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Bayes-Genis A, Aimo A, Jhund P, Richards M, de Boer RA, Arfsten H, Fabiani I, Lupón J, Anker SD, González A, Castiglione V, Metra M, Mueller C, Núñez J, Rossignol P, Barison A, Butler J, Teerlink J, Filippatos G, Ponikowski P, Vergaro G, Zannad F, Seferovic P, Rosano G, Coats AJS, Emdin M, Januzzi JL. Biomarkers in heart failure clinical trials. A review from the Biomarkers Working Group of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:1767-1777. [PMID: 36073112 DOI: 10.1002/ejhf.2675] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Pardeep Jhund
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henrike Arfsten
- Clinical Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Josep Lupón
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapy (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Arantxa González
- CIBERCV, Carlos III Institute of Health, Madrid, Spain.,Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | | | - Marco Metra
- Cardiology Department, ASST Spedali Civili; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Julio Núñez
- CIBERCV, Carlos III Institute of Health, Madrid, Spain.,Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain
| | | | - Andrea Barison
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John Teerlink
- Heart Failure and of the Echocardiography Laboratory, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques-Plurithématique 1433, and Inserm U1116 CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Petar Seferovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | | | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
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2
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Alphonsus CS, Govender P, Rodseth RN, Biccard BM. Natriuretic peptide-directed medical therapy: a systematic review. Perioper Med (Lond) 2020; 9:5. [PMID: 32095234 PMCID: PMC7027249 DOI: 10.1186/s13741-019-0134-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 12/16/2019] [Indexed: 12/29/2022] Open
Abstract
Natriuretic peptides (NP) are strongly associated with perioperative cardiovascular events. However, in patients with raised NP, it remains unknown whether treatment to reduce NP levels prior to surgery results in better perioperative outcomes. In this systematic review and meta-analysis, we investigate NP-directed medical therapy in non-surgical patients to provide guidance for NP-directed medical therapy in surgical patients. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcome was to determine whether NP-directed medical therapy is effective in reducing NP levels within 6 months, compared to standard of care. The secondary outcome was to determine whether reducing NP levels is associated with decreased mortality. Full texts of 18 trials were reviewed. NP-directed medical therapy showed no significant difference compared to standard care in decreasing NP levels (standardized mean difference − 0.04 (− 0.16, 0.07)), but was associated with a 6-month (relative risk (RR) 0.82 (95% confidence interval (CI) 0.68–0.99)) reduction in mortality.
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Affiliation(s)
| | | | - Reitze N Rodseth
- 3Consultant Anaesthesiologist, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Bruce M Biccard
- 1Consultant Anaesthesiologist, University of Cape Town, Western Cape, South Africa
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3
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Zheng H, Li L, Liang H, Qu J, Li J, Cui Y, Chen X. Normalization of N-Terminal Pro-B-Type Natriuretic Peptide After Cardiac Surgery Among Children With Tetralogy of Fallot. Am J Cardiol 2018; 122:2125-2130. [PMID: 30293655 DOI: 10.1016/j.amjcard.2018.08.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/21/2018] [Accepted: 08/24/2018] [Indexed: 12/01/2022]
Abstract
The aim of this study was to temporally measure N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels over a period of 18 months after corrective surgery among children with tetralogy of Fallot (TOF) and to explore how commonly used pharmaceuticals (i.e., spironolactone and digoxin) might affect the normalization pattern. This retrospective study included 136 children with a median age of 7 months who underwent cardiac surgery for TOF. NT-proBNP level was measured at 1, 3, 6, 12, and 18 months after the surgery. Normalization of NT-proBNP was defined as an NT-proBNP level ≤250 pg/ml. The commonly used pharmaceuticals spironolactone and digoxin after discharge were collected. The normalization pattern, normalization time, and potential influence of the pharmaceuticals were determined. The rate of normalization was 24.2% (95% confidence interval [CI] 8.58% to 68.4%) per 100 person-days. Kaplan-Meier survival analysis showed a median normalization time of 517 (95% CI 429.6 to 604.3) days. The children whose NT-proBNP level did not normalize had a significantly higher readmission rate than those whose NT-proBNP level normalized (19.0% vs 2.8%, p = 0.018). Multivariable logistic regression models confirmed that the regular users of spironolactone, alone (odds ratio = 1.45, 95% CI 1.15 to 1.83) or in combination with digoxin (odds ratio = 1.28, 95% CI 1.03 to 1.58), had markedly faster recovery trajectories for measures of NT-proBNP than the irregular users of both. In conclusion, NT-proBNP normalization after cardiac surgery for TOF is a lengthy process, and irregular use of spironolactone could lead to failure in recovery and hospital readmission.
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Affiliation(s)
- Haiqing Zheng
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lijuan Li
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jiangbo Qu
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jianbin Li
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yanqin Cui
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Xinxin Chen
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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Vizzardi E, Regazzoni V, Caretta G, Gavazzoni M, Sciatti E, Bonadei I, Trichaki E, Raddino R, Metra M. Mineralocorticoid receptor antagonist in heart failure: Past, present and future perspectives. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2014; 3:6-14. [PMID: 29450163 PMCID: PMC5801434 DOI: 10.1016/j.ijchv.2014.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/08/2014] [Indexed: 12/24/2022]
Abstract
Aldosterone is involved in various deleterious effects on the cardiovascular system, including sodium and fluid retention, myocardial fibrosis, vascular stiffening, endothelial dysfunction, catecholamine release and stimulation of cardiac arrhythmias. Therefore, aldosterone receptor blockade may have several potential benefits in patients with cardiovascular disease. Mineralocorticoid receptor antagonists (MRAs) have been shown to prevent many of the maladaptive effects of aldosterone, in particular among patients with heart failure (HF). Randomized controlled trials have demonstrated efficacy of MRA in heart failure with reduced ejection fraction, both in patients with NYHA functional classes III and IV and in asymptomatic and mildly symptomatic patients (NYHA classes I and II). Recent data in patients with heart failure with preserved ejection fraction are encouraging. MRA could also have anti-arrhythmic effects on atrial and ventricular arrhythmias and may be helpful in patient ischemic heart disease through prevention of myocardial fibrosis and vascular damage. This article aims to discuss the pathophysiological effects of aldosterone in patients with cardiovascular disease and to review the current data that support the use of MRA in heart failure.
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Affiliation(s)
- Enrico Vizzardi
- Corresponding author. Tel.: + 39 303995679; fax: + 39 303996801Corresponding author.Tel.: + 39 303995679; fax: + 39 303996801
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Turgut F, Balogun RA, Abdel-Rahman EM. Renin-angiotensin-aldosterone system blockade effects on the kidney in the elderly: benefits and limitations. Clin J Am Soc Nephrol 2010; 5:1330-9. [PMID: 20498247 DOI: 10.2215/cjn.08611209] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The proportion of the population that is elderly (age>or=65 years) is growing across the world. The increasing longevity of humans results in a higher number of elderly patients' presenting with multiple chronic diseases such as hypertension, diabetes, and chronic kidney disease (CKD). These problems increase morbidity and mortality in the elderly. Overactivity of the renin-angiotensin-aldosterone system (RAAS) is associated with the development of hypertension, cardiovascular events, and CKD, so targeting the RAAS is a logical therapeutic approach. Elderly patients present special concerns regarding the benefits versus risks of using RAAS blockers. Plasma renin activity declines with age, which has been attributed to the effect of age-associated nephrosclerosis. Plasma aldosterone is also reduced with age, resulting in a greater risk for hyperkalemia in older individuals, especially when coupled with the age-associated decline in GFR. Moreover, the elderly have a higher frequency of concurrent conditions and are on many medications, which may further increase the risk for adverse effects of RAAS blocking agents. Unfortunately, there is a paucity of literature that is specifically aimed at studying elderly using the RAAS blockers. We present in our in-depth review data regarding benefits and limitations of the use of the RAAS blockades on the various sites along the RAAS pathway for elderly patients. Specific attention was given to the role of combination RAAS blockade therapy and higher monotherapy dosing in the treatment of hypertension in the elderly.
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Affiliation(s)
- Faruk Turgut
- Department of Medicine, University of Virginia Health System, P.O. Box 800133, Charlottesville, VA 22908, USA.
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