Is natriuretic peptide effective in screening for subclinical heart failure among cancer survivors?
C Soh, J Wong, G Zhu, A Azad, K Whitmore, T MarwickAbstract
Background
Long-term cancer survivors are predisposed to asymptomatic cardiac structural and functional abnormalities consistent with stage B heart failure (SBHF). N-terminal pro-B-type natriuretic peptide (NT-proBNP) is guideline-recommended for SBHF evaluation and has been recommended in ESMO guidelines for screening in survivors. However, its utility as a biomarker for subclinical cardiac dysfunction in survivors remains unproven.
Purpose
To evaluate the diagnostic performance of NT-proBNP for identifying SBHF in long-term cancer survivors.
Methods
Asymptomatic survivors aged ≥40 years, ≥5 years post-cancer therapy and with at least 1 cardiovascular risk factor underwent NT-proBNP measurement and standard echocardiography. SBHF was defined as diastolic dysfunction, systolic dysfunction (reduced global longitudinal strain [GLS] or left ventricular ejection fraction [LVEF]) or LV hypertrophy (LVH). Multivariable logistic regression assessed associations between NT-proBNP with SBHF phenotypes, adjusting for age, sex, diabetes, blood pressure and antihypertensive medication. Discriminatory performance was evaluated using area under the receiver operating characteristics curve (AUC), with sensitivity and specificity examined across clinically relevant thresholds.
Results
Among 441 long-term survivors (mean age 65.0±8.9 years, 85.7% female), higher NT-proBNP concentrations were independently associated with SBHF (adjusted OR 1.63 [95%CI 1.20-2.22], p=0.002) and reduced GLS (adjusted OR 1.81 [1.32-2.50], p<0.001). Associations with diastolic dysfunction, LVH, and reduced LVEF were not statistically significant. Overall discrimination was poor, with AUCs ranging from 0.60 to 0.64. The conventional threshold of >125pg/mL demonstrated limited sensitivity (42.7%) and specificity (68.2%) for SBHF. Lowering the threshold to >55pg/mL improved sensitivity (82.3%) but substantially reduced specificity (30.3%).
Conclusion
In long-term cancer survivors, NT-proBNP demonstrates limited discrimination for SBHF and lacks adequate sensitivity at conventional thresholds, restricting its role as a standalone screening strategy for preclinical heart failure in this vulnerable population.ROC curves for BNP in SBHF screeningPerformance of NT-proBNP in SBHF screening