Abstract
BackgroundThe prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF) is well-established. However, whether it could facilitate the risk stratification of HF patients with implantable cardioverter-defibrillator (ICD) is still unclear.ObjectiveTo determine the associations between baseline NT-proBNP and outcomes of all-cause mortality and first appropriate shock due to sustained ventricular tachycardia/ventricular fibrillation (VT/VF) in ICD recipients.Methods and resultsN-terminal pro-B-type natriuretic peptide was measured before ICD implant in 500 patients (mean age 60.2 ± 12.0 years; 415 (83.0%) men; 231 (46.2%) Non-ischemic dilated cardiomyopathy (DCM); 136 (27.2%) primary prevention). The median NT-proBNP was 854.3 pg/ml (interquartile range [IQR]: 402.0 to 1,817.8 pg/ml). We categorized NT-proBNP levels into quartiles and used a restricted cubic spline to evaluate its nonlinear association with outcomes. The incidence rates of mortality and first appropriate shock were 5.6 and 9.1%, respectively. After adjusting for confounding factors, multivariable Cox regression showed a rise in NT-proBNP was associated with an increased risk of all-cause mortality. Compared with the lowest quartile, the hazard ratios (HRs) with 95% CI across increasing quartiles were 1.77 (0.71, 4.43), 3.98 (1.71, 9.25), and 5.90 (2.43, 14.30) for NT-proBNP (p for trend < 0.001). A restricted cubic spline demonstrated a similar pattern with an inflection point found at 3,231.4 pg/ml, beyond which the increase in NT-proBNP was not associated with increased mortality (p for nonlinearity < 0.001). Fine-Gray regression was used to evaluate the association between NT-proBNP and first appropriate shock accounting for the competing risk of death. In the unadjusted, partial, and fully adjusted analysis, however, no significant association could be found regardless of NT-proBNP as a categorical variable or log-transformed continuous variable (all p > 0.05). No nonlinearity was found, either (p = 0.666). Interactions between NT-proBNP and predefined factors were not found (all p > 0.1).ConclusionIn HF patients with ICD, the rise in NT-proBNP is independently associated with increased mortality until it reaches the inflection point. However, its association with the first appropriate shock was not found. Patients with higher NT-proBNP levels might derive less benefit from ICD implant.
Highlights
Sudden cardiac death (SCD) represents a heavy health burden accounting for 15–20% of all deaths around the world [1, 2]
The prognostic importance of NT-proBNP has been broadly studied in patients with heart failure (HF), but remains largely unexplored in HF patients with implantable cardioverter-defibrillator (ICD)
Since published data have shown that NTproBNP has a close relationship with all-cause mortality [15, 16], pump failure death [15, 16], and sudden death in a variety of populations [21–27], it is expected to be a promising marker for HF with ICD
Summary
Sudden cardiac death (SCD) represents a heavy health burden accounting for 15–20% of all deaths around the world [1, 2]. Most SCD events occur in the community-based population without a prior history of structural heart disease, making it difficult to predict [5]. Preventive strategies have been focusing on the high-risk population, such as those with severe heart disease. An implantable cardioverter-defibrillator (ICD) therapy is the widely accepted effective modality to reduce SCD in current guidelines [6, 7]. There is an urgent need to find an additional indicator to identify patients more likely to benefit from ICD therapy. The prognostic value of N-terminal pro-B-type natriuretic peptide (NTproBNP) in heart failure (HF) is well-established. Whether it could facilitate the risk stratification of HF patients with implantable cardioverter-defibrillator (ICD) is still unclear
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