Preoperative B-type natriuretic peptide independently predicts perioperative cardiac complications in vascular surgery: a systematic review and meta-analysis

Background

Patients undergoing major vascular surgery remain at substantial risk of perioperative cardiac complications despite contemporary management. Preoperative risk stratification is essential to guide optimisation, perioperative monitoring, and postoperative surveillance. Circulating B-type natriuretic peptide (BNP), a marker of myocardial wall stress, may provide objective risk assessment beyond conventional clinical predictors.

Purpose

To quantify the independent prognostic value of preoperative BNP testing for adverse perioperative outcomes in vascular surgery and to assess its incremental contribution to established risk stratification pathways.

Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to identify studies evaluating the association between preoperative BNP levels and postoperative outcomes in adult patients undergoing vascular surgery.

Eligible studies included randomized controlled trials and observational cohorts. Two reviewers independently performed study selection, data extraction, and quality assessment. Multivariable-adjusted effect estimates were pooled using a random-effects model. Primary outcomes included perioperative cardiac events (myocardial infarction, myocardial injury, cardiac death), stroke, mortality, and length of stay. Heterogeneity was assessed using the I² statistic.

Results

Eleven studies including 3,062 patients met inclusion criteria; all were observational cohorts. Across studies, elevated preoperative BNP was consistently associated with increased perioperative cardiac complications, particularly myocardial infarction, myocardial injury, cardiac death, stroke, and longer hospital stay. The direction of effect was concordant across vascular procedures and risk profiles where reported. Evidence for short-term mortality was directionally consistent but limited.

Five studies reporting multivariable-adjusted effect estimates were pooled in the primary analysis. Elevated BNP was independently associated with a significantly increased risk of perioperative cardiac events (pooled OR 4.08; 95% CI 3.20–5.20; p<0.001). No evidence of between-study heterogeneity was observed (I² = 0%), indicating highly consistent adjusted effects across studies.

Conclusions

Preoperative BNP elevation is associated with an approximately fourfold increase in perioperative cardiac risk in patients undergoing vascular surgery. The strength, independence, and consistency of this association support the integration of natriuretic peptide testing into multimodal perioperative risk assessment frameworks.

BNP measurement may facilitate risk-directed monitoring intensity and tailored perioperative management strategies in high-risk patients. Prospective studies are warranted to define optimal biomarker thresholds and implementation pathways before routine guideline endorsement.Forest plot: Adj OR for cardiac events vs BNP