Prognostic value of brain natriuretic peptide in acute pulmonary embolism

Abstract

Introduction: The relationship between brain natriuretic peptide (BNP) increase in acute pulmonary embolism (PE) and the increase in mortality and morbidity has frequently been suggested in small studies but its global prognostic performance remains largely undefined. We performed a systematic review and meta-analysis of data to examine the prognostic value of elevated BNP for short-term all-cause mortality and serious adverse events.

Methods: The authors reviewed PubMed, BioMed Central, and the Cochrane database and conducted a manual review of article bibliographies. Using a prespecified search strategy, we included a study if it used BNP or N-terminal pro-BNP biomarkers as a diagnostic test in patients with documented PE and if it reported death, the primary endpoint of the meta-analysis, in relation to BNP testing. Studies were excluded if they were performed in patients without certitude of PE or in a subset of patients with cardiogenic shock. Twelve relevant studies involving a total of 868 patients with acute PE at baseline were included in the meta-analysis using a random-effects model.

Results: Elevated BNP levels were significantly associated with short-term all-cause mortality (odds ratio [OR] 6.57, 95% confidence interval [CI] 3.11 to 13.91), with death resulting from PE (OR 6.10, 95% CI 2.58 to 14.25), and with serious adverse events (OR 7.47, 95% CI 4.20 to 13.15). The corresponding positive and negative predictive values for death were 14% (95% CI 11% to 18%) and 99% (95% CI 97% to 100%), respectively.

Conclusion: This meta-analysis indicates that, while elevated BNP levels can help to identify patients with acute PE at high risk of death and adverse outcome events, the high negative predictive value of normal BNP levels is certainly more useful for clinicians to select patients with a likely uneventful follow-up.

Figure 1

Flow diagram for study selection. BNP, brain natriuretic peptide; RVD, right ventricular dysfunction.

Figure 2

Odds ratio (OR) for death based on elevated or normal brain natriuretic peptide levels in acute pulmonary embolism. CI, confidence interval; df, degrees of freedom.

Figure 3

Pooled sensitivities (a) and specificities (b) of elevated brain natriuretic peptide levels to predict short-term death in acute pulmonary embolism. CI, confidence interval; df, degrees of freedom.

Figure 4

Plot of symmetric summary receiver operator characteristic (SROC) of elevated brain natriuretic peptide levels to predict short-term death. The receiver operator characteristic curve provides a graphical display of diagnostic accuracy by plotting 1 – specificity in the horizontal axis and sensitivity in the vertical axis. The pertinent area under the curve (AUC) and Q* statistic (the point where sensitivity and specificity are maximal), both with standard errors (SEs), are also included.