Elevated NT-proBNP as a cardiovascular disease risk equivalent

1. In this prospective cohort study, participants with elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP ≥ 450 pg/mL) were found to have similar cardiovascular disease and mortality when compared to participants with prior cardiovascular disease.

2. Participants with an elevated NT-proBNP ≥450 pg/mL have a significantly higher risk of all-cause death and cardiovascular mortality

Evidence Rating Level: 2 (Good)

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a good predictor of cardiovascular events, particularly heart failure (HF). Currently, guidelines do not recommend the use of cardio biomarkers such as NT-proBNP for clinical decision-making in individuals without overt HF. However, the guidelines do suggest that further evidence about the prognostic value of cardio biomarkers may result in future guideline changes. NT-proBNP elevation may help with risk stratification of patients and help to identify otherwise asymptomatic high risk individuals. This study hypothesizes the existence of a fraction of individuals in the community at high cardiovascular mortality risk without a significant history of disease, that could be identified using NT-proBNP. This study was a prospective cohort analysis from the Atherosclerosis Risk in Communities (ARIC) study. In total, the final group consisted of 9,789 participants aged 54 – 76 years from four communities in the United States. Patients were followed for over twenty years, with a baseline starting in 1996 to 1998. Participants without cardiovascular disease were categorized by NT-proBNP, into <125, 125 – 449, and ≥450 pg/mL. Endpoints analyzed included cardiovascular events such as coronary artery disease, stroke, and heart failure, and participants were followed through until December 2019. With respect to baseline characteristics, 13% of the initial participants had a history of cardiovascular disease, and in comparison, adults in the NT-proBNP ≥450 pg/mL group were older, had a lower BMI, were more likely to be female, white, and more likely to have hypertension, diabetes mellitus, or chronic kidney disease. Overall, there were 4,562 deaths, with higher levels of NT-proBNP being linearly associated with risk of death. Participants with highest NT-proBNP levels were found to have similar or higher rates of cardiovascular disease and mortality compared to those with known cardiovascular disease. In addition, comparing the highest NT-proBNP group (≥450 pg/mL) to the lowest (<125 pg/mL), the highest group had significantly higher risks of all-cause death, cardiovascular mortality, cardiovascular disease, atherosclerotic disease, and heart failure. Overall, results from this study suggest that NT-proBNP elevation is a cardiovascular risk equivalent and is useful for monitoring cardiovascular risk in the community setting. A limitation of this study is that given the participant population, the findings cannot be applied to the general population, but this study is an excellent and promising first step into the use of NT-proBNP for risk stratification.

Click to read the study in AM JMED

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