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Postoperative Pro-Adrenomedullin Levels Predict Mortality in Thoracic Surgery Patients: Comparison With Acute Physiology and Chronic Health Evaluation IV Score*

Schoe, Abraham MD1; Schippers, Emile F. MD, PhD2; Struck, Joachim PhD3; Ebmeyer, Stefan MD3; Klautz, Robert J.M. MD, PhD4; de Jonge, Evert MD, PhD1; van Dissel, Jaap T. MD, PhD2

doi: 10.1097/CCM.0000000000000709
Clinical Investigations
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SDC

Objectives: Risk assessment in ICU patients using commonly used prognostic models may be influenced using different data definitions and by errors in data collection. We investigated whether a set of biomarkers (procalcitonin, MR-pro-adrenomedullin, CT-pro-endothelin-1, CT-pro-arginine vasopressin, and MR-pro-atrial natriuretic peptide), alone or as a panel, could be useful in postoperative risk assessment for hospital mortality in comparison with the Acute Physiology and Chronic Health Evaluation IV score.

Design: In a prospective observational cohort study, we analyzed 800 consecutive patients undergoing elective cardiac surgery. We assessed biomarker levels on admission to the ICU and every 6 hours thereafter for 24 hours. For every postoperative time point and for every biomarker, we determined the predictive value for hospital mortality and made a comparison with the Acute Physiology and Chronic Health Evaluation IV score.

Setting: Intensive care of an academic referral hospital.

Patients: A total of 800 consecutive patients undergoing elective cardiac surgery.

Interventions: None.

Measurements and Main Results: MR-pro-adrenomedullin is a good predictor of mortality (c-statistic at time point 6 hr after admission to the ICU, 0.940; 95% CI, 0.918–0.956) and performed better than the Acute Physiology and Chronic Health Evaluation IV score (c-statistic, 0.842; 95% CI, 0.811–0.868). The c-statistic did not change significantly on the time points 6, 12, and 18 hours after admission. Using a cutoff value for proadrenomedullin taken 6 hours after admission on ICU (time point 2) of 3.2 nmol/L sensitivity was 81.8% and specificity 93.9%, the positive likelihood ratio was 13.3, positive predictive value was 31.0%, and negative predictive value was 99.4%. Patients with a MR-pro-adrenomedullin above this cutoff level had an odds ratio of 68.9 (95% CI, 22.2–213.1) for not surviving their hospital stay. The other biomarkers had less predictive power.

Conclusions: In elective cardiac surgery, MR-pro-adrenomedullin measured between 6 and 18 hours after admission to the ICU is a better predictor of hospital mortality in comparison with the Acute Physiology and Chronic Health Evaluation IV score.

Supplemental Digital Content is available in the text.

1Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.

2Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.

3Thermo Fisher Scientific/B.R.A.H.M.S. GmbH, Hennigsdorf, Germany.

4Department of Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.

* See also p. 494.

Current address for Dr Joachim Struck: AdrenoMed AG, Hennigsdorf, Germany.

The study was conducted at the Leiden University Medical Center, Leiden, The Netherlands.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by the Department of Infectious Diseases and the Department of Intensive Care both from Leiden University Medical Center, Leiden, the Netherlands. Biomarkers were analyzed by Thermo Fisher Scientific/B.R.A.H.M.S. GmbH, Hennigsdorf, Germany. The costs for transport an analysis was at their courtesy.

Dr. Schoe disclosed Thermo Fisher Scientific/B.R.A.H.M.S. GmbH as other relationship (analyzed the biomarker samples). Dr. Ebmeyer is employed by ThermoFisher Scientific (manufacturer of the assay). Dr. Struck is employed by B.R.A.H.M.S. GmbH (At time of study was employed by B.R.A.H.M.S. GmbH, which manufactures assays used in the study. No longer employed there) and disclosed that his former employer, B.R.A.H.M.S. GmbH, holds patent rights on assays used in the study. The institution of Dr. Klautz served as board member for Medtronic Advisory Board; consulted for Edwards LifeSciences Educational Board; received grant support from Medtronic, Edwards LifeSciences, and St Jude Medical; and lectured for St Jude Medical, Medtronic, Edwards LifeScience, and Sorin. Dr. van Dissel disclosed other support from B.R.A.H.M.S.-ThermoFisher Berlin (performed some of the biomarker assays). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: a.schoe@lumc.nl

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