Biomarkers for the diagnosis and management of heart failure

Promising directions in the treatment of chronic heart failure: improving old or developing new ones?

Unprecedented advances of recent decades in clinical pharmacology, cardiac surgery, arrhythmology, and cardiac pacing have significantly improved the prognosis in patients with chronic heart failure (CHF). However, unfortunately, heart failure continues to be associated with high mortality. The solution to this problem consists in simultaneous comprehensive use in clinical practice of all relevant capabilities of continuously improving methods of heart failure treatment proven to be effective in randomized controlled trials (especially when confirmed by the results of studies in real clinical practice), on the one hand, and in development and implementation of innovative approaches to CHF treatment, on the other hand. This is especially relevant for CHF patients with mildly reduced and preserved left ventricular ejection fraction, as poor evidence base for the possibility of improving the prognosis in such patients cannot justify inaction and leaving them without hope of a clinical improvement in their condition. The lecture consistently covers the general principles of CHF treatment and a set of measures aimed at inotropic stimulation and unloading (neurohormonal, volumetric, hemodynamic, and immune) of the heart and outlines some promising areas of disease-modifying therapy.

Integration of RNA molecules data with prior-knowledge driven Joint Deep Semi-Negative Matrix Factorization for heart failure study

Heart failure (HF) is the main manifestation of cardiovascular disease. Recent studies have shown that various RNA molecules and their complex connections play an essential role in HF’s pathogenesis and pathological progression. This paper aims to mine key RNA molecules associated with HF. We proposed a Prior-knowledge Driven Joint Deep Semi-Negative Matrix Factorization (PD-JDSNMF) model that uses a hierarchical nonlinear feature extraction method that integrates three types of data: mRNA, lncRNA, and miRNA. The PPI information is added to the model as prior knowledge, and the Laplacian constraint is used to help the model resist the noise in the genetic data. We used the PD-JDSNMF algorithm to identify significant co-expression modules. The elements in the module are then subjected to bioinformatics analysis and algorithm performance analysis. The results show that the PD-JDSNMF algorithm can robustly select biomarkers associated with HF. Finally, we built a heart failure diagnostic model based on multiple classifiers and using the Top 13 genes in the significant module, the AUC of the internal test set was up to 0.8714, and the AUC of the external validation set was up to 0.8329, which further confirmed the effectiveness of the PD-JDSNMF algorithm.

Alterations in gut microbiota and metabolites associated with altitude-induced cardiac hypertrophy in rats during hypobaric hypoxia challenge

The gut microbiota is involved in host responses to high altitude. However, the dynamics of intestinal microecology and their association with altitude-related illness are poorly understood. Here, we used a rat model of hypobaric hypoxia challenge to mimic plateau exposure and monitored the gut microbiome, short-chain fatty acids (SCFAs), and bile acids (BAs) over 28 d. We identified weight loss, polycythemia, and pathological cardiac hypertrophy in hypoxic rats, accompanied by a large compositional shift in the gut microbiota, which is mainly driven by the bacterial families of Prevotellaceae, Porphyromonadaceae, and Streptococcaceae. The aberrant gut microbiota was characterized by increased abundance of the Parabacteroides, Alistipes, and Lactococcus genera and a larger Bacteroides to Prevotella ratio. Trans-omics analyses showed that the gut microbiome was significantly correlated with the metabolic abnormalities of SCFAs and BAs in feces, suggesting an interaction network remodeling of the microbiome-metabolome after the hypobaric hypoxia challenge. Interestingly, the transplantation of fecal microbiota significantly increased the diversity of the gut microbiota, partially inhibited the increased abundance of the Bacteroides and Alistipes genera, restored the decrease of plasma propionate, and moderately ameliorated cardiac hypertrophy in hypoxic rats. Our results provide an insight into the longitudinal changes in intestinal microecology during the hypobaric hypoxia challenge. Abnormalities in the gut microbiota and microbial metabolites contribute to the development of high-altitude heart disease in rats.

Biomarkers in heart failure clinical trials. A review from the Biomarkers Working Group of the Heart Failure Association of the European Society of Cardiology

The approval of new heart failure (HF) therapies has slowed over the past two decades in part due to the high costs of conducting large randomized clinical trials that are needed to adequately power major clinical endpoint studies. Several biomarkers have been identified reflecting different elements of HF pathophysiology, with possible applications in diagnosis, risk stratification, treatment monitoring, and even in the design of clinical trials. Biomarkers could potentially be used to refine study inclusion criteria to enable enrolment of patients who are more likely to respond to a therapeutic intervention, despite being at sufficient risk to meet pre-determined study endpoint rates. When there is a close relationship between biomarker levels and clinical endpoints, changes in biomarker levels after a given treatment can act as a surrogate endpoint, potentially reducing the duration and cost of a clinical trial. Natriuretic peptides have been widely used in clinical trials with a variable amount of added value, which such variation being probably due to the absence of a close pathophysiological connection to the study drug. Notable exceptions to this include sacubitril/valsartan and vericiguat. Future studies should seek to adopt unbiased approaches for discovery of true companion diagnostics; with -omics-based tools, biomarkers might be more precisely selected for use in clinical trials to identify responses that closely reflect the biological effects of the drug under investigation. Finally, biomarkers associated with cardiac damage and remodelling, such as cardiac troponin, could be employed as safety endpoints provided that standardization between different assays is achieved.

Differential Adaptation of Biventricular Myocardial Kinetic Energy in Patients With Repaired Tetralogy of Fallot Assessed by MR Tissue Phase Mapping

BACKGROUND

The myocardial kinetic energy (KE) and its association with pulmonary regurgitation (PR) have yet to be investigated in repaired tetralogy of Fallot (rTOF) patients.

PURPOSE

To evaluate the adaptation of myocardial KE in rTOF patients by tissue phase mapping (TPM).

STUDY TYPE

Prospective.

POPULATION

A total of 49 rTOF patients (23 ± 5 years old; male = 32), 47 normal controls (22 ± 1 year old; male = 29).

FIELD STRENGTH/SEQUENCE

3-T/2D dark-blood three-directional velocity-encoded gradient-echo sequence.

ASSESSMENT

Left and right ventricle (LV, RV) myocardial KE in radial (KE_r ), circumferential (KE_ø ), longitudinal (KE_z ) directions. The proportions of KE in each direction to the sum of all KE (KE_røz ): %KE_r , %KE_ø , %KE_z . PR fraction.

STATISTICAL TEST

Student's t test, multivariable regression. Statistical significance: P < 0.05.

RESULTS

In rTOF group, LV KE_z remained normal in systole (P = 0.565) and diastole (P = 0.210), whereas diastolic LV %KE_z (62% ± 14% vs. 72% ± 7%) and systolic LV %KE_ø (9% ± 6% vs. 20% ± 7%) were significantly decreased. The KE_r and %KE_r of both ventricles significantly increased in the rTOF group (RV in diastole: 6 ± 3 vs. 3 ± 1 μJ and 54% ± 13% vs. 27% ± 7%). The rTOF group exhibited significantly higher RV/LV ratios of %KE_r (systole: 1.3 ± 0.3 vs. 1.0 ± 0.3) and %KE_ø (systole: 1.6 ± 0.8 vs. 1.0 ± 0.3) and significantly lower ratios of %KE_z in systole (0.7 ± 0.2 vs. 1.0 ± 0.1) and diastole (0.5 ± 0.2 vs. 0.9 ± 0.1). In multivariable regression analysis, the RV peak systolic KE_røz , RV systolic KE_z , and LV diastolic %KE_ø were independently associated with PR fraction in the rTOF group (adjusted R²  = 0.479).

DATA CONCLUSION

In rTOF patients, the adaptation of the KE proportion occurred earlier than that of the KE amplitude, and the biventricular balance of %KE was disrupted. PR may cause differential KE adaptation in RV and LV. TPM-derived KE may be useful in investigation of myocardial adaptation in rTOF patients.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 3.

Biomarkers of HFpEF: Natriuretic Peptides, High-Sensitivity Troponins and Beyond

Heart failure (HF) is a significant cause of morbidity and mortality worldwide. HF with preserved ejection fraction (HFpEF) is a complex syndrome, often participated by several cardiac and extracardiac conditions, including chronic kidney disease, pulmonary disease, anaemia and advanced age. Circulating biomarkers reflecting pathophysiological pathways involved in HFpEF development and progression may assist clinicians in early diagnosis and management of this condition. Natriuretic peptides (NPs) are cardioprotective hormones released by cardiomyocytes in response to pressure or volume overload and in response to activation of neuro-endocrine-immune system. The relevance of B-type NP (BNP) and N-terminal pro-B-type NP (NT-proBNP) for diagnosis and risk stratification has been extensively demonstrated, and these biomarkers are emerging tools for population screening and as guides to the start of treatment in subclinical HF. On the contrary, conflicting evidence exists on the value of NPs to guide HF therapy. Among the other biomarkers, high-sensitivity troponins and soluble suppression of tumorigenesis-2 are the most promising biomarkers for risk stratification, predicting outcome independently from NPs. In this review, some novel biomarkers are being tested in such clinical scenario, more tightly linked to specific pathophysiological processes of cardiac damage.

Meta-Analysis of Physical Training on Natriuretic Peptides and Inflammation in Heart Failure

Physical training has been reported to attenuate myocardial stress and inflammation in heart failure (HF). We aimed to assess the impact of physical training on B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide (NT-proBNP), as well as biomarkers of inflammation-C-reactive protein, tumor necrosis factor α (TNF-α), and interleukins (ILs). A systematic electronic literature search was conducted up to May 2021 in PubMed, Cochrane Library, CINAHL, Embase, and SPORTDiscus to identify randomized clinical trials reporting associations between any formal physical training intervention and biomarker levels in patients with HF. Random-effects meta-analyses was used to calculate pooled correlations between physical training and blood biomarkers. Biomarker outcomes were expressed as mean difference or ratio of means and 95% confidence interval between the intervention and control groups, according to the normality of the data. A total of 38 trials were included in the final meta-analysis (2,652 randomized patients). Physical training was associated with decreased B-type natriuretic peptide (p = 0.02), NT-proBNP (p <0.01), C-reactive protein (p <0.00001), TNF-α (p = 0.03), IL-6 (p = 0.04), and IL-1β (p = 0.001). Aerobic continuous training was associated with a 35% reduction in NT-proBNP (p = 0.01); ≥150 min/week of exercise was associated with a greater reduction in TNF-α levels (p = 0.0004), and aerobic interval training was associated with lower IL-6 levels (p = 0.01). In conclusion, physical training in patients with HF is associated with beneficial effects on natriuretic peptides and biomarkers of inflammation because they were all reduced by the intervention.

Biomarkers in heart failure: Relevance in the clinical practice

Early detection and risk stratification of patients with heart failure (HF) are crucial to improve outcomes. Given the complexity of the pathophysiological processes of HF and the involvement of multi-organ systems in different stages of HF, clinical prognostication of HF can be challenging. In this regard, several biomarkers have been investigated for diagnosis, screening, and risk stratification of HF patients. These biomarkers can be classified as biomarkers of myocardial stretch such as B-type natriuretic peptide, biomarkers of neurohormonal activation, biomarkers of inflammation and oxidative stress and biomarkers of cardiac hypertrophy, fibrosis and remodeling. In this paper, we summarize current evidence supporting the use of selected biomarkers in HF. We review their diagnostic, prognostic and therapeutic role in the management of HF. We also discuss potential factors limiting the use of these novel biomarkers in the clinical practice and highlight the challenges of adopting a multi-biomarker strategy.

Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure

Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.

Head-to-head comparison between recommendations by the ESC and ACC/AHA/HFSA heart failure guidelines

Recommendations represent the core messages of guidelines, and are particularly important when the body of scientific evidence is rapidly growing, as in the case of heart failure (HF). The main messages from two latest major HF guidelines, endorsed by the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA), are partially overlapping, starting from the four pillars of treatment for HF with reduced ejection fraction. Some notable differences exist, in part related to the timing of recent publications (most notably, the Universal Definition of HF paper and the EMPEROR-Preserved trial), and in part reflecting differing views of the natural history of HF (with a clear differentiation between stages A and B HF in the ACC/AHA/HFSA guidelines). Different approaches are proposed to specific issues such as risk stratification and implantable cardioverter defibrillator use for primary prevention in HFrEF patients with non-ischaemic aetiology. The ACC/AHA/HFSA guidelines put a greater emphasis on some issues that are particularly relevant to the US setting, such as the cost-effectiveness of therapies and the impact of health disparities on HF care. A comparison between guideline recommendations may give readers a deeper understanding of the ESC and ACC/AHA/HFSA guidelines, and help them apply sensible approaches to their own practice, wherever that may be in the world. A comparison may possibly also help further harmonization of recommendations between future guidelines, by identifying why some areas have led to conflicting recommendation, even when ostensibly reviewing the same published evidence.

Novel Biomarkers of Renal Dysfunction and Congestion in Heart Failure

Heart failure is a major public health problem and, despite the constantly emerging, new, effective treatments, it remains a leading cause of morbidity and mortality. Reliable tools for early diagnosis and risk stratification are crucial in the management of HF. This explains a growing interest in the development of new biomarkers related to various pathophysiological mechanisms of HF. In the course of this review, we focused on the markers of congestion and renal dysfunction in terms of their interference with cardiovascular homeostasis. Congestion is a hallmark feature of heart failure, contributing to symptoms, morbidity, and hospitalizations of patients with HF and has, therefore, become a therapeutic target in AHF. On the other hand, impaired renal function by altering the volume status contributes to the development and progression of HF and serves as a marker of an adverse clinical outcome. Early detection of congestion and an adequate assessment of renal status are essential for the prompt administration of patient-tailored therapy. This review provides an insight into recent advances in the field of HF biomarkers that could be potentially implemented in diagnosis and risk stratification of patients with HF.

Biomarkers of Myocardial Injury and Remodeling in Heart Failure

With its complicated pathophysiology, high incidence and prevalence, heart failure remains a major public concern. In hopes of improving diagnosis, treatment and prognosis, the utility of many different biomarkers is researched vigorously around the world. In this review, biomarkers of myocardial remodeling and fibrosis (galectin-3, soluble isoform of suppression of tumorigenicity 2, matrix metalloproteinases, osteopontin, interleukin-6, syndecan-4, myostatin, procollagen type I C-terminal propeptide, procollagen type III N-terminal propeptide, vascular endothelial growth factor, nitric oxidase synthetase and asymmetric dimethylarginine), myocyte injury (heart-type fatty acid-binding protein, glutathione S-transferase P1 and heat shock protein 60), as well as iron metabolism (ferritin, transferrin saturation, soluble transferrin receptor and hepcidin), are considered in terms of possible clinical applicability and significance. Our short review consists of a summary of the aforementioned cardiovascular biomarkers’ clinical relevance and perspectives.

Analytical validation of a novel point‐of‐care immunoassay for canine N‐terminal pro‐brain natriuretic peptide analysis

Background

N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) is a widely used point‐of‐care (POC) cardiac biomarker in human medicine. Canine NT‐proBNP is used less in veterinary medicine, possibly due to the lack of a POC canine NT‐proBNP assay resulting in temporal delay, increased degradation in transport, and high reported variability in the available assay. A new quantitative POC analyzer allows fast, onsite measurement of NT‐proBNP, minimizing preanalytical error and reducing variability.

Objective

We aimed to analytically validate an NT‐proBNP assay (Vcheck) according to American Society of Veterinary Clinical Pathology (ASVCP) and Clinical Laboratory Improvement Amendments (CLIA) specifications.

Methods

Archived and prospective plasma and serum samples were collected from male and female, client‐owned dogs of various breeds with cardiac abnormalities (n = 81) and a healthy control population (n = 225). Precision, accuracy, analytical sensitivity, and specificity, and other statistical analyses were performed.

Results

Imprecision was considered acceptable with a coefficient of variation ranging from 9% at 4000 pmol/L to 20% at 600 pmol/L. The lower limit of quantitation was 650 pmol/L based on repetitive measures evaluation. Comparison of the Vcheck assay with the Cardiopet NT‐proBNP assay revealed an excellent correlation with minimal bias when preanalytical factors were controlled. Significant degradation of NT‐proBNP occurred when current methods were used at refrigerated and room temperatures, which could change diagnostic and prognostic decision‐making. Age‐partitioned reference intervals have high reference values of 750 pmol/L and 1280 pmol/L for juvenile and adult dogs, respectively.

Conclusions

The Vcheck NT‐ProBNP assay provides analytically acceptable results. Onsite testing can minimize variability related to preanalytical error and provide clinically useful contemporaneous results. Samples should be centrifuged immediately and analyzed within 2 hours of collection.

Biomarkers in the management of acute heart failure: state of the art and role in COVID-19 era

Acute heart failure (AHF) affects millions of people worldwide, and it is a potentially life‐threatening condition for which the cardiologist is more often brought into play. It is crucial to rapidly identify, among patients presenting with dyspnoea, those with AHF and to accurately stratify their risk, in order to define the appropriate setting of care, especially nowadays due to the coronavirus disease 2019 (COVID‐19) outbreak. Furthermore, with physical examination being limited by personal protective equipment, the use of new alternative diagnostic and prognostic tools could be of extreme importance. In this regard, usage of biomarkers, especially when combined (a multimarker approach) is beneficial for establishment of an accurate diagnosis, risk stratification and post‐discharge monitoring. This review highlights the use of both traditional biomarkers such as natriuretic peptides (NP) and troponin, and emerging biomarkers such as soluble suppression of tumourigenicity (sST2) and galectin‐3 (Gal‐3), from patients' emergency admission to discharge and follow‐up, to improve risk stratification and outcomes in terms of mortality and rehospitalization.

Inflammation, Anxiety, and Stress in Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and serious neurodevelopmental disorder characterized by symptoms of inattention and/or hyperactivity/impulsivity. Chronic and childhood stress is involved in ADHD development, and ADHD is highly comorbid with anxiety. Similarly, inflammatory diseases and a pro-inflammatory state have been associated with ADHD. However, while several works have studied the relationship between peripheral inflammation and stress in affective disorders such as depression or bipolar disorder, fewer have explored this association in ADHD. In this narrative review we synthetize evidence showing an interplay between stress, anxiety, and immune dysregulation in ADHD, and we discuss the implications of a potential disrupted neuroendocrine stress response in ADHD. Moreover, we highlight confounding factors and limitations of existing studies on this topic and critically debate multidirectional hypotheses that either suggest inflammation, stress, or anxiety as a cause in ADHD pathophysiology or inflammation as a consequence of this disease. Untangling these relationships will have diagnostic, therapeutic and prognostic implications for ADHD patients.

Development of an Electrochemical Immunosensor for Detection of Cardiac Troponin I at the Point-of-Care

Cardiac troponin I (cTnI) plays an important role in the assessment of various cardiac diseases. However, accurate detection of cTnI at the point-of-care (POC) remains unfeasible. In this study, we report the development of an electrochemical immunosensor designed for rapid and accurate cTnI detection in pre-hospital settings. Rapid cTnI analysis of whole blood samples was then performed. cTnI measurements were highly correlated with the results of the standard clinical laboratory method for cTnI detection. The results of this study suggest that the proposed POC immunosensor can deliver fast and accurate cTnI analysis in pre-hospital settings to achieve rapid diagnosis and guide patient management.