Combination of high-sensitive C-reactive protein with logistic EuroSCORE improves risk stratification in TAVI patients

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Anja Stundl

According to Anja Stundl (Department of Medicine II, Heart Center Bonn, University Hospital, Bonn, Germany) and others, high-sensitive C-reactive protein (hs-CRP) can be used alongside the logistic EuroSCORE as an independent predictor of one-year all-cause mortality in patients undergoing transcatheter aortic valve implantation (TAVI). The authors note that the combination of both “might help to better predict procedural risk and outcome”.

Stundl et al write in EuroIntervention that, at present, heart teams use scoring systems—such as the logistic EuroSCORE and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score—that have been designed for surgical aortic valve replacement to predict outcomes in patients undergoing TAVI. However, they add that their applicability to TAVI patients is “questionable as they are strongly based on certain comorbidities that are related to outcome in standard surgical risk populations, but do not address the particularities influencing outcome in TAVI-procedures”.

Therefore, the authors say, there is a need for prediction models that specifically address issues relating to TAVI. Given that previous studies have looked at the role of biomarkers in predicting risk in aortic stenosis patients, the aim of the present study was to determine whether circulating biomarkers representing different pathophysiologic systems (i.e. hs-CRP) could be used to identify TAVI patients at higher risk of adverse clinical outcomes. It also reviewed whether these biomarkers provide prognostic information beyond that of established predictive risk algorithms.

Reviewing data for 683 consecutive patients who underwent TAVI at their centre (Heart Center Bonn) between January 2014 and August 2018, Stundl et al found that patients who died within the first year of TAVI being performed had significantly higher clinical risk score results—including increased median biomarker levels. They report: “When biomarkers were categorised into tertiles, values in the uppermost tertile for each biomarker were all significantly associated with increased one-year mortality except for hs-troponin.”

In a multivariate analysis looking at predictors of cumulative mortality, only the logistic EuroSCORE and hs-CRP were independent predictors and showed the strongest association with one-year all-cause mortality. Neither NTproBNP nor hs-troponin I were found to be independent predictors (both of which are well known biomarkers for cardiovascular disease), which the authors comment may partly be because the study cohort only included patients from 2014 onwards. They note that these patients had a median age of 81, a median STS-PROM score of 3.8 and would have been treated according to clinical best practice with next-generation devices. “In other words, failure of NTproBNP and hs-troponin I may be a matter of both less sickness of the patients and considerable progress in research and technique that has been made,” Stundl et al observe.

They write that the combination of logistic EuroSCORE and hs-CRP had “significant added value [to EuroSCORe alone] for the prediction of one-year all-cause mortality”, adding “using these two readily available predictive risk parameters enables us to identify patients scheduled for TAVI with favourable or adverse outcome prior to the planned procedure and to reconsider the decision once made.”

Stundl and study investigator Jan-Malte Sinning (Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany) comment: “Our suggestion for TAVI patients with elevated CRP is that they could undergo the procedure after an active inflammatory process has been ruled out; however, CRP reflects a higher comorbidity burden (could also be a marker of frailty and “vulnerability”) and these patients will have a worse prognosis than patients without CRP elevation. We are currently working on a biomarker score in aortic stenosis patients (treated with TAVI or conservatively) and will evaluate whether specific biomarkers might help to sort out specific patients or even might indicate futility.”

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