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Anesthesiology:
doi: 10.1097/01.anes.0000300067.02618.28
Correspondence

The Future for B-type Natriuretic Peptide in Preoperative Assessment

Mahla, Elisabeth M.D.*; Watzinger, Norbert M.D.; Toller, Wolfgang M.D.

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In Reply:—

We thank Dr. Struthers et al. for their interest in our article1 and their suggestions for future research based both on high preoperative levels of brain natriuretic peptide (BNP) and the specifics of underlying cardiac pathology.
We are well aware that fully phenotyping, i.e., identification of the underlying cardiac disease and targeted therapy, comprises current and future possibilities for primary and secondary prevention in the individual cardiologic patient, as recently highlighted by Drs. Struthers and Lang.2
Preoperative phenotyping, however, is often limited by timely constrictions due to concomitant and disabling illness that necessitates a rapid surgical intervention. Furthermore, surgical illness and the specifics of the perioperative period (obesity, immobilization, opioids, anemia, catecholamine surges, and hypercoagulability) may both obscure and aggravate the underlying cardiac disease. In addition, recent trials in patients with stable coronary artery disease demonstrated that knowledge of functional coronary artery stenoses and subsequent prophylactic revascularization did not improve cardiac outcome when compared with optimized conventional therapy.3,4
For many years, anesthesiologists have been relying on clinical risk indices to define perioperative cardiac risk.5 Recently BNP, though being an “unspecific” marker of cardiac damage, outperformed risk indices6 and stress testing.7 In the future, determination of BNP might therefore complement anesthesiologic risk assessment by identifying high-risk/high-BNP patients and define the best time (preoperative, early postoperative, or after surgical rehabilitation) for further cardiac evaluation and targeted therapy. However, because of the lack of well-established cutoffs of BNP,2 influence of various patient-specific factors,8 and perioperative undulation of BNP, “high” values will have to be defined and validated in future studies in different surgical settings.
Elisabeth Mahla, M.D.,*
Norbert Watzinger, M.D.,
Wolfgang Toller, M.D.
*Medical University Graz, Graz, Austria. elisabeth.mahla@meduni-graz.at
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References

1. Mahla E, Baumann A, Rehak P, Watzinger N, Vicenzi MN, Maier R, Tiesenhausen K, Metzler H, Toller W: N-terminal pro-brain natriuretic peptide identifies patients at high risk for adverse outcome after vascular surgery. Anesthesiology 2007; 106:1088–95

2. Struthers A, Lang C: The potential to improve primary prevention in the future by using BNP/N-BNP as an indicator of silent “pancardiac” target organ damage: BNP/N-BNP could become for the heart what microalbuminuria is for the kidney. Eur Heart J 2007; 28:1678–82

3. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG: Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004; 351:2795–804

4. Poldermans D, Schouten O, Vidakovic R, Bax JJ, Thomson IR, Hoeks SE, Feringa HH, Dunkelgrun M, de Jaegere P, Maat A, van Sambeek MR, Kertai MD, Boersma E: A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V Pilot Study. J Am Coll Cardiol 2007; 49:1763–9

5. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2002; 39:542–53

6. Dernellis JM, Panaretou MP: Assessment of cardiac risk before noncardiac surgery: Brain natriuretic peptide in 1590 patients. Heart 2006; 92:1645–50

7. Feringa HH, Schouten O, Dunkelgrun M, Bax JJ, Boersma E, Elhendy A, de Jonge R, Karagiannis SE, Vidakovic R, Poldermans D: Plasma N-terminal pro-B-type natriuretic peptide as long-term prognostic marker after major vascular surgery. Heart 2007; 93:226–31

8. Maisel A: The coming of age of natriuretic peptides: The emperor does have clothes! J Am Coll Cardiol 2006; 47:61–4

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