Preoperative levels of natriuretic peptides and the incidence of postoperative atrial fibrillation after noncardiac surgery: a prospective cohort study

Abstract

Background: Postoperative atrial fibrillation (POAF) is associated with clinically significant short- and long-term complications after noncardiac surgery. Our aim was to describe the incidence of clinically important POAF after noncardiac surgery and establish the prognostic value of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in this context.

Methods: The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study was a prospective cohort study involving patients aged 45 years and older who had inpatient noncardiac surgery that was performed between August 2007 and November 2013. We determined 30-day incidence of clinically important POAF (i.e., resulting in angina, congestive heart failure, symptomatic hypotension or requiring treatment) using logistic regression models to analyze the association between preoperative NT-proBNP and POAF.

Results: In 37 664 patients with no history of atrial fibrillation, we found that the incidence of POAF was 1.0% (95% confidence interval [CI] 0.9%-1.1%; 369 events); 3.2% (95% CI 2.3%-4.4%) in patients undergoing major thoracic surgery, 1.3% (95% CI 1.2%-1.5%) in patients undergoing major nonthoracic surgery and 0.2% (95% CI 0.1%-0.3%) in patients undergoing low-risk surgery. In a subgroup of 9789 patients with preoperative NT-proBNP measurements, the biomarker improved the prediction of POAF risk over conventional prognostic factors (likelihood ratio test p < 0.001; fraction of new information from NT-proBNP was 16%). Compared with a reference NT-proBNP measurement set at 100 ng/L, adjusted odds ratios for the occurrence of POAF were 1.31 (95% CI 1.15-1.49) at 200 ng/L, 2.07 (95% CI 1.27-3.36) at 1500 ng/L and 2.39 (95% CI 1.26-4.51) at 3000 ng/L.

Interpretation: We determined that the incidence of clinically important POAF after noncardiac surgery was 1.0%. We also found that preoperative NT-proBNP levels were associated with POAF independent of established prognostic factors. Trial registration: ClinicalTrials.gov, no. NCT00512109.

Conflict of interest statement

Competing interests: P.J. Devereaux has received grants from Abbott Diagnostics, Boehringer Ingelheim, Roche Diagnostics and Siemens, as well as a grant and products from Philips Healthcare outside the submitted work. Emmanuelle Duceppe has received an investigator-initiated grant and a donation-in-kind (assays) from Roche Diagnostics during the conduct of the study. She also received an investigator-initiated grant and a donation-in-kind (assays) from Abbott Laboratories, and an investigator-initiated grant from Boehringer Ingelheim outside of the submitted work. Pablo Alonso-Coello’s institution received funding from the Instituto de Salud Carlos III (Madrid, Spain) and Fundació La Marató de TV3 (Esplugues de Llobregat, Spain). No other competing interests were declared.

© 2020 Joule Inc. or its licensors.

Figures

Figure 1:

Flow chart for selection of study patients. Note: AF = atrial fibrillation, NT-proBNP = N-terminal pro–brain-type natriuretic peptide.

Figure 2:

Histograms presenting distributions of values of N-terminal pro–brain-type natriuretic peptide (NT-proBNP) stratified by the occurrence of postoperative atrial fibrillation (POAF). Median values of NT-proBNP in both groups are marked with broken lines. Values of NT-proBNP winsorized at the 99th percentile (i.e., 98 most extreme values replaced with 5732 ng/L) for increased readability.

Figure 3:

Unadjusted (left) and adjusted (right) relation between N-terminal pro–brain-type natriuretic peptide (NT-proBNP) measurement and postoperative atrial fibrillation (POAF). The test for nonlinearity of the estimated unadjusted relation between NT-proBNP and POAF had a p value = 0.01. The test for nonlinearity of the estimated relation had a p value = 0.2 in the multivariable analysis. The grey area represents 95% confidence intervals. Note: OR = odds ratio.