NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation

Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Cardiovascular Revascularization Medicine

NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation☆,☆☆ Giampaolo Niccoli a,⁎, Micaela Conte a, Simona Marchitti b, Rocco A. Montone a, Francesco Fracassi a, Rocco Grippo a, Marco Roberto a, Francesco Burzotta a, Carlo Trani a, Antonio Maria Leone a, Franca Bianchi b, Sara Di Castro b, Massimo Volpe b,c, Filippo Crea a, Speranza Rubattu b,c,⁎⁎ a b c

Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy IRCCS Neuromed, Pozzilli, Italy Department of Clinical and Molecular Medicine, School of Medicine and Psychology, Sapienza University, Rome, Italy

a r t i c l e

i n f o

Article history: Received 15 November 2015 Received in revised form 22 February 2016 Accepted 24 February 2016 Available online xxxx Keywords: Percutaneous coronary intervention Cardiovascular risk NT-proANP NT-proBNP

a b s t r a c t Background: Natriuretic peptides are diagnostic/prognostic biomarkers in major cardiovascular diseases. We aimed at assessing the predictive role of N-terminal pro-A-type (NT-proANP) and pro-B-type (NT-proBNP) natriuretic peptides levels toward cardiovascular outcome in both stable and unstable coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) in a non-primary PCI setting. Methods: A total of 395 patients undergoing PCI with stent implantation for either stable angina (SA) or non STelevation acute coronary syndrome (NSTE-ACS) were enrolled. Pre-procedural NT-proANP and NT-proBNP levels were measured. Occurrence of major adverse cardiac events (MACEs), composite of cardiac death, non-fatal myocardial infarction, and clinically driven target lesion revascularization (c-TLR), was the endpoint of the study. Follow up mean time was 48.53 ± 14.69 months. Results: MACEs occurred in forty-four patients (11%) during follow up. Both NT-proANP levels [3170 (2210–4630) vs 2283 (1314–3913) fmol/mL, p = 0.004] and NT-proBNP levels [729 (356–1353) vs 511 (267–1006) fmol/mL, p = 0.04] were significantly higher in patients with MACEs compared to patients without MACEs. Similar results were found when considering hard MACEs (myocardial infarction and cardiac death). NTproANP levels were significantly higher in patients with c-TLR compared with patients without c-TLR [3705 (2766–5184) vs 2343 (1340–3960) fmol/mL, p = 0.021]. At multivariate analysis, NT-proANP levels were a significant predictor of MACEs (HR 1.09, 95% CI 1.03–1.18, p = 0.04). Kaplan–Meyer curves revealed that patients with elevated NT-proANP levels (N2.100 fmol/mL) had a lower MACE free survival (p = 0.003). Conclusions: Both NT-proANP and NT-proBNP levels were higher in CAD patients experiencing MACEs following PCI in a non-primary setting. Notably, only NT-proANP levels significantly affected prognosis after PCI. © 2016 Elsevier Inc. All rights reserved.

☆ Conflicts of interest: none declared. ☆☆ Condensed abstractThe predictive role of both NT-proANP and NT-proBNP circulating levels toward cardiovascular outcome was assessed in a cohort of both stable and unstable CAD patients undergoing PCI in a non-primary PCI setting. Following PCI, higher levels of both NT-proNPs were associated to higher occurrence of MACEs [composite of cardiac death, non-fatal myocardial infarction and clinically driven target lesion revascularization (c-TLR)] at follow up. This finding was confirmed when restricting the analysis to hard MACEs (cardiac death, myocardial infarction). Only NT-proANP levels were significantly associated to c-TLR and were an independent predictor of MACEs by Cox regression analysis. Kaplan–Meyer curves revealed that patients with elevated NT-proANP levels (N2.100 fmol/mL) had a lower MACE free survival (p = 0.003).NT-proANP levels measurement can be proposed as a valuable tool to identify patients at higher risk for MACEs following PCI. ⁎ Correspondence to: G. Niccoli, Institute of Cardiology, Catholic University of the Sacred Heart, Rome. Tel.: +39 06 30154187; fax: +39 06 3055535. ⁎⁎ Correspondence to: S. Rubattu, Clinical and Molecular Medicine Department, School of Medicine and Psychology, Sapienza University, S. Andrea Hospital, IRCCS Neuromed, Pozzilli (Is), Rome, Italy. Tel.: +39 06 33775979; fax: +39 06 33775061. E-mail addresses: [email protected] (G. Niccoli), [email protected] (S. Rubattu).

1. Introduction Natriuretic peptides (NPs) exert important functions within the cardiovascular system, including hemodynamic properties and contribution to both cardiac and vessel structural remodeling [1,2]. Both atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were found to exert anti-hypertrophic, anti-fibrotic and anti-proliferative effects in cardiomyocytes, fibroblasts, endothelial and vascular smooth muscle cells [2]. Moreover, NPs interfere with key mechanisms of atherosclerosis, i.e. proliferation, angiogenesis, apoptosis and inflammation [2]. The close relationship with cardiovascular hemodynamic and structure makes NP levels a very sensitive marker of cardiovascular disease (CVD) risk in the general population [3–7] and a valuable diagnostic and prognostic factor in established CVDs [2]. In fact, the clinical usefulness of NPs appears well established in both stable and unstable coronary atherosclerotic disease, with particular regard to prognostic implications [8–12].

http://dx.doi.org/10.1016/j.carrev.2016.02.012 1553-8389/© 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

2

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

Stent-related events along with native coronary atherosclerosis progression are main determinants of long-term outcome in patients treated by percutaneous coronary intervention (PCI). The need of useful predictive markers of cardiovascular outcome following coronary stent implantation is a relevant clinical issue. Based on knowledge on the prognostic role of NPs in ischemic heart disease [2,8–12], a valuable field of application of circulating NP levels assay in cardiology practice may be the prediction of cardiovascular outcome following PCI. In fact, previous clinical trials support a prognostic role of NT-proBNP levels toward cardiovascular risk following PCI [13,14]. Since available evidence on the predictive role of different NPs following PCI is scarce, we aimed at exploring the prognostic role of both preprocedural NT-proANP and NT-proBNP circulating levels in coronary artery disease (CAD) patients who underwent stent implantation in a non-primary PCI setting. 2. Methods 2.1. Patient population We enrolled 395 patients presenting with either stable angina (SA) or non ST-elevations acute coronary syndrome (NSTE-ACS) who underwent PCI from January 2009 to December 2010 at the Catholic University of Rome and for whom a pre-procedural blood sample was available. Overall, 481 patients were initially screened for the study. Exclusion criteria were: acute ST-elevation myocardial infarction (n = 30), chronic systolic and/or diastolic heart failure (n = 20), severe valvular disease (n = 5), systemic inflammatory diseases (n = 4), moderate– severe kidney disease (n = 10), acute and chronic infections (n = 3), autoimmune diseases (n = 3), liver diseases (n = 2), neoplasia (n = 3), evidence of immunologic disorders (n = 2), use of antiinflammatory or immunosuppressive drugs (n = 3), and recent (3 months) surgical procedures or trauma (n = 1). Patients with instent restenosis of drug-eluting stent (DES) or bare-metal stent (BMS) were excluded as well as patients with stent implantation in the last 12 months before the start of the study in order to avoid potential effects of previously implanted stents. Biological measurements were available in all patients. In all patients cardiovascular risk factors were carefully examined, including a family history of early CAD [first degree relative with a history of myocardial infarction (MI) b 60 years], hypercholesterolemia (total cholesterol N 200 mg/dL or treated hypercholesterolemia), smoking habit [current regular use (any amount) or cigarette withdrawal more than 2 months], hypertension (systolic blood pressure N 140 mmHg and/or diastolic blood pressure N 90 mmHg or treated hypertension). History of CAD was defined as any previous diagnosis of SA or ACS. Patients underwent mono-dimensional and bi-dimensional echocardiography and left ventricular ejection fraction (LVEF) was measured with 2D echo Simpson's biplane. The choice between BMS or DES was left at the operator discretion. All patients received the same DES if more than one lesion per patient was treated. Post-procedural therapies, including antiplatelet therapy, were prescribed according to current guidelines. All patients received aspirin and clopidogrel at least 2 hours before the procedure. Following PCI, aspirin was prescribed lifelong and clopidogrel for 12 months in NSTE-ACS patients. The duration of clopidogrel therapy in SA patients was based on the type of implanted stent (1 month for BMS and 1 year for DES). A clinical follow-up was planned at 12, 24, 36 and 48 months after discharge, and data about the follow-up were available for all patients. The primary endpoint of the study was the occurrence of MACEs, defined as the composite of cardiovascular death, MI and clinically driven target lesion revascularization (c-TLR). A secondary endpoint was the occurrence of hard MACE, defined as the composite of cardiac death and MI. Cardiac death was ascertained by contacting the family doctor or the hospital where the patient died. MI was diagnosed by elevation

of CK-MB levels above the 99th percentile upper reference limit associated with typical chest pain [15]. C-TLR was carried out in the presence of a diameter stenosis N50% within 5 mm proximal or distal to the previously implanted stent. C-TLR was clinically driven either due to recurrent angina or to evidence of ischemia by stress test. This study complied with the Declaration of Helsinki. All patients provided informed written consent and the study was approved by the Ethics Committee of the Catholic University of Rome. 2.2. Coronary angiographic evaluation An expert angiographer (M.C.), unaware of NP values, evaluated angiographic images both qualitatively and quantitatively. Lesion morphology was assessed by using the modified American College of Cardiology/American Heart Association grading system (type A, B1, B2, and C), whereas CAD severity by counting the number of coronary artery branches showing at least one critical stenosis (N70% reduction in lumen diameter). Digital angiograms were quantitatively analyzed offline with the use of an automated edge-detection system (CMS; Medis Medical Imaging Systems, The Netherlands). All measurements were performed on images obtained after intracoronary nitrate administration. The following angiographic parameters were obtained: reference vessel diameter, minimal lumen diameter, percent of diameter stenosis, which were evaluated both at baseline and at the end of the procedure, lesion length, and total stent length. The procedure was considered successful if residual stenosis was b30% with TIMI flow grade 3. 2.3. Blood sampling and NP levels assay Blood samples were obtained just prior coronary angiography. Biochemical analyses (renal function parameters, glucose, total, HDL and HDL cholesterol, triglycerides, troponin T) were performed with specific biochemical methods on automatic analyzers (Thermo Scientific) of the clinical laboratory. For hormonal measurement, blood was firstly collected in ethylene-diamine-tetraacetic-acid (EDTA) vacutainer tubes, centrifuged at 3000 rpm at 4 °C; and plasma was stored at −80 °C for blind batch analysis. Thereafter, assays of NT-proANP and NT-proBNP plasma levels were performed by commercially available Elisa kits (Gruppe Biomedica, Wien, Austria). 2.4. Statistical analysis Data distribution for continuous variables was assessed according to the Kolmogorov–Smirnov test. Continous variables not following normal distribution were expressed as median and interquartile range, whereas other continuous variables were expressed as mean ± SD; categorical variables were expressed as proportions. Unpaired t-test or Mann Whitney U-test was used for comparisons of continuous variables between two groups; categorical variables were compared using the chi square test or the Fisher's exact test, as appropriate. Correlations between continuous variables were analyzed using Pearson or Spearman test, as appropriate. In this study, there was only right censoring of the data, i.e. MACE did not occur in the remaining patients before the end of follow up and use of Cox proportional hazard ratio (HR) model is allowed with this type of data. Event-free survival was measured from the date of discharge to the occurrence of MACE or to the date of last known follow up evaluation. Thus, as primary analysis, we performed a simple Cox regression analysis using all variables on their original continuous scale in order to estimate the unadjusted HR of all variables. We also calculated the 95% confidence interval (CI) of the coefficient of the Cox regression. Adjusted HRs were calculated according to multivariable Cox regression analysis, including variables with p of significance ≤ 0.1 at univariate analysis. Survival curves using Kaplan–Meier methods were made for NT-proNPs according to the cut-off values derived from ROC curves analysis and compared by the log-rank test. In particular, cut-off values of 2.100 fmol/mL and 100 fmol/mL for NT-

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

proANP and NT-proBNP, respectively, were used. Statistical significance was considered for p values b 0.05. All analyses were performed using SPSS version 20 (SPSS Inc., Chicago, IL, USA).

3. Results 3.1. Main features and clinical outcomes of the study population We included 303 patients (76.7%) with NSTE-ACS and 92 patients (23.3%) with SA. Follow up mean time was 48.53 ± 14.69 months. Baseline clinical, angiographic and procedural data of the study population are shown in Table 1. At a mean follow up of 4 years, 44 (11%) patients experienced MACEs. In particular, 3 patients had a cardiac death and 1 patient died as a consequence of a stroke; 25 patients had MI and 15 patients underwent c-TLR. Baseline clinical, angiographic, procedural and laboratory characteristics according to MACEs occurrence are reported in Table 2. No significant correlations were detected between blood creatinine values and NT-proNPs levels: creatinine vs NT-proANP (r = 0.063; p = 0.420) and creatinine vs NT-proBNP (r = 0.013; p = 0.871).

3

3.2. Clinical outcome according to NT-proANP and NT-proBNP plasma levels Patients with MACEs had significantly higher pre-procedural NTproANP and NT-proBNP levels compared with patients without MACEs (Table 2). Moreover, patients with hard MACEs had significantly higher pre-procedural NT-proANP [3058 (2122–5154) vs 2330 (1328–3951), fmol/mL p = 0.024] and NT-proBNP levels [915 (374–1538) vs 512 (273–1005), fmol/mL p = 0.026] compared with patients without hard MACEs. Of note, patients with c-TLR had significantly higher pre-procedural NT-proANP levels [3705 (2766–5184) vs 2343 (1340–3960) fmol/mL, p = 0.021] compared with patients without c-TLR, whereas no difference in baseline NT-proBNP levels was observed [504 (275–726) vs 526 (280–1038) fmol/mL, p = 0.57]. 3.3. Predictors of MACEs and survival analysis At the univariate analysis both NT-proANP and NT-proBNP levels were significantly associated with a higher occurrence of MACEs (Table 3). However, only NT-proANP levels retained their predictive value at multivariate analysis (Table 4).

Table 1 Baseline clinical, laboratory, angiographic and procedural characteristics in the overall patient population and according to the clinical presentation. Variables Clinical variables Age, years, mean ± SD Male, n (%) Hypertension, n (%) Smoking, n (%) Dyslipidaemia, n (%) Diabetes, n (%) Family history of CAD, n (%) Previous CAD, n (%) Previous PCI, n (%) Previous CABG, n (%) Multivessel disease, n (%) LEVF, %, median (range) TIMI risk score Laboratory assays Creatinine, mg/dL, mean (range) NT-proANP, fmol/mL, median (range) NT-proBNP, fmol/mL, median (range) Total cholesterol, mg/dL, mean ± SD HDL, mg/dL, mean ± SD LDL, mg/dL, mean ± SD Triglycerides, mg/dL, mean ± SD Hemoglobin, mg/dL, mean ± SD Glycaemia, mg/dL, median (range) Troponin T, ng/mL, median (range) Medical therapy at discharge Βeta-blockers, n (%) ACE-I/ARB, n (%) Statin, n (%) Antiplatelet drugs, n (%) Angiographic and procedural data Number of stent for patients, mean ± SD Stent type BMS, n (%) Stenosis length, mm, median (range) RVD pre, mm, median (range) MLD pre, mm, mean ± SD DS % pre, mean ± SD MLD post, mm, mean ± SD Pre-dilatation, n (%) Post-dilatation, n (%) Stent length, mm, median (range) Stent diameter, mm, mean ± SD Acute gain, mm, mean ± SD

All patients (N = 395)

ACS 303 (76.7%)

SA 92 (23.3%)

p

70 ± 11 278 (70.4) 301 (76.2) 141 (35.7) 230 (58.2) 103 (26.1) 104 (26.3) 106 (26.8) 96 (24.3) 31 (7.8) 207 (52.4) 60 (55–65) –

68 ± 12 211 (69.6) 228 (75.2) 106 (35.0) 175 (57.8) 75 (24.8) 75 (24.8) 85 (28.1) 75 (24.8) 27 (8.9) 165 (54.5) 61 (57–64) 2.2 ± 1.9

74 ± 15 67 (72.8) 73 (19) 35 (38) 55 (59.8) 28 (30.4) 29 (31.5) 21 (22.8) 21 (22.8) 4 (4.3) 42 (45.7) 58 (54–63) –

0.9 (0.81–1.20) 2376 (1383–4130) 523 (276–1036) 187 ± 50.9 44 ± 11.8 112 ± 42 143 ± 67.1 14 ± 1.6 106 (92–139) 9.432 (1.257–16.306)

0.85 (0.75–1.11) 2174 (1431–3949) 413 (243–1143) 174 ± 53 39 ± 19 104 ± 37 137 ± 57 13.5 ± 1.8 101 (99–125) 13.322 (7.431–19.436)

0.89 (0.79–1.17) 2098 (1432–4049) 476 (313–1094) 179 ± 46 43 ± 11 109 ± 41 144 ± 71 13.9 ± 1.9 104 (94–137) 0.000 (0.000–0.000)

252 (67.2) 258 (68.8) 272 (72.7) 371 (98.9)

198 (65.3) 202 (66.7) 212 (70.0) 283 (93.4)

54 (58.7) 56 (60.9) 60 (65.2) 88 (95.7)

0.26 0.32 0.44 0.62

1.3 ± 0.4

1.2 ± 0.4

1.3 ± 0.5

0.95 0.62

120 (30.4) 17.9 (12.8–25.4) 2.63 (2.2–3.1) 0.86 ± 0.5 69.5 ± 16.8 2.7 ± 0.5 320 (81.0) 255 (64.6) 22.5 (18–33) 3.1 ± 0.5 1.8 ± 0.6

95 (31.4) 16.4 (11.9–24.9) 2.49 (2.21–2.95) 0.79 ± 0.80 72.3 ± 17.6 2.3 ± 0.4 210 (69.3) 250 (82.5) 23.4 (17.5–32.6) 2.8 ± 0.8 1.7 ± 0.7

25 (27.2) 17.4 (12.3–23.9) 2.34 (2.19–3.23) 0.93 ± 0.96 69.4 ± 15.6 2.5 ± 0.6 65 (70.7) 70 (76.1) 24.3 (19.6–34.7) 3.2 ± 0.9 1.9 ± 0.8

0.83 0.6 0.48 0.62 0.80 0.28 0.22 0.35 0.78 0.18 0.15 0.94 – 0.75 0.83 0.78 0.55 0.63 0.45 0.62 0.74 0.96 b0.001

0.39 0.56 0.56 0.21 0.96 0.28 0.17 0.69 0.87 0.63

ACE-I: angiotensin-converting-enzyme inhibitor; ARB: angiotensin receptor blocker; BMS: bare metal stent; CABG: coronary artery bypass graft; CAD: coronary artery disease; DES: drugeluting stent; PCI: percutaneous coronary intervention; ACS acute coronary syndrome; SA stable angina; RVD reference vessel diameter; MLD minimum lumen diameter; DS diameter stenosis.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

4

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

Table 2 Baseline clinical, laboratory, angiographic and procedural characteristics according to MACEs occurrence. Variables Clinical variables Age, years, mean ± SD Male, n (%) Hypertension, n (%) Smoking, n (%) Dyslipidaemia, n (%) Diabetes, n (%) Family history of CAD, n (%) Previous CAD, n (%) Previous PCI, n (%) Previous CABG, n (%) Clinical presentation Stable angina, n (%) NSTE-ACS, n (%) Multivessel disease, n (%) LEVF, %, median (range) Laboratory assays Creatinine, mg/dL, median (range) NT-proANP, fmol/mL, median (range) NT-proBNP (fmol/mL), median (range) Total cholesterol, mg/dL, mean ± SD HDL, mg/dL, mean ± SD LDL, mg/dL, mean ± SD Triglyceride, mg/dL, mean ± SD Hemoglobin, g/dL, mean ± SD Glycaemia, mg/dL, median (range) Troponin T, ng/mL, median (range) Medical therapy at discharge Beta-blocker, n (%) ACE-I/ARB, n (%) Statin, n (%) Antiplatelet drugs, n (%) Angiographic and procedural data Number of stents for patient, mean ± SD Stent type BMS, n (%) DES, n (%) Stenosis length, mm, median (range) RVD pre, mm, median (range) MLD pre, mm, median (range) DS % pre, mm, mean ± SD MLD post, mm, median (range) DS% post, median (range) Stent length (mm), median (range) Predilatation, n (%) Stent diameter, mm, mean ± SD Acute gain, mm, mean ± SD

Patients with MACE (n = 44)

Patients without MACE (n = 351)

p

70 ± 10 35 (79.5) 34 (77.3) 21 (47.7) 27 (61.4) 11 (25) 9 (20.5) 13 (30.2) 12 (27.9) 3 (7.0)

70 ± 11 243 (74.1) 267 (81.2) 120 (36.5) 203 (61.7) 92 (28) 95 (28.9) 93 (30.0) 84 (27.1) 28 (9.0)

0.86 0.43 0.54 0.28 0.97 0.68 0.24 0.98 0.91 1.0 1.0

10 (23) 34 (77) 29 (65.9) 60 (51–65)

82 (23) 269 (77) 178 (50.7) 60 (55–65)

0.66 0.32

0.8 (0.7–1.2) 3170 (2210–4630)

1 (0.8–1.2) 2283 (1314–3913)

0.26 0.004

729 (356–1353)

511 (267–1006)

0.04

190 ± 50.2

166 ± 32

0.02

39 ± 9.0 113 ± 42.0 169 ± 64.3

44 ± 12.0 99 ± 32.7 142 ± 67.9

0.17 0.24 0.31

15 ± 1.3

14 ± 1.7

0.14

106 (92–138) 10.437 (5.482–13.738)

99 (90–153) 8.484 (3.843–11.437)

0.9 0.39

25 (58.1) 30 (69.8) 27 (62.8) 43 (100)

213 (68.9) 215 (69.4) 231 (74.5) 306 (98.7)

0.17 0.96 0.1 1.0

1.2 ± 0.6

1.2 ± 0.5

0.56

12 (28) 32 (72) 23 (15–29)

109 (31) 242 (69) 23 (17–32)

0.50

2.6 (2.2–3.2) 0.87 (0.4–1.6) 70.3 ± 14.1 2.6 ± 0.5 11 (7–16) 23 (15–39)

2.6 (2.2–3.1) 0.85 (0.5–1.6) 69.7 ± 17.3 2.7 ± 0.5 12 (7–17) 23 (17–32)

0.47 0.75 0.83 0.7 0.76 0.50

35 (79.5%) 3.1 ± 0.6

271 (82.4%) 3.2 ± 0.6

0.65 0.60

1.8 ± 0.7

1.8 ± 0.6

0.46

0.73

ACE-I: angiotensin-converting-enzyme inhibitor; ARB: angiotensin receptor blocker; BMS: bare metal stent; CABG: coronary artery bypass graft; CAD: coronary artery disease; DES: drug-eluting stent; LVEF: left ventricular ejection fraction; PCI: percutaneous coronary intervention; NSTE-ACS: non ST-elevation acute coronary syndrome; RVD reference vessel diameter; MLD minimum lumen diameter; DS diameter stenosis.

Table 3 Predictors of MACE at univariate analysis. Variables Clinical variables Age Male gender Hypertension Smoking Dyslipidaemia Diabetes Family history Previous CAD Previous PCI Previous CABG Clinical presentation (NSTE-ACS) Multivessel disease LVEF Laboratory assays Creatinine NT-proANP NT-proBNP Total cholesterol HDL LDL Triglyceride Hemoglobin Glycaemia Troponin T Medical therapy at discharge Beta-blockers ACE-I/ARB Statin Antiplatelet drugs Angiographic and procedural data BMS Number of stents implanted Stenosis length RVD pre MLD pre DS% pre RVD post MLD post DS% post Stent length Stent diameter Pre-dilatation Post-dilatation Acute gain

HR

95% CI

p

0.99 1.30 0.86 1.03 0.94 0.88 0.64 0.99 1.08 0.83 1.19 1.21 0.96

0.97–1.02 0.62–2.71 0.42–1.74 0.67–1.59 0.51–1.74 0.44–1.74 0.31–1.34 0.52–1.91 0.55–2.10 0.26–2.70 0.57–2.49 0.67–2.22 0.92–1.01

0.61 0.48 0.67 0.90 0.85 0.71 0.24 0.98 0.83 0.76 0.64 0.53 0.08

0.95 1.15 1.09 0.99 0.96 0.99 1.01 1.25 1.01 1.34

0.49–1.82 1.08–1.20 1.03–1.16 0.98–1.00 0.90–1.02 0.97–1.01 1.00–1.02 0.82–1.90 1.00–1.02

0.87 0.015 0.034 0.07 0.20 0.20 0.36 0.30 0.16

0.68 1.00 0.58 0.78

0.37–1.26 0.52–1.92 0.31–1.08 0.36–1.34

0.22 0.99 0.08 0.25

0.91 0.83 1.01 1.17 1.10 1.00 0.95 0.96 0.99 1.01 0.85 0.92 0.93 0.88

0.48–1.75 0.45–1.54 0.99–1.03 0.83–1.63 0.62–1.93 0.98–1.02 0.56–1.63 0.55–1.69 0.96–1.04 0.99–1.02 0.45–1.60 0.44–1.92 0.50–1.70 0.54–1.43

0.79 0.55 0.32 0.37 0.75 0.92 0.86 0.89 0.84 0.38 0.61 0.82 0.8 0.59

ACE-I: angiotensin-converting-enzyme inhibitor; ARB: angiotensin receptor blocker; BMS: bare metal stent; CABG: coronary artery bypass graft; CAD: coronary artery disease; DES: drug-eluting stent; LVEF: left ventricular ejection fraction; PCI: percutaneous coronary intervention; NSTE-ACS: non ST-elevation acute coronary syndrome; RVD reference vessel diameter; MLD minimum lumen diameter; DS diameter stenosis.

Finally, Supplementary Tables 1 and 2 (online appendix) show NTproANP levels according to clinical, angiographic, procedural and laboratory data. Notably, patients with statin therapy had lower NTproANP levels compared with patients without statin therapy [2254 (1242–3910) vs 2834 (1783–4306) fmol/mL, p = 0.04 respectively]. Significant correlation was found between NT-proANP and NT-proBNP levels (r = 0.424, p b 0.02) without any colinearity (tolerance 0.206, VIF 4.865).

Table 4 Predictors of MACE at multivariate analysis.

Kaplan–Meier curves demonstrated that patients with elevated NTproANP levels (N2.100 fmol/mL) had a lower MACE free survival when compared with those having lower NT-proANP levels (b2.100 fmol/mL) (p = 0.003) (Fig. 1), regardless of the type of implanted stent (p for interaction = 0.10 for BMS vs DES). No difference in term of survival was found according to NT-proBNP cut-off value (p = 0.14) (Fig. 2).

Variables

HR

95% CI

p

Diabetes LVEF NT-proANP NT-proBNP Statin Total cholesterol

1.25 0.79 1.11 1.06 0.74 0.99

0.76–1.44 0.69–1.03 1.04–1.16 0.92–1.10 0.06–8.42 0.97–1.01

0.32 0.09 0.04 0.09 0.87 0.29

BMS: bare metal stent; LVEF: left ventricular ejection fraction.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

5

Fig. 1. Kaplan Meyer curves for MACE-free survival according to baseline NT-proANP plasma levels above or below the cut-off value of 2100 fmol/L.

4. Discussion Our study provides the original demonstration that both NT-proANP and NT-proBNP circulating levels are related to the cardiovascular outcome of CAD patients following stent implantation with either BMS or DES in a non-primary PCI setting. In fact, following coronary revascularization, higher levels of both NT-proNPs associated to higher MACEs occurrence at follow up, and this finding was confirmed when restricting the analysis to hard MACE (cardiac death, MI). Interestingly, NTproANP levels were associated to c-TLR, and were the only independent predictor of MACEs by Cox regression analysis and they associated to worse prognosis. Notably, renal function did not affect our results. Recently, new properties of NPs have been discovered, such as an interaction with cellular growth and proliferation at the vascular level [2]. In CAD, it has been shown that circulating NP levels increase in parallel to the increase of coronary plaque stenosis, reaching a plateau level at the highest degree of vessel stenosis, irrespective of the underlying myocardial disease [16]. Moreover, NPs are significantly more expressed in human coronary explants of advanced atherosclerotic lesions as compared to early atherosclerotic lesions [17]. Notably, overexpression of ANP has been tested as a strategic procedure to inhibit vascular cell proliferation and reduce neointima lesion formation [18]. Noteworthy, irrespective of the precise type of pathogenetic contribution, either a contributory or a defense mechanism, it has been well ascertained that both NT-proNPs levels predict cardiovascular events,

independently of traditional risk factors, in patients with either stable or unstable CAD [8–12]. There is still incomplete information concerning the role of NTproNPs levels in cardiovascular outcome following PCI. The latter represents an open clinical issue that deserves further investigation. In fact, there is the need of suitable markers able to predict cardiovascular events following PCI, particularly after the introduction of DES. Few papers reported that elevated BNP levels are independent predictor of worse cardiovascular outcome, including TLR, following elective DES implantation [19–21]. Post-PCI BNP levels behaved as an independent predictor of MACEs over the subsequent 12 months of follow up [22]. Interestingly, additional studies described a drop of NT-proBNP levels following either PCI or surgical revascularization, although no prognostic implications were explored in that context [23]. In the GUSTO-IV substudy higher NT-proBNP levels helped to identify patients with reduced mortality associated with early coronary revascularization [13]. In the PLATO substudy higher NT-proBNP levels indicated an increased risk of future events both in invasively and noninvasively managed patients and predicted a greater absolute benefit from ticagrelor treatment [14]. Notably, the only comparison between the two components of the NPs family, performed in order to characterize their trends at the time of coronary PCI, found a prominent increase of BNP versus ANP levels during PCI with a prompt return to baseline at 4 hours after the end of the procedure [24], likely as a consequence of BNP being a more sensitive marker of transient ischemia during

Fig. 2. Kaplan Meyer curves for MACE-free survival according to baseline NT-proBNP plasma levels above or below the cut-off value of 400 fmol/L.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

6

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx

coronary revascularization. A reduction of NT-proANP levels was observed 24 hours after PCI and it was greater in patients with complete compared with those with incomplete revascularization [25]. Herein, we confirm that elevated NT-proBNP levels are associated to higher MACE occurrence over the follow up of CAD patients receiving a coronary stent in a non-primary PCI setting. Interestingly, our study revealed a significant predictive role for cardiovascular outcome of NTproANP levels. In fact, a Cox regression analysis revealed that preprocedural NT-proANP level was the only variable significantly related to MACEs occurrence prediction. Furthermore, higher NT-proANP levels associated to worse survival. Finally, NT-proANP levels behaved as a biomarker of stent failure, being significantly increased in patients undergoing c-TLR during follow up. NT-proBNP is mainly secreted from the ventricle in response to ventricular stress from volume and pressure overload [1]. Therefore, elevations of NT-proBNP level may reflect adverse hemodynamic alterations. In particular, the reason why elevations of NT-proBNP levels predict future cardiovascular events may depend on subclinical levels of inducible ischemia [26]. On the other hand, NT-proANP levels may better reflect vascular dysfunction. In fact, several studies have shown that ANP exerts remarkable effects on proliferation, angiogenesis and contractility in cells of the vascular wall [27–29] and that it contributes to preserve endothelial function in the general population [30]. Physiological concentrations of ANP promote endothelial cell regeneration after the atherosclerotic damage [31], whereas supraphysiological levels of ANP exert an opposite effect by reducing endothelial cell regeneration and cell migration [27]. These properties may justify a higher sensitivity of NT-proANP levels for early signs of vascular disease and they may explain the significant association with c-TLR as well as the predictive role for MACEs after PCI observed in our study. We acknowledge few limitations of the present study. First, we did not include patients with ST-elevation myocardial infarction (STEMI), treated by urgent PCI, in whom the compromised LVEF might imply a predominant role for NT-proBNP rather than NT-proANP levels with regard to prognostic stratification purposes. Secondly, our study did not enroll consecutive patients undergoing PCI, but only patients for whom a pre-procedural blood sample was available, potentially creating a bias in the selection of patients. Thirdly, the design of our investigation did not allow us to consider post-revascularization levels of both NT-proNPs. Therefore, we cannot exclude that post PCI NT-proBNP levels could be a more sensitive marker of future MACEs than pre-PCI levels. Moreover, we did not perform SYNTAX score and we did not have information about coronary artery disease complexity. Finally, given the small number of events rate, analysis of individual endpoints is not feasible and we refrained from any multivariable model building because of the high risk of overfitting.

5. Conclusions Our study is the first investigation that explores and compares predictive implications of both NT-proANP and NT-proBNP circulating levels in CAD patients following non-primary PCI. We found that NTproANP levels were related to cardiovascular outcome following stent implantation and to hard MACEs (cardiac death, MI) independently from risk factors, angiographic and procedural characteristics. In our study, NT-proANP levels were associated to c-TLR, were an independent predictor of MACEs and were associated to worse prognosis. These findings may be related to the autocrine and paracrine effects exerted by ANP on both endothelial and vascular smooth muscle cells and to its relevant contribution to vascular remodeling and pathology. Therefore, our current findings underscore NT-proANP levels measurement as a potential useful tool to identify patients at higher risk for MACEs following PCI who need more aggressive medical treatments, and those at higher risk of stent failure who may need repeat PCI.

Further studies are certainly required to better support our current original evidence. Source of funding This work was supported by a grant (Ricerca Corrente) from the Italian Ministry of Health to MV and SR; and by the 5‰ grant to MV and SR. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.carrev.2016.02.012. References [1] Levis ER, Gardner DG, Samson WK. Natriuretic peptides. N Engl J Med 1998;339: 321–8. [2] Volpe M, Rubattu S, Burnett Jr J. Natriuretic peptides in cardiovascular diseases: current use and perspectives. Eur Heart J 2014;35:419–25. [3] Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland T, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 2004; 350:655–63. [4] Kistorp C, Raymond I, Pedersen F, Gustafsson F, Faber J, Hildebrandt P. N-terminal pro-brain natriuretic peptide, C-reactive protein, and urinary albumin levels as predictors of mortality and cardiovascular events in older adults. JAMA 2005;293: 1609–16. [5] McKie PM, Cataliotti A, Sangaralingham SJ, Ichiki T, Cannone V, Bailey KR, et al. Predictive utility of atrial, N-terminal pro-atrial, and N-terminal pro-B-type natriuretic peptides for mortality and cardiovascular events in the general community: a 9year follow-up study. Mayo Clin Proc 2011;86:1154–60. [6] Welsh P, Doolin O, Willeit P, Packard C, Macfarlane P, Cobbe S, et al. N-terminal proB-type natriuretic peptide and the prediction of primary cardiovascular events: results from 15-year follow-up of WOSCOPS. Eur Heart J 2013;34:443–50. [7] Barbato A, Sciarretta S, Marchitti S, Iacone R, Di Castro S, Stanzione R, et al. Aminoterminal natriuretic peptides and cardiovascular risk in an Italian male adult cohort. Int J Cardiol 2011;152:245–6. [8] Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal proB-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med 2005;352:666–75. [9] Barbato E, Bartunek J, Marchitti S, Mangiacapra F, Stanzione R, Delrue L, et al. NTproANP circulating level is a prognostic marker in stable ischemic heart disease. Int J Cardiol 2012;155:311–2. [10] Sabatine MS, Morrow DA, de Lemos JA, Omland T, Sloan S, Jarolim P, et al. Evaluation of multiple biomarkers of cardiovascular stress for risk prediction and guiding medical therapy in patients with stable coronary disease. Circulation 2012;125:233–40. [11] Squire IB, O'Brien RJ, Demme B, Davies JE, Ng LL. N-terminal pro-atrial natriuretic peptide (N-ANP) and N-terminal pro-B-type natriuretic peptide (N-BNP) in the prediction of death and heart failure in unselected patients following acute myocardial infarction. Clin Sci 2004;107:309–16. [12] Lindberg S, Jensen JS, Pedersen SH, Galatius S, Goetze JP, Mogelvang R. MR-proANP improves prediction of mortality and cardiovascular events in patients with STEMI. Eur J Prev Cardiol 2015;22:693–700. [13] James SK, Lindback J, Tilly J, Siegbahn A, Venge P, Armstrong P, et al. Troponin-T and N-terminal pro-B-type natriuretic peptide predict mortality benefit from coronary revascularization in acute coronary syndromes: a GUSTO-IV substudy. J Am Coll Cardiol 2006;48:1146–54. [14] Wallentin L, Lindholm D, Siegbahn A, Wernroth L, Becker RC, Cannon CP, et al. Biomarkers in relation to the effects of ticagrelor in comparison with clopidogrel in non-ST-elevation acute coronary syndrome patients managed with or without inhospital revascularization. Circulation 2014;129:293–303. [15] Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33:2551–67. [16] Barbato E, Rubattu S, Bartunek J, Berni A, Sarno G, Vanderheyden M, et al. Role of cardiac natriuretic peptides in human coronary atherosclerosis. Atherosclerosis 2009; 206:258–64. [17] Casco VH, Veinot JP, Kuroski de Bold MLK, Masters RG, Stevenson MM, et al. Natriuretic peptide system gene expression in human coronary arteries. J Histochem Cytochem 2002;50:799–809. [18] Larifla L, Deprez I, Pham I, Rideau D, Louzier V, Adam M, et al. Inhibition of vascular smooth muscle cell proliferation and migration in vitro and neointimal hyperplasia in vivo by adenoviral-mediated atrial natriuretic peptide delivery. J Gene Med 2012; 14:459–67. [19] Hasumi E, Iwata H, Kohro T, Manabe I, Kinugawa K, Morisaki N, et al. Diagnostic implication of change in b-type natriuretic peptide (BNP) for prediction of subsequent target lesion revascularization following sirorimus-eluting stent deployment. Int J Cardiol 2013;168:1429–34. [20] Masaki Y, Shimada K, Kojima T, Miyauchi K, Inoue K, Kiyanagi T, et al. Clinical significance of the measurements of plasma N-terminal pro-B-type natriuretic peptide levels in patients with coronary artery disease who have undergone elective drugeluting stent implantation. J Cardiol 2011;57:303–10.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012

G. Niccoli et al. / Cardiovascular Revascularization Medicine xxx (2016) xxx–xxx [21] Yildirir A, Acikel S, Ertan C, Aydinalp A, Ozin B, Muderrisoglu H. Value of periprocedural B-type natriuretic peptide levels in predicting cardiac events after elective percutaneous coronary intervention. Acta Cardiol 2008;63:47–52. [22] Kalra PR, Gomma A, Daly C, Jr Clague, Squire IB, Ng LL, et al. Reduction in plasma concentrations of N terminal pro B type natriuretic peptide following percutaneous coronary intervention. Heart 2004;90:1334–5. [23] Palazzuoli A, Poldermans D, Capobianco S, Giannotti G, Iovine F, Campagna MS, et al. Rise and fall of B-type natriuretic peptide levels in patients with coronary artery disease and normal left ventricular function after cardiac revascularization. Coron Artery Dis 2006;17:419–23. [24] Kyriakides ZS, Markianos M, Michalis L, Antoniadis A, Nikolaou NI, Kremastinos DT. Brain natriuretic peptide increases acutely and much more prominently than atrial natriuretic peptide during coronary angioplasty. Clin Cardiol 2000;23:285–8. [25] Klinge R, Jorgensen B, Thaulow E, Sirnes PA, Hall C. N-terminal proatrial natriuretic peptide in angina pectoris: impact of revascularization by angioplasty. Int J Cardiol 1999;68:1–8.

7

[26] Noman A, George J, Struthers A. A new use for B-type natriuretic peptide: to detect myocardial ischemia in non-heart failure patients. Br J Diab Vasc Dis 2010;10:78–82. [27] Kook H, Itoh H, Choi BS, Sawada N, Doi K, Hwang TJ, et al. Physiological concentration of atrial natriuretic peptide induces endothelial regeneration in vitro. Am J Physiol Heart Circ Physiol 2003;284:H1388–97. [28] Hiroshi I, Pratt RE, Dzau VJ. Atrial natriuretic polypeptide inhibits hypertrophy of vascular smooth muscle cells. J Clin Invest 1990;86:1690–7. [29] Morishita R, Gibbons GH, Pratt RE, Tomita N, Kaneda Y, Ogihara T, et al. Autocrine and paracrine effects of atrial natriuretic peptide gene transfer on vascular smooth muscle and endothelial cellular growth. J Clin Invest 1994;94:824–9. [30] Kathiresan S, Gona P, Larson MG, Vita JA, Mitchell GF, Tofler GH, et al. Cross-sectional relations of multiple biomarkers from distinct biological pathways to brachial artery endothelial function. Circulation 2006;113:938–45. [31] Rubattu S, Sciarretta S, Valenti V, Stanzione R, Volpe M. Natriuretic peptides: an update on bioactivity, potential therapeutic use, and implication in cardiovascular diseases. Am J Hypertens 2008;21:733–41.

Please cite this article as: Niccoli G, et al, NT-proANP and NT-proBNP circulating levels as predictors of cardiovascular outcome following coronary stent implantation, Cardiovasc Revasc Med (2016), http://dx.doi.org/10.1016/j.carrev.2016.02.012