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J Am Coll Cardiol, 2003; 41:1264-1272, doi:10.1016/S0735-1097(03)00168-2
© 2003 by the American College of Cardiology Foundation
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CLINICAL STUDY: ACUTE CORONARY SYNDROMES/INFARCTION

Evaluation of B-type natriuretic peptide for risk assessment in unstable Angina/Non–ST-elevation myocardial infarction

B-type natriuretic peptide and prognosis in TACTICS-TIMI 18

David A. Morrow, MD, MPH*,*, James A. de Lemos, MD{dagger}, Marc S. Sabatine, MD, MPH*, Sabina A. Murphy, MPH{ddagger}, Laura A. Demopoulos, MD§, Peter M. DiBattiste, MD§, Carolyn H. McCabe, BS*, C. Michael Gibson, MD, MS, FACC{ddagger}, Christopher P. Cannon, MD, FACC* and Eugene Braunwald, MD, FACC*

* Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
{dagger} Donald W. Reynolds Cardiovascular Research Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
{ddagger} Harvard Clinical Research Institute, Boston, Massachusetts, USA
§ Merck & Co, West Point, Pennsylvania, USA

Manuscript received October 27, 2002; revised manuscript received December 4, 2002, accepted December 26, 2002.

* Reprint requests and correspondence: Dr. David A. Morrow, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA.
dmorrow{at}partners.org

OBJECTIVES: This study was designed to evaluate B-type natriuretic peptide (BNP) for risk assessment and clinical decision making over a range of cut points, alone and with cardiac troponin I (cTnI), in patients with non–ST-elevation acute coronary syndromes (ACS).

BACKGROUND: B-type natriuretic peptide holds promise for risk stratification. Additional evidence regarding optimal decision limits, use in combination with troponin, and use in targeting therapy is needed before acceptance into clinical use for ACS.

METHODS: We evaluated BNP at baseline in 1,676 patients with non–ST-elevation ACS randomized to early invasive versus conservative management.

RESULTS: Patients with elevated BNP (>80 pg/ml; n = 320) were at higher risk of death at seven days (2.5% vs. 0.7%, p = 0.006) and six months (8.4% vs. 1.8%, p < 0.0001). The association between BNP and mortality at six months (adjusted odds ratio [OR] 3.3; 95% confidence interval [CI] 1.7 to 6.3) was independent of important clinical predictors, including cTnI and congestive heart failure (CHF). Patients with elevated BNP had a fivefold higher risk of developing new CHF by 30 days (5.9% vs. 1.0%, p < 0.0001). B-type natriuretic peptide added prognostic information to cTnI, discriminating patients at higher mortality risk among those with negative (OR 6.9; 95% CI 1.9 to 25.8) and positive (OR 4.1; 95% CI 1.9 to 9.0) baseline cTnI results. No difference was observed in the effect of invasive versus conservative management when stratified by baseline levels of BNP (pinteraction ≥ 0.6).

CONCLUSIONS: Elevated BNP (>80 pg/ml) at presentation identifies patients with non–ST-elevation ACS who are at higher risk of death and CHF and adds incremental information to cTnI. Additional work is needed to identify therapies that may reduce the risk associated with increased BNP.

Abbreviations and Acronyms
  ACS
  acute coronary syndrome(s)
  BNP
  B-type natriuretic peptide
  CHF
  congestive heart failure
  CI
  confidence interval
  CK-MB
  creatine kinase-MB
  cTnI
  cardiac troponin I
  HF
  heart failure
  MI
  myocardial infarction
  NSTEMI
  non–ST-elevation myocardial infarction
  OR
  odds ratio
  TIMI
  Thrombolysis In Myocardial Infarction
  UA
  unstable angina




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