Assessing AF Risk Post-Stroke via BIOSIGNAL and PRECISE Using Natriuretic Peptides

The following is a summary of “Natriuretic Peptides to Classify Risk of Atrial Fibrillation Detection After Stroke: Analysis of the BIOSIGNAL and PRECISE Cohort Studies,” published in the July 2024 issue of Neurology by Cameron et al.

Despite increased atrial fibrillation (AF) detection with prolonged cardiac monitoring (PCM) after ischemic stroke, limitations in access and patient burden restrict its use.

Researchers conducted a retrospective study to evaluate whether mid-regional pro-atrial natriuretic peptide (MR-proANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) could identify patients unlikely to develop AF following ischemic stroke, potentially optimizing PCM allocation.

They analyzed individuals from the Biomarker Signature of Stroke Aetiology (BIOSIGNAL) study, including patients with ischemic stroke, no known AF, and cardiac monitoring for at least 3 days. Validation was conducted in the Preventing Recurrent Cardioembolic Stroke, Right Approach, Right Patient (PRECISE) study, involving 28 days of cardiac monitoring in individuals with ischemic stroke or transient ischemic attack and no known AF. The primary outcome was the absence of AF detection. The discriminatory ability of MR-proANP and NT-proBNP was evaluated and combined with clinical factors to identify individuals without AF. A decision curve analysis was performed using combined data to assess the net reduction in unnecessary PCM using models based on a 15% threshold probability for detecting AF.

The results showed 621 individuals from the BIOSIGNAL study. The clinical multivariable prediction model incorporated age, NIH Stroke Scale score, lipid-lowering therapy, creatinine, and smoking status. The area under the receiver-operating characteristic curve (AUROC) for clinical variables was 0.68 (95% CI 0.62–0.74), which improved when log₁₀MR-proANP was added (0.72, 0.66–0.78; P=0.001) or log₁₀NT-proBNP (0.71, 0.65–0.77; P=0.009). Performance was comparable between models using log₁₀MR-proANP versus log₁₀NT-proBNP (P=0.28). A total of 239 individuals were involved in PRECISE study, the AUROC for clinical variables was 0.68 (0.59–0.76), which increased with log₁₀NT-proBNP (0.73, 0.65–0.82; P<0.001) or log₁₀MR-proANP (0.79, 0.72–0.86; P<0.001). The model with log₁₀MR-proANP outperformed that with log₁₀NT-proBNP (P=0.03). Models could potentially reduce the number of individuals undergoing prolonged cardiac monitoring by 30% (clinical and log₁₀MR-proANP), 27% (clinical and log₁₀NT-proBNP), or 20% (clinical only).

Investigators concluded that MR-proANP and NT-proBNP testing effectively identified patients unlikely to develop AF post-stroke, potentially reducing PCM use by 30% while maintaining AF detection rates.

Source: neurology.org/doi/10.1212/WNL.0000000000209625

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