NT-proBNP predicts risk of incident ventricular arrhythmias in adults with an ICD
N-terminal pro-B-type natriuretic peptide for prediction of ventricular arrhythmias: Data from the SMASH study
Introduction and methods
Background
Predicting the risk of ventricular arrhythmia (VA) is challenging due to a large number of heart disease conditions that can result in VA and subsequently sudden cardiac death (SCD). Previous work demonstrated that NT-proBNP is associated with a higher risk of SCD in patients with chronic HF, ischemic heart disease, HCM, and in the general population [1-4]. However, it is unclear whether there is an association between NT-proBNP and incident VA.
Aim of the study
The study aim was to evaluate whether there is an association between NT-proBNP and device-recorded and adjudicated incident VA.
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Methods
The authors performed the biomarker study of the SMASH (Scandinavian Multicenter study to Advance risk Stratification in Heart disease - ventricular arrhythmia) 1 trial. SMASH 1 was an prospective, observational, multicenter study that enrolled adults with an implantable cardioverter defibrillator (ICD) who had a life expectancy of >2 years. In this analysis, 490 patients were included. The mean time from ICD implantation to study inclusion was 5.1±6.6 years. 255 (52%) patients had a primary prevention ICD indication, whereas 135 (28%) patients had cardiac resynchronization therapy with ICD indication. The mean follow-up period was 3.10±0.74 years.
Outcomes
The primary outcome in the SMASH study was incident VA, defined as episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) resulting in appropriately delivered ICD therapies, namely, electrical shock or antitachycardia pacing, or sustained ventricular tachyarrhythmia (>100 b.p.m. and >30 s). Recorded VA events were adjudicated by experienced cardiac electrophysiologists who were blinded to NT-proBNP concentrations.
Main results
- Higher baseline NT-proBNP concentrations were associated with greater risk of incident VA (HR: 1.39; 95%CI: 1.22-1.58 per log unit increase; P<0.001).
- The association between higher NT-proBNP and greater risk of VA was still present after correcting for age, sex, and BMI (HR: 1.37; 95%CI: 1.20-1.58; P<0.001) and after correcting for CAD, HF, eGFR, and LVEF (HR: 1.22; 95%CI: 1.03-1.45; P=0.02).
- Patients in the highest NT-proBNP quartile (NT‐proBNP range 1488–35 000 ng/L) had a significant higher risk of VA compared with patients in the lowest NT-proBNP quartile (NT-proBNP range 16–203 ng/L; HR: 3.86; 95%CI: 2.10-7.10; P<0.001).
- There was a stronger association between NT-proBNP concentrations and incident VA in patients with a secondary prevention ICD indication compared with patients with a primary prevention indication (HR: 1.59; 95%CI: 1.34-1.88; P<0.001; and HR: 1.24; 95%CI: 1.02-1.51; P=0.03; respectively).
- Changes in NT-proBNP from baseline to follow-up were not associated with subsequent incident VA (HR: 1.00; 95%CI: 0.66-1.52; P=0.98).
Conclusion
Higher NT-proBNP concentrations were associated with incident VA, independently of established risk factors for cardiac arrest. Serial measurements of NT-proBNP were not beneficial for arrhythmic risk stratification. The authors concluded “[o]ur data suggest that NT‐proBNP may be a helpful tool for assessing VA risk, particularly in patients with a secondary ICD indication.”.
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