The Prognostic Value of B-Type Natriuretic Peptide in Patients with Acute Coronary Syndromes

TLDR

B‑type natriuretic peptide, a ventricular neurohormone, has been shown to predict outcomes after myocardial infarction, yet its prognostic value in non‑ST‑segment‑elevation acute coronary syndromes remains underexplored. In the Orbofiban‑TIMI 16 study, BNP was measured in plasma 40 ± 20 hours after symptom onset in 2,525 ACS patients, and baseline levels were correlated with 30‑day and 10‑month outcomes. Higher baseline BNP quartiles were associated with progressively greater 10‑month mortality, myocardial infarction, and heart‑failure risk, with adjusted odds ratios up to 5.8, indicating that an early single BNP measurement provides powerful risk stratification across the ACS spectrum.

Abstract

Brain (B-type) natriuretic peptide is a neurohormone synthesized predominantly in ventricular myocardium. Although the circulating level of this neurohormone has been shown to provide independent prognostic information in patients with transmural myocardial infarction, few data are available for patients with acute coronary syndromes in the absence of ST-segment elevation.We measured B-type natriuretic peptide in plasma specimens obtained a mean (+/-SD) of 40+/-20 hours after the onset of ischemic symptoms in 2525 patients from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis in Myocardial Infarction 16 study.The base-line level of B-type natriuretic peptide was correlated with the risk of death, heart failure, and myocardial infarction at 30 days and 10 months. The unadjusted rate of death increased in a stepwise fashion among patients in increasing quartiles of base-line B-type natriuretic peptide levels (P< 0.001). This association remained significant in subgroups of patients who had myocardial infarction with ST-segment elevation (P=0.02), patients who had myocardial infarction without ST-segment elevation (P<0.001), and patients who had unstable angina (P<0.001). After adjustment for independent predictors of the long-term risk of death, the odds ratios for death at 10 months in the second, third, and fourth quartiles of B-type natriuretic peptide were 3.8 (95 percent confidence interval, 1.1 to 13.3), 4.0 (95 percent confidence interval, 1.2 to 13.7), and 5.8 (95 percent confidence interval, 1.7 to 19.7). The level of B-type natriuretic peptide was also associated with the risk of new or recurrent myocardial infarction (P=0.01) and new or worsening heart failure (P<0.001) at 10 months.A single measurement of B-type natriuretic peptide, obtained in the first few days after the onset of ischemic symptoms, provides powerful information for use in risk stratification across the spectrum of acute coronary syndromes. This finding suggests that cardiac neurohormonal activation may be a unifying feature among patients at high risk for death after acute coronary syndromes.