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N-terminal pro-B-type natriuretic peptide for risk assessment in patients with atrial fibrillation: Insights from the aristotle trial (apixaban for the prevention of stroke in subjects with atrial fibrillation)
Hijazi, Ziyad Wallentin, Lars Siegbahn, Agneta Andersson, Ulrika Christersson, Christina Ezekowitz, Justin Gersh, Bernard J. Hanna, Michael Hohnloser, Stefan Horowitz, John
Hijazi, Ziyad
Wallentin, Lars
Siegbahn, Agneta
Andersson, Ulrika
Christersson, Christina
Ezekowitz, Justin
Gersh, Bernard J.
Hanna, Michael
Hohnloser, Stefan
Horowitz, John
Abstract
Objectives This study sought to assess the prognostic value of N-terminal pro–B-type natriuretic peptide (NT-proBNP) in patients with atrial fibrillation (AF) enrolled in the ARISTOTLE (Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation) trial, and the treatment effect of apixaban according to NT-proBNP levels. Background Natriuretic peptides are associated with mortality and cardiovascular events in several cardiac diseases. Methods In the ARISTOTLE trial, 18,201 patients with AF were randomized to apixaban or warfarin. Plasma samples at randomization were available from 14,892 patients. The association between NT-proBNP concentrations and clinical outcomes was evaluated using Cox proportional hazard models, after adjusting for established cardiovascular risk factors. Results Quartiles of NT-proBNP were: Q1, 363 ng/l; Q2, 364 to 713 ng/l; Q3, 714 to 1,250 ng/l; and Q4, > 1,250 ng/l. During 1.9 years, the annual rates of stroke or systemic embolism ranged from 0.74% in the bottom NT-proBNP quartile to 2.21% in the top quartile, an adjusted hazard ratio of 2.35 (95% confidence interval [CI]: 1.62 to 3.40; p < 0.0001). Annual rates of cardiac death ranged from 0.86% in Q1 to 4.14% in Q4, with an adjusted hazard ratio of 2.50 (95% CI: 1.81 to 3.45; p < 0.0001). Adding NT-proBNP levels to the CHA2DS2VASc score improved C-statistics from 0.62 to 0.65 (p ¼ 0.0009) for stroke or systemic embolism and from 0.59 to 0.69 for cardiac death (p < 0.0001). Apixaban reduced stroke, mortality, and bleeding regardless of the NT-proBNP level. Conclusions NT-proBNP levels are often elevated in AF and independently associated with an increased risk of stroke and mortality. NT-proBNP improves risk stratification beyond the CHA2DS2VASc score and might be a novel tool for improved stroke prediction in AF. The efficacy of apixaban compared with warfarin is independent of the NT-proBNP level. (Apixaban for the Prevention of Stroke in Subjects With Atrial Fibrillation [ARISTOTLE]; NCT00412984) (J Am Coll Cardiol 2013;61:2274–84) ª 2013 by the American College of Cardiology Foundation
Keywords
atrial fibrillation, natriuretic peptides, NT-proBNP, risk assessment
Date
2013
Type
Journal article
Journal
Journal of the American College of Cardiology
Book
Volume
61
Issue
22
Page Range
2274-2284
Article Number
ACU Department
Collections
Relation URI
Source URL
Event URL
Open Access Status
Open access
License
File Access
Controlled