La fraction amino-terminale du peptide natriurétique de type B pour prédire le devenir des patients ayant une sténose aortique à bas débit : sa supériorité au peptide natriurétique de type B et son rôle pour aider la décision thérapeutique

Authors: Annabi, Mohamed Salah
Advisor: Clavel, Marie-AnnickPibarot, Philippe
Abstract: Background: In classical low-flow, low gradient aortic stenosis (CLF-AS i.e. with low left ventricular [LV] ejection fraction), aortic valve intervention (AVI) is recommended if true severe AS (TSAS) is confirmed. However, there is little evidence on the prognostic values of the clinical activation ratio of B-type natriuretic peptide (BNP-ratio) versus aminoterminal-proBNP (NT-proBNP-ratio) as surrogates of LV impairment to risk-stratify the patients. Methods: BNP and NT-proBNP-ratios were calculated by dividing the actual serum level by the upper predicted value for age and sex. Their prognostic values were studied using receiver-operating characteristic (ROC) curves and Cox proportional hazards regression adjusting for TSAS, initial treatment (AVI or conservative management [ConsRx]), age, sex and the euroSCORE (model-1), and taking time to death as an endpoint. The survival benefit of AVI according to the degree of LV impairment was studied using the best biomarker. Results: BNP-ratio significantly predicted one-year (area under the ROC curve [AUC]) 0.62±0.04, p=0.026) but not three-year mortality, and a BNP-ratio>7.4 tended to predict time to death (adjusted HR=2.14 [1.00-4.58], p=0.05). NT-proBNP-ratio significantly predicted one and three-year mortality (AUC=0.67±0.04 and 0.66±0.05, both p=0.001), and independently predicted time to death (HR=1.39 /per one increment of LogNT-proBNP-ratio, [1.11-1.74], p=0.004). In a head-to-head comparison, the AUCs for one and three-year mortality were higher with NT-proBNP-ratio versus BNP-ratio (p<0.009). NT-proBNP-ratio but not BNP-ratio independently predicted mortality and significantly improved model-1 (Likelihood ratio test Chi2=15.953, p=0.0003). The category-free net reclassification index of NT-proBNP-ratio when added to model-1 was 0.71 (p=0.008) versus 0.38 (p=0.15) for BNP-ratio. Finally, in patients with NTproBNP-ratio >11 the adjusted HR of death associated with AVI was 0.52 ([0.31-0.85], p=0.009). On the other hand, NT-proBNP-ratio <11 identified patients (54% with peudosevere AS) in whom short-term event-free survival was excellent under conservative management. Conclusion: NT-proBNP-ratio is a powerful independent predictor of death and should be preferred over BNPratio to risk-stratify CLF-AS patients. The assessment of LV function impairment using NT-proBNP-ratio has important clinical implications and should be complementary to the determination of true AS severity.
Document Type: Mémoire de maîtrise
Issue Date: 2018
Open Access Date: 25 January 2019
Grantor: Université Laval
Collection:Thèses et mémoires

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