CLINICAL RESEARCH: BIOMARKERS
Natriuretic peptides as predictors of non-sudden and sudden cardiac death after acute myocardial infarction in the beta-blocking era
Jari M. Tapanainen, MD*,
Kai S. Lindgren, MD*,
Timo H. Mäkikallio, MD*,
Olli Vuolteenaho, MD ,
Juhani Leppäluoto, MD and
Heikki V. Huikuri, MD, FACC*,*
* Division of Cardiology, Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
Department of Physiology, Oulu University, Oulu, Finland
Manuscript received May 22, 2003;
revised manuscript received August 15, 2003,
accepted September 16, 2003.
* Reprint requests and correspondence: Dr. Heikki V. Huikuri, Professor of Medicine, Division of Cardiology, Department of Internal Medicine, Oulu University Hospital, Kajaanintie 50, 90220 Oulu, Finland.
heikki.huikuri{at}oulu.fi
OBJECTIVES: This prospective study tested whether the natriuretic peptides predict cardiac death among patients using beta-blocking therapy after an acute myocardial infarction (AMI).
BACKGROUND: Natriuretic peptides have provided prognostic information after AMI, but their predictive value has not been well established in the era of beta-blocker use.
METHODS: A series of 521 patients (mean age 61 ± 10 years) with AMI was included in the study. The end points were total mortality and non-sudden and sudden cardiac death (SCD). Plasma concentrations of atrial natriuretic peptide (ANP), N-terminal atrial natriuretic propeptide (N-ANP), brain natriuretic peptide (BNP), and ejection fraction (EF) were analyzed before hospital discharge. The cardiac medication was optimized (e.g., adherence to beta-blocking therapy was 97% at discharge and 95% at one year after AMI).
RESULTS: During a mean follow-up of 43 ± 13 months, total mortality was 11.5% (60/521), cardiac mortality was 6.3% (33/521), and 3.1% (16/521) experienced SCD. On univariate analysis, high levels of all measured peptides and low EF predicted the occurrence of non-SCD (p < 0.001 for all). Peptides and EF also predicted the occurrence of SCD (p < 0.05), with elevated BNP (>23.0 pmol/l) being the most powerful predictor (hazard ratio [HR] 4.4, 95% confidence interval [CI] 1.4 to 13.8; p = 0.01). After adjusting for clinical variables, only elevated BNP (HR 3.9, 95% CI 1.2 to 12.3, p = 0.02) and low EF (<40%) (p = 0.03) remained as significant predictors of SCD.
CONCLUSIONS: Natriuretic peptides retain their prognostic value in the beta-blocking era among survivors of AMI. Elevated BNP provides information on the risk of subsequent SCD, independent of clinical variables and left ventricular EF.
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Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | ANP | = atrial natriuretic peptide | | BNP | = brain natriuretic peptide | | CI | = confidence interval | | EF | = ejection fraction | | HF | = heart failure | | HR | = hazard ratio | | ICD | = implantable cardioverter-defibrillator | | LV | = left ventricular | | N-ANP | = N-terminal atrial natriuretic propeptide | | SCD | = sudden cardiac death |
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