09, p=0,001). O modelo de regressão logística multivariável demonstrou que o MHR só foi preditor independente no grupo STEMI com score TIMI de alto risco. Na análise de correlação, houve uma correlação positiva significativa entre o MHR e o score TIMI em doentes com STEMI (r=0,479, p<0,001). O valor de cut-off do MHR para o score TIMI alto em doentes STEMI foi 2,409 com uma sensibilidade de 43,06% e uma especificidade de 87,18% (AUC, 0,669; 95% com um intervalo de confiança de [CI], 0,569-0,8769; p=0,003) na análise de curva de ROC.
Este estudo indicou que o MHR está independente e significativamente associado ao score TIMI em doentes com STEMI. O MHR é um novo marcador de base inflamatória e pode ser um preditor independente de eventos cardiovasculares futuros em doentes com STEMI.
Cardiac biomarkers in acute myocardial infarction
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Their usefulness, however, lies in risk stratification, shown in large trials such as Orbofiban in Patients with Unstable coronary Syndromes (OPUS)-TIMI 16 and TACTICS TIMI 18 as well as smaller trials. BNP/NT-proBNP are independent predictors of death [116,160,164,167,168,170–181] and heart failure [116,159–161,166,174,179,182] independent of left ventricular ejection fraction and this risk is graduated. They predict those who incur adverse left ventricular remodelling (progressive dilatation and cardiac dysfunction) [161,172,183], with a correlation better than for cTn [165].
Each year, a large number of patients are seen in the Emergency Department with presentations necessitating investigation for possible acute myocardial infarction. Patients can be stratified by symptoms, risk factors and electrocardiogram results but cardiac biomarkers also have a prime role both diagnostically and prognostically. This review summarizes both the history of cardiac biomarkers as well as currently available (established and novel) assays. Cardiac troponin, our current “gold standard” biomarker criterion for the diagnosis of myocardial infarction has high sensitivity and specificity for this diagnosis and therapies instituted in patients with elevated troponin have been shown to influence outcomes. Other markers of myocardial necrosis, inflammation and neurohormonal activity have also been shown to have either diagnostic or prognostic utility, but none have been shown to be superior to troponin. The measurement of multiple biomarkers and the use of point of care markers may accelerate current diagnostic protocols for the assessment of such patients.
TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: A meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients
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This was especially marked in studies evaluating UA/NSTEMI or STEMI alone with higher revascularization rates in validation cohorts. It is worth noticing that, apart from STEMI patients, and despite recent guidelines no more than half of overall patients have undergone percutaneous or surgical revascularization, with an important burden of unfavorable effects, both for short and long term outcomes, as recently demonstrated [73,74]. The effect of these management strategies in derivation cohorts could also affect variables resulting in independent predictors of adverse events, thus underlying the need of new scores using more contemporary databases.
Acute coronary syndromes (ACS) represent a difficult challenge for physicians. Risk scores have become the cornerstone in clinical and interventional decision making.
PubMed was systematically searched for ACS risk score studies. They were divided into ACS studies (evaluating Unstable Angina; UA, Non ST Segment Elevation Myocardial Infarction; NSTEMI, and ST Segment Elevation Myocardial Infarction; STEMI), UA/NSTEMI studies or STEMI studies. The c-statistics of validation studies were pooled when appropriate with random-effect methods. 7 derivation studies with 25,525 ACS patients and 15 validation studies including 257,654 people were formally appraised. Pooled analysis of GRACE scores, both at short (0.82; 0.80–0.89 I.C 95%) and long term follow up (0.84; 0.82–0.87; I.C 95%) showed the best performance, with similar results to Simple Risk Index (SRI) derivation cohorts at short term. For NSTEMI/UA, 18 derivation studies with 56,560 patients and 18 validation cohorts with 56,673 patients were included. Pooled analysis of validations studies showed c-statistics of 0.54 (95% CI = 0.52–0.57) and 0.67 (95% CI = 0.62–0.71) for short and long term TIMI validation studies, and 0.83 (95% CI = 0.79–9.87) and 0.80 (95% CI = 0.74–0.89) for short and long term GRACE studies. For STEMI, 15 studies with 134,557 patients with derivation scores, and 17 validation studies with 187,619 patients showed a pooled c-statistic of 0.77 (95% CI = 0.71–0.83) and 0.77 (95% CI = 0.72–0.85) for TIMI at short and long term, and a pooled c-statistic of 0.82 (95% CI = 0.81–0.83) and 0.81 (95% CI = 0.80–0.82) for GRACE at short and long terms respectively.
TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE performing better. There are other potentially useful ACS risk scores available however these have not undergone rigorous validation. This study suggests that these other scores may be potentially useful and should be further researched.
The value of apelin-36 and brain natriuretic peptide measurements in patients with first ST-elevation myocardial infarction
2010, Clinica Chimica Acta
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We assessed the similar group of low risk first STEMI patients previously. BNP obtained early after admission had the strongest predictive value, compared to traditional tools for risk stratification [15]. In summary, our study provides information that in low risk STEMI patients, treated with pPCI and with preserved LVEF the decrease of plasma apelin-36 concentrations and the increase of plasma BNP concentrations could be found in the first days after the onset of myocardial infarction.
We aimed to assess apelin—novel endogenous ligand for the angiotensin-like 1 receptor in patients with ST-elevation myocardial infarction (STEMI) and to compare its value with B-type natriuretic peptide (BNP).
In 78 consecutive patients with first STEMI treated with primary PCI, plasma apelin-36 (RIA) and BNP (MEIA) concentrations were measured twice: on admission and on the fifth day of hospitalization. Left ventricle ejection fraction (LVEF) was assessed on admission and composite endpoint (CEP)—after 1 year follow-up.
During the 5-day interval median plasma BNP level significantly increased and median plasma apelin concentration significantly decreased. BNP, but not apelin, correlated with low LVEF (< 50%). In ROC analysis only BNP measurements were diagnostic for low LVEF. In ANOVA test, in patients with CEP, a significant decrease in apelin (but not BNP) concentrations measured in 5-day interval was found. ROC analysis identified only second BNP measurement as significant to estimate adverse outcome 0.627 in the prediction of CEP (95% confidence interval = 0.507–0.736).
Following STEMI there is a decrease of plasma apelin-36 concentration and an increase of plasma BNP concentration. BNP is better, than apelin diagnostic value for the detection of impaired LVEF. Both BNP and apelin have prognostic value, although both needs further evaluation.
B-type natriuretic peptide and RISK-PCI Score in the risk assessment in patients with STEMI treated by primary percutaneous coronary intervention
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^☆: Grant supported by the Medical University in Bialystok, Poland, No 3-53710 L.

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Prognostic significance of the admission plasma B-type natriuretic peptide measurement in patients with first ST-elevation myocardial infarction in comparison with C-reactive protein and TIMI risk score☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients population

Results

Discussion

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Lancet

J Am Coll Cardiol

Troponins in acute coronary syndromes

Semin Vasc Med

The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes

N Engl J Med

Natriuretic peptides for risk stratification of patients with acute coronary syndromes

Eur J Heart Fail

The risk score profile: a novel approach to characterizing the risk of populations enrolled in clinical studies

Eur Heart J