NT-BNP in Stable Coronary Artery Disease

NT-BNP in Stable Coronary Artery Disease

Menon Venu
US Cardiovascular Disease 2006
Published: March 2007
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The management of patients with stable coronary artery disease (CAD) is characterized by the utilization of proven medical therapy and on-going effective risk stratification. Periodic assessment of patient symptomatology and functionality, evaluation and control of traditional risk factors, presence and extent of ischemia, extent of CAD and left ventricular function, and referral to revascularization when indicated all play an important role in delivering optimal care. A reliable biomarker or group of markers that would provide incremental data to predict risk for cardiovascular morbidity and death would certainly enhance clinical care in the out-patient setting. An enhanced appreciation of risk may lead to adequate up-titration of medical therapy and improve patient compliance in high risk subsets.The biomarker would be most useful if it further guided targeted treatment strategies that would in turn optimize patient outcome.

The role of natriuretic peptides has evolved rapidly since their original discovery approximately a quarter century ago. An understanding of this complex homeostatic system has led to rapid advances that have been quickly translated from the basic laboratory to practical usage by the patients beside. Brain natriuretic peptide (BNP) and N-terminal (NT-BNP) have emerged as promising molecules for assay and are now available for routine clinical use.The negative predictive value of NT-BNP in ruling out a cardiac etiology of shortness of breath is now established in current clinical practice.The utility of NT-BNP in risk stratification of subjects with acute coronary syndromes (ACS); and as a screening tool for occult LV dysfunction has been documented. The role of NT-BNP in guiding the titration of medical therapy is actively being explored. This manuscript will review the potential of the NT-BNP assay in the setting of stable CAD.

Lessons from the Prior Index Event
A large proportion of patients with stable coronary artery disease have had a prior index myocardial infarction (MI) or non-ST elevation myocardial infarction (NSTEMI). Baseline NT-BNP measurements, regardless of the sample timing (on presentation; early 12–24 hours and sub-acute >3 days), during the index clinical presentation, have consistently been shown to be of utility as a predictive marker for short- and long-term mortality.The discriminating power of the assay is noted even when analysis is limited to patients without any clinical evidence of heart failure. NT-BNP has been shown to be an independent predictor of mortality in these studies. However, a significant proportion of the predictive ability of increasing levels of NT-BNP in the acute setting is due to its association with other well established clinical risk factors: age, female gender, diabetes mellitus, hypertension, previous MI, heart failure, resting heart rate, and ST-segment depression; renal dysfunction and inflammatory markers like CRP. NT-BNP measurements have also been correlated with myocardium at risk, infarct size, and extent and complexity of coronary artery disease.The assay may thus be best appreciated as a non specific marker that appears to provide the clinician with an overall cross sectional risk estimate. The clinician taking care of the stable patient with CAD should utilize this information in the downstream assessment of patients in an outpatient setting. A number of clinical observations support the utility of NT-BNP as a biomarker in the setting of an acute coronary syndrome. For the benefit of the readership; some of the studies focusing in this area are summarized below.

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