EDITORIAL COMMENT
European Journal of Cardio-Thoracic Surgery 46 (2014) e81 doi:10.1093/ejcts/ezu382
Pierre-Emmanuel Falcoz* Department of Thoracic Surgery, University Hospital, Strasbourg, France * Corresponding author. Department of Thoracic Surgery, University Hospital, 67000 Strasbourg, France. Tel: +33-3-69551134; fax: +33-3-69551895; e-mail: [email protected] (P.-E. Falcoz).
Keywords: B-natriuretic peptide • Cardiovascular complication • Pulmonary complication • Pulmonary resection • Perioperative management • Non-small-cell lung cancer
In the present article, Cagini et al. [1] seek to address the very invigorating question of the role of B-natriuretic peptides (BNPs) in predicting adverse cardiopulmonary events after thoracic surgery. In this single-centre prospective short-term observational cohort study, 294 consecutive patients undergoing scheduled pulmonary resections were enrolled over 18 months (April 2012 to October 2013). The results showed that patients who developed postoperative complications had a significantly greater BNP increase (P < 0.0001) when compared with those without complications. In addition, a postoperative day 1 BNP concentration ≥118.5 pg/ml (area under the curve = 0.65) was associated with a three-fold risk of developing postoperative pulmonary complications [odds ratio (OR) = 2.94]. Interestingly, in the subset of patients undergoing major lung resections (lobectomy or pneumonectomy), BNP concentration was the strongest independent predictor of complications (OR = 3.49). The authors concluded that BNP concentration measured 24 h after pulmonary resection is an independent predictor of postoperative complications and that patients with elevated BNP concentrations are at increased risk for adverse cardiopulmonary events. This stimulating paper helps to clarify some of the controversies regarding the use of cardiac biomarkers in the clinical settings and appropriately investigates some of the dogmas in this area. European 2009 guidelines did not recommend routine biomarker sampling to prevent cardiac events among patients undergoing non-cardiac surgery, whereas preoperative measurement of BNP was recommended to obtain prognostic information on perioperative and late cardiac events in very high-risk patients [2]. However, the results of this well-designed study may affect future patient management. Indeed, the predictive value of the concentration of postoperative BNP might reflect the influence of not only intraoperative procedural manoeuvers but also cardiac-related complications after surgery and may consequently be used to identify a subset of patients at major risk, requiring enhanced diagnostic, therapeutic effort and the accurate follow-up. Why should thoracic surgeons be considered with the findings of this rigorous study? Not only because the current contribution confirms, in turn, that BNP concentrations are powerful independent predictors of perioperative cardiovascular complications [3, 4]; rather because this stimulating paper has successfully ‘opened one door leading to ten more’ in the burgeoning field of cardiac biomarker
assessment. Indeed, there are now obviously growing evidence in the literature that the use of cardiac biomarkers is successful in improving risk stratification and guiding medical decision [5]. However, the exact cut-off for the unfavourable prognostic value of an early postoperative increase of BNP concentrations still needs to be determined [6, 7]. Future works that aimed to establish clinical scores in this framework may be the clue in assessing the usefulness of BNP concentrations as a guide to therapy affecting prognosis. For now, Cagini et al. are to be congratulated on their contribution in this area. Their findings will certainly prove to be most beneficial to the thoracic surgery community.
REFERENCES [1] Cagini L, Andolfi M, Leli C, Potenza R, Ragusa M, Scarnecchia E et al. B-type natriuretic peptide following thoracic Surgery. A predictor of postoperative cardiopulmonary complications. Eur J Cardiothorac Surg 2014; doi:10.1093/ ejcts/ezu348. [2] Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G et al. Task force for preoperative cardiac risk assessment and perioperative cardiac managmeent in non-cardiac surgery; European Society of Cardiology (ESC). Guidelines for preoperative cardiac risk assessment and perioperative cardiac managmeent in non-cardiac surgery. Eur Heart J 2009;30:2769–812. [3] Karthikeyan G, Moncur RA, Levine O, Heels-Ansdell D, Chan MT, AlonsoCoello P et al. Is a preoperative brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of non cardiac surgery? A systematic review and meta-analysis of observational studies. J Am Coll Cardiol 2009;54:1599–606. [4] Rodseth RN, Biccard BM, Chu R, Lurati Buse GA, Thabane L, Bakhai A et al. Postoperative B-type natriuretic peptide for prediction of major cardiac events in patients undergoing non cardiac surgery; systematic review and individual patients meta-analysis. Anesthesiology 2013;119:270–83. [5] Rodseth RN, Biccard BM, Le Manach Y, Sessler DI, Lurati Buse GA, Thabane L et al. The prognostic value of pre-operative and postoperative B-natriuretic peptides in patients indergoing non cardiac surgery. J Am Coll Cardiol 2014; 63:170–80. [6] Tayama K, Takamori S, Mitsuoka M, Hayashi A, Tamura K, Mifume H et al. Natriuretic peptides after pulmonary resection. Ann Thorac Surg 2002;73: 1582–6. [7] Nojiri T, Inoue M, Yamamoto K, Maeda H, Takeuchi Y, Funakoshi Y et al. B-type natriuretic peptide as a predictor of postoperative cardiopulmonary complications in elderly patients undergoing pulmonary resection for lung cancer. Ann Thorac Surg 2011;92:1051–5.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
THORACIC
B-type natriuretic peptide following thoracic surgery
European Journal of Cardio-Thoracic Surgery 46 (2014) e81 doi:10.1093/ejcts/ezu382
Pierre-Emmanuel Falcoz* Department of Thoracic Surgery, University Hospital, Strasbourg, France * Corresponding author. Department of Thoracic Surgery, University Hospital, 67000 Strasbourg, France. Tel: +33-3-69551134; fax: +33-3-69551895; e-mail: [email protected] (P.-E. Falcoz).
Keywords: B-natriuretic peptide • Cardiovascular complication • Pulmonary complication • Pulmonary resection • Perioperative management • Non-small-cell lung cancer
In the present article, Cagini et al. [1] seek to address the very invigorating question of the role of B-natriuretic peptides (BNPs) in predicting adverse cardiopulmonary events after thoracic surgery. In this single-centre prospective short-term observational cohort study, 294 consecutive patients undergoing scheduled pulmonary resections were enrolled over 18 months (April 2012 to October 2013). The results showed that patients who developed postoperative complications had a significantly greater BNP increase (P < 0.0001) when compared with those without complications. In addition, a postoperative day 1 BNP concentration ≥118.5 pg/ml (area under the curve = 0.65) was associated with a three-fold risk of developing postoperative pulmonary complications [odds ratio (OR) = 2.94]. Interestingly, in the subset of patients undergoing major lung resections (lobectomy or pneumonectomy), BNP concentration was the strongest independent predictor of complications (OR = 3.49). The authors concluded that BNP concentration measured 24 h after pulmonary resection is an independent predictor of postoperative complications and that patients with elevated BNP concentrations are at increased risk for adverse cardiopulmonary events. This stimulating paper helps to clarify some of the controversies regarding the use of cardiac biomarkers in the clinical settings and appropriately investigates some of the dogmas in this area. European 2009 guidelines did not recommend routine biomarker sampling to prevent cardiac events among patients undergoing non-cardiac surgery, whereas preoperative measurement of BNP was recommended to obtain prognostic information on perioperative and late cardiac events in very high-risk patients [2]. However, the results of this well-designed study may affect future patient management. Indeed, the predictive value of the concentration of postoperative BNP might reflect the influence of not only intraoperative procedural manoeuvers but also cardiac-related complications after surgery and may consequently be used to identify a subset of patients at major risk, requiring enhanced diagnostic, therapeutic effort and the accurate follow-up. Why should thoracic surgeons be considered with the findings of this rigorous study? Not only because the current contribution confirms, in turn, that BNP concentrations are powerful independent predictors of perioperative cardiovascular complications [3, 4]; rather because this stimulating paper has successfully ‘opened one door leading to ten more’ in the burgeoning field of cardiac biomarker
assessment. Indeed, there are now obviously growing evidence in the literature that the use of cardiac biomarkers is successful in improving risk stratification and guiding medical decision [5]. However, the exact cut-off for the unfavourable prognostic value of an early postoperative increase of BNP concentrations still needs to be determined [6, 7]. Future works that aimed to establish clinical scores in this framework may be the clue in assessing the usefulness of BNP concentrations as a guide to therapy affecting prognosis. For now, Cagini et al. are to be congratulated on their contribution in this area. Their findings will certainly prove to be most beneficial to the thoracic surgery community.
REFERENCES [1] Cagini L, Andolfi M, Leli C, Potenza R, Ragusa M, Scarnecchia E et al. B-type natriuretic peptide following thoracic Surgery. A predictor of postoperative cardiopulmonary complications. Eur J Cardiothorac Surg 2014; doi:10.1093/ ejcts/ezu348. [2] Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G et al. Task force for preoperative cardiac risk assessment and perioperative cardiac managmeent in non-cardiac surgery; European Society of Cardiology (ESC). Guidelines for preoperative cardiac risk assessment and perioperative cardiac managmeent in non-cardiac surgery. Eur Heart J 2009;30:2769–812. [3] Karthikeyan G, Moncur RA, Levine O, Heels-Ansdell D, Chan MT, AlonsoCoello P et al. Is a preoperative brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of non cardiac surgery? A systematic review and meta-analysis of observational studies. J Am Coll Cardiol 2009;54:1599–606. [4] Rodseth RN, Biccard BM, Chu R, Lurati Buse GA, Thabane L, Bakhai A et al. Postoperative B-type natriuretic peptide for prediction of major cardiac events in patients undergoing non cardiac surgery; systematic review and individual patients meta-analysis. Anesthesiology 2013;119:270–83. [5] Rodseth RN, Biccard BM, Le Manach Y, Sessler DI, Lurati Buse GA, Thabane L et al. The prognostic value of pre-operative and postoperative B-natriuretic peptides in patients indergoing non cardiac surgery. J Am Coll Cardiol 2014; 63:170–80. [6] Tayama K, Takamori S, Mitsuoka M, Hayashi A, Tamura K, Mifume H et al. Natriuretic peptides after pulmonary resection. Ann Thorac Surg 2002;73: 1582–6. [7] Nojiri T, Inoue M, Yamamoto K, Maeda H, Takeuchi Y, Funakoshi Y et al. B-type natriuretic peptide as a predictor of postoperative cardiopulmonary complications in elderly patients undergoing pulmonary resection for lung cancer. Ann Thorac Surg 2011;92:1051–5.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
THORACIC
B-type natriuretic peptide following thoracic surgery
