Biomarkers: optimizing treatment guidance in heart failure

Utility of perinatal natriuretic peptide for predicting neonatal heart failure

BACKGROUND

We evaluated the significance of perinatal plasma natriuretic peptide (NP) levels in neonates with congenital heart defects (CHDs) or arrhythmias and determined whether measurement of perinatal plasma NP levels and echocardiographic assessment in utero could predict heart failure after birth.

METHODS

The study was conducted between 2012 and 2016 to evaluate the correlation of perinatal atrial NP (ANP) and brain NP (BNP) levels at birth with the modified Ross score after birth and the cardiovascular profile (CVP) score before birth.

RESULTS

A total of 122 singletons with CHDs or arrhythmias and 27 controls were analyzed. Neonatal blood sampling was performed at a median of 0.7 h (range, 0.1-1.5) after birth. The neonatal plasma ANP and BNP levels shortly after birth were significantly higher than those in the umbilical artery (UA) plasma. The ANP and BNP levels in UA and neonatal blood were correlated with the modified Ross score. The neonatal plasma ANP and BNP levels and the modified Ross scores were inversely correlated with the CVP score in neonates with CHDs or arrhythmias. The area under the receiver operating characteristic curve of UA ANP levels for predicting neonatal heart failure was highest among those for the CVP score, perinatal plasma ANP and BNP levels, and their combinations.

CONCLUSIONS

The plasma ANP and BNP levels increased markedly shortly after birth. Assessment of the UA plasma ANP level at birth and the CVP score in utero may be utilized to predict neonatal heart failure.

Galectin-3 and soluble RAGE as new biomarkers of post-infarction cardiac remodeling

Post-infarction remodeling is a clinical problem with no curative treatment. Our objective was to search for new biomarkers of cardiac remodeling that have clinical value after ST-segment elevation myocardial infarction (STEMI). This pilot study enrolled 67 consecutive patients with de novo STEMI who underwent revascularization by primary angioplasty. Echocardiography studies of cardiac function were completed during the first 48 h post-STEMI and after 6 months of follow-up. Galectin-3 and soluble receptor for advanced glycation end products (sRAGE) were tested in the peripheral venous blood during the 24 h post-infarction. Cardiac remodeling was defined as changes ≥ 15% in the left ventricular end-systolic volume (LVESV) or > 10% in the left atrial area (LAA). An inverse association was found between galectin-3 (r_s = - 0.296; p < 0.001) and sRAGE (r_s = - 0.327; p < 0.001) levels and the basal left ventricle ejection fraction (LVEF). However, only galectin-3 was directly associated with the increase in LVESV (r_s = 0.389; p = 0.007) and LVEDV (r_s = 0.314; p = 0.031) during the follow-up. sRAGE was inversely related to the change in LAA (r_s = - 0.320; p = 0.032). These data are consistent with galectin-3, but not sRAGE levels, as a predictor of left ventricle remodeling (OR 1.036, 95% CI 1.002-1.071; p = 0.039). Galectin-3 and sRAGE levels that were measured during hospitalization are inversely related to basal LVEF after a STEMI. Galectin-3 levels are a predictor of adverse post-STEMI LV remodeling, whereas sRAGE levels exhibited an inverse relationship with left atrial remodeling. KEY MESSAGES: Post-infarction remodeling is a clinical problem with no curative treatment. New biomarkers for remodeling after acute myocardial infarction were explored. Early post-STEMI galectin-3 and soluble RAGE are inversely related with left ventricle function. Galectin-3 levels were predictors of adverse post-STEMI left ventricle remodeling. Soluble RAGE levels were associated with left atrial remodeling.

Significance of Atrial and Brain Natriuretic Peptide Measurements in Fetuses With Heart Failure

Fetal heart failure is mainly caused by congenital heart defect and arrhythmia. It is difficult to appropriately diagnose the severity of fetal heart failure simply by ultrasonography because the development of a fetal heart in fetoplacental circulation and how well the fetal myocardium can adapt to postnatal cardiopulmonary circulation are challenging to assess. In adult cardiology, natriuretic peptides (NPs) are the most useful biomarker of heart failure; however, studies investigating NP levels in the fetuses and amniotic fluid are quite limited. Furthermore, little is known about their production and metabolism. This review summarized the most relevant findings on NP levels in the umbilical cord blood and amniotic fluid. The findings can then extend their use as a diagnostic biomarker of heart failure in fetuses with congenital heart defect and/or arrhythmia.

Implications of the ACC/AHA risk score for prediction of heart failure: the Rotterdam Study

BACKGROUND

Despite the growing burden of heart failure (HF), there have been no recommendations for use of any of the primary prevention models in the existing guidelines. HF was also not included as an outcome in the American College of Cardiology/American Heart Association (ACC/AHA) risk score.

METHODS

Among 2743 men and 3646 women aged ≥ 55 years, free of HF, from the population-based Rotterdam Study cohort, 4 Cox models were fitted using the predictors of the ACC/AHA, ARIC and Health-ABC risk scores. Performance of the models for 10-year HF prediction was evaluated. Afterwards, performance and net reclassification improvement (NRI) for adding NT-proBNP to the ACC/AHA model were assessed.

RESULTS

During a median follow-up of 13 years, 429 men and 489 women developed HF. The ARIC model had the highest performance [c-statistic (95% confidence interval [CI]): 0.80 (0.78; 0.83) and 0.80 (0.78; 0.83) in men and women, respectively]. The c-statistic for the ACC/AHA model was 0.76 (0.74; 0.78) in men and 0.77 (0.75; 0.80) in women. Adding NT-proBNP to the ACC/AHA model increased the c-statistic to 0.80 (0.78 to 0.83) in men and 0.81 (0.79 to 0.84) in women. Sensitivity and specificity of the ACC/AHA model did not drastically change after addition of NT-proBNP. NRI(95%CI) was - 23.8% (- 19.2%; - 28.4%) in men and - 27.6% (- 30.7%; - 24.5%) in women for events and 57.9% (54.8%; 61.0%) in men and 52.8% (50.3%; 55.5%) in women for non-events.

CONCLUSIONS

Acceptable performance of the model based on risk factors included in the ACC/AHA model advocates use of this model for prediction of HF risk in primary prevention setting. Addition of NT-proBNP modestly improved the model performance but did not lead to relevant discrimination improvement in clinical risk reclassification.

Plasma natriuretic peptide levels in fetuses with congenital heart defect and/or arrhythmia

OBJECTIVE

Diagnosing fetal heart failure remains challenging because it is difficult to know how well the fetal myocardium will perform as loading conditions change. In adult cardiology, natriuretic peptides (NPs) are established markers of heart failure. However, the number of studies investigating NP levels in fetuses is quite limited. The aim of this study was to evaluate the significance of plasma NP levels in the assessment of heart failure in fetuses with a congenital heart defect (CHD) and/or arrhythmia.

METHODS

This was a prospective observational study conducted at a tertiary pediatric cardiac center. A total of 129 singletons with CHD and/or arrhythmia and 127 controls were analyzed between 2012 and 2015. Umbilical cord plasma atrial NP, brain NP and N-terminal pro-brain NP levels at birth were compared with ultrasonography findings indicating fetal heart failure, such as cardiovascular profile (CVP) score and morphological characteristics.

RESULTS

Fetuses with CHD and/or arrhythmia had higher NP levels than did controls (P < 0.01). NP levels of fetuses with CHD and/or arrhythmia were correlated inversely with CVP score (P for trend < 0.01). No differences in NP levels were found in fetuses with CHD and/or arrhythmia and a CVP score of ≥ 8 in comparison to controls. Multivariate analysis showed that a CVP score of ≤ 5, tachy- or bradyarrhythmia at birth, preterm birth and umbilical artery pH < 7.15 were associated independently with high NP levels (P < 0.01). Among fetuses with a CVP score of ≤ 7, abnormal venous Doppler sonography findings were significantly more common and more severe in fetuses with tachy- or bradyarrhythmia than in those with CHD, and those with tachy- or bradyarrhythmia had higher NP levels than did those with CHD (P = 0.01). Fetuses with right-heart defect and moderate or severe tricuspid valve regurgitation had significantly higher NP levels than did fetuses with other types of CHD (P < 0.01).

CONCLUSIONS

Plasma NP levels in fetuses with CHD and/or arrhythmia are correlated with the severity of fetal heart failure. Elevated NP levels are attributed mainly to an increase in central venous pressure secondary to arrhythmia or atrioventricular valve regurgitation due to CHD, rather than to the morphological abnormality itself. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Comparison of clinical efficacy of metoprolol combined with irbesartan and hydrochlorothiazide and non-invasive ventilator in the emergency treatment of patients with severe heart failure

Clinical efficacy of metoprolol combined with irbesartan and hydrochlorothiazide and non-invasive ventilator in the emergency treatment of patients with severe heart failure (HF) was investigated. A retrospective analysis of the medical records of 124 patients with severe HF admitted to Binzhou Medical University Hospital from May 2012 to August 2016 was performed. Among them, 78 patients who were treated with metoprolol combined with irbesartan and hydrochlorothiazide and non-invasive ventilator for emergency treatment were enrolled into the Research Group, while the Control Group consisted of 46 patients treated with routine medical treatment. Echocardiographic parameters, 6-minute walking test results, the efficacy of the emergency treatment, cardiac function grading, left ventricular ejection fraction (LVEF) and brain natriuretic peptide (BNP) levels were compared between the two groups. After the emergency treatment, the echocardiographic indexes of both groups increased to different extents (P<0.05). Compared with the results before, patients of both groups walked longer within six minutes after the emergency treatment (P<0.05). After the emergency treatment, the BNP expression levels in the two groups decreased to different degrees (P<0.05). After a 7-day emergency treatment, the efficiency rate of treatment of the Research Group was higher than that of the Control Group (P<0.05). The method is helpful for the recovery of respiratory function, for relieving symptoms in short time, improving cardiac function and promising high safety, using metoprolol and irbesartan and hydrochlorothiazide combined with non-invasive ventilator had satisfactory clinical efficacy in the emergency treatment of patients with severe heart failure and is thus worthy of clinical promotion.

Suppressed MMP-9 Activity in Myocardial Infarction-Related Cardiogenic Shock Implies Diminished Rage Degradation

BACKGROUND

Receptor for advanced glycation end products (RAGE) and its cleavage fragment soluble RAGE (sRAGE) are opposite players in inflammation. Enhanced monocytic RAGE expression and decreased plasma sRAGE levels are associated with higher mortality in infarction-related cardiogenic shock. Active matrix metalloproteinase-9 (MMP-9) has been implied in RAGE ectodomain cleavage and subsequently sRAGE shedding in vitro. We investigated MMP-9 activity in myocardial infarction-induced cardiogenic shock with regard to RAGE/sRAGE regulation.

METHODS AND RESULTS

We determined MMP-9 serum activity by zymography and tissue inhibitor of matrix metalloproteinases (TIMP-1) expression by Western blot and correlated it to RAGE/sRAGE data in patients with cardiogenic shock after acute myocardial infarction (CS, n = 30), in patients with acute myocardial infarction without shock (AMI, n = 20) and in healthy volunteers (n = 20).MMP-9 activity is increased in AMI (P = 0.02 versus controls), but significantly decreased in CS with lowest levels in non-survivors (n = 13, P = 0.02 versus AMI). In all patients, MMP-9 activity correlated inversely with RAGE expression on circulating monocytes (r = -0.57; P = 0.0001; n = 50).TIMP-1 levels showed an inverse regulation in comparison to active MMP-9 with significantly decreased levels in AMI as compared with controls (P = 0.02 versus controls) and highest levels in non-survivors of CS (P <0.001 versus AMI).

CONCLUSIONS

Serum MMP-9 activity is increased in acute myocardial infarction, but markedly suppressed in cardiogenic shock. Maintaining MMP-9 activity could be a therapeutic target to limit RAGE-induced deleterious inflammation in cardiogenic shock.

Chronic exposure to water-pipe smoke induces cardiovascular dysfunction in mice

Water-pipe tobacco smoking is becoming prevalent in all over the world including Western countries. There are limited data on the cardiovascular effects of water-pipe smoke (WPS), in particular following chronic exposure. Here, we assessed the chronic cardiovascular effects of nose-only WPS exposure in C57BL/6 mice. The duration of the session was 30 minutes/day, 5 days/week for 6 consecutive months. Control mice were exposed to air. WPS significantly increased systolic blood pressure. The relative heart weight and plasma concentrations of troponin-I and B-type natriuretic peptide were increased in mice exposed to WPS. Arterial blood gas analysis showed that WPS caused a significant decrease in [Formula: see text] and an increase in [Formula: see text] WPS significantly shortened the thrombotic occlusion time in pial arterioles and venules and increased the number of circulating platelet. Cardiac lipid peroxidation, measured as thiobarbituric acid-reactive substances, was significantly increased, while superoxide dismutase activity, total nitric oxide activity, and glutathione concentration were reduced by WPS exposure. Likewise, immunohistochemical analysis of the heart revealed an increase in the expression of inducible nitric oxide synthase and cytochrome c by cardiomyocytes of WPS-exposed mice. Moreover, hearts of WPS-exposed mice showed the presence of focal interstitial fibrosis. WPS exposure significantly increased heart DNA damage assessed by Comet assay. We conclude that chronic nose-only exposure to WPS impairs cardiovascular homeostasis. Our findings provide evidence that long-term exposure to WPS is harmful to the cardiovascular system and supports interventions to control the spread of WPS, particularly amid youths.NEW & NOTEWORTHY No data are available on the chronic cardiovascular effects of water-pipe smoke (WPS). Our findings provide experimental evidence that chronic exposure to WPS increased blood pressure, relative heart weight, troponin I, and B-type natriuretic peptide in plasma and induced hypoxemia, hypercapnia, and thrombosis. Moreover, WPS caused cardiac oxidative stress, DNA damage, and fibrosis.

Galectin 3: association to neurohumoral activity, echocardiographic parameters and renal function in outpatients with heart failure

Background

Galectin 3 (Gal-3) reflects cardiac fibrosis in heart failure HF, but has also been associated to renal fibrosis and impaired renal function. Previous research has suggested that Gal-3 could be a cardio-renal biomarker, but it has never been tested simultaneous in a single study whether Gal-3 reflects echocardiographic measures, neurohumoral activity and renal function.

The aim of this study was to evaluate the relationship between plasma concentrations of Gal-3 and neurohumoral activity, myocardial and renal function in patients with HF, including advanced echocardiographic measures and 24-h urinary albumin excretion (albuminuria).

Methods

We prospectively enrolled 132 patients with reduced left ventricular ejection fraction (LVEF) referred to an outpatient HF clinic. The patients had a median age of 70 years (interquartile rage: 64–75), 26.5 % were female, median LVEF was 33 % (27–39 %) and 30 % were in NYHA class III-IV.

Results

Patients with plasma concentrations of Gal-3 above the median had significantly lower estimated glomerular filtration rate (eGFR) and this association remained significant in multivariate regression analysis (β: −0.010; 95 % CI −0.012–-0.008; P < 0.001), adjusted for age, gender, medical treatment. Plasma concentrations of Gal-3 were not associated with albuminuria (Beta: 0.008; 95 % CI:-0.028–0.045; P = 0.652). There were no association between plasma concentrations of Gal-3 and myocardial function or structure estimated by LVEF, LVmassIndex, LVIDd, E/é or LV global longitudinal strain (P > 0.05 for all). In multivariate analyses plasma concentrations of Gal-3 were significantly associated with the cardiac biomarkers: NT-proBNP (β: 0.047; 95 % CI: 0.008–0.086; P = 0.020), proANP (β: 0.137; 95 % CI: 0.067–0.207; P < 0.001), chromogranin A (β: 0.123; 95 % CI: 0.052–0.194; P < 0.001) and Copeptin (β: 0.080; 95 % CI: 0.000–0.160; P = 0.049). Multivariate analysis was adjusted for eGFR, age, gender and medical treatment.

Conclusions

Increased plasma concentrations of Gal-3 are associated with reduced eGFR and increased plasma concentrations of NT-proBNP, proANP, chromogranin A and Copeptin, but not with echocardiographic parameters reflecting myocardial function. These results suggest that Gal-3 reflects both increased neurohumoral activity and reduced eGFR, but not myocardial function in patients with systolic HF.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0290-7) contains supplementary material, which is available to authorized users.

Galectin-3 and sST2 in prediction of left ventricular ejection fraction after myocardial infarction

BACKGROUND

Fibrosis is a pivotal event in infarct repair and progressive remodeling after myocardial infarction (MI). Biomarkers may be used to monitor fibrosis, and therefore we evaluated the predictive value of galectin-3 and sST2 for cardiac remodeling after MI.

METHODS

Plasma galectin-3 and sST2 were measured in patients admitted with primary percutaneous coronary intervention (PCI) for acute MI, at baseline and at 4months. Left ventricular ejection fraction (LVEF) and infarct size were measured after 4months with cardiac MRI (CMR).

RESULTS

In total, 247 patients had blood samples and CMR data available (mean age 57.7±11.6years; 79.8% male). Increased baseline galectin-3 (≥17.8ng/mL) identified patients with lower LVEF (50.3% (±9.1) vs. non-elevated galectin-3 55.0% (±8.0); P<0.001), and larger infarct size (13.8g. (±12.9) vs. 8.6g. (±8.7); P=0.002) after 4months. Elevated sST2 (≥35.0ng/mL) did not predict decreased LVEF or larger infarct size. Furthermore we showed that at baseline, galectin-3 was an independent predictor for LVEF (β=-0.18; P=0.005) and infarct size (β=0.18; P=0.004). We repeated the analyses using median values of galectin-3 (13.4ng/mL) and sST2 (30.3ng/mL) as a cut point, and this validated our results.

CONCLUSION

The fibrosis biomarker galectin-3, but not sST2, taken immediately after MI, predicts LVEF and infarct size after 4months. We hypothesize that galectin-3 may play a role in the pathophysiology of cardiac remodeling after acute MI.

Clinical use of novel biomarkers in heart failure: towards personalized medicine

Biomarkers play an important role in heart failure. They provide us information about the mechanisms involved in specific types of heart failure and can identify patients at higher risk. Although the majority of biomarker studies in heart failure focus on their prognostic value, the clinical applicability of prognostication in heart failure needs to be established. However, biomarkers can be used for many other purposes. For example, they can help us with the diagnosis of heart failure, and they can be used to select our therapy, leading to personalized tailored therapy. Finally, when biomarkers are causally involved in the disease process, they can even become targets for therapy. The present paper reviews the established and potential value of the novel heart failure biomarkers, mid-regional atrial natriuretic peptide, soluble ST2, growth differentiation factor 15, galectin-3, renal tubular damage markers, and microRNAs. Their potential clinical value will be discussed and compared with the reference markers, the natriuretic peptides.

Labeling galectin-3 for the assessment of myocardial infarction in rats

Background

Galectin-3 is a ß-galactoside-binding lectin expressed in most of tissues in normal conditions and overexpressed in myocardium from early stages of heart failure (HF). It is an established biomarker associated with extracellular matrix (ECM) turnover during myocardial remodeling. The aim of this study is to test the ability of ¹²³I-galectin-3 (IG3) to assess cardiac remodeling in a model of myocardial infarction (MI) using imaging techniques.

Methods

Recombinant galectin-3 was labeled with iodine-123 and in vitro binding assays were conducted to test ¹²³I-galectin-3 ability to bind to ECM targets. For in vivo studies, a rat model of induced-MI was used. Animals were subjected to magnetic resonance and micro-SPETC/micro-CT imaging two (2 W-MI) or four (4 W-MI) weeks after MI. Sham rats were used as controls. Pharmacokinetic, biodistribution, and histological studies were also performed after intravenous administration of IG3.

Results

In vitro studies revealed that IG3 shows higher binding affinity (measured as counts per minute, cpm) (p < 0.05) to laminin (2.45 ± 1.67 cpm), fibronectin (4.72 ± 1.95 cpm), and collagen type I (1.88 ± 0.53 cpm) compared to bovine serum albumin (BSA) (0.88 ± 0.31 cpm). Myocardial quantitative IG3 uptake (%ID/g) was higher (p < 0.01) in the infarct of 2 W-MI rats (0.15 ± 0.04%) compared to control (0.05 ± 0.03%). IG3 infarct uptake correlates with the extent of scar (r_s = 1, p = 0.017). Total collagen deposition in the infarct (percentage area) was higher (p < 0.0001) at 2 W-MI (24.2 ± 5.1%) and 4 W-MI (30.4 ± 7.5%) compared to control (1.9 ± 1.1%). However, thick collagen content in the infarct (square micrometer stained) was higher at 4 W-MI (20.5 ± 11.2 μm²) compared to control (4.7 ± 2.0 μm², p < 0.001) and 2 W-MI (10.6 ± 5.1 μm², p < 0.05).

Conclusions

This study shows, although preliminary, enough data to consider IG3 as a potential contrast agent for imaging of myocardial interstitial changes in rats after MI. Labeling strategies need to be sought to improve in vivo IG3 imaging, and if proven, galectin-3 might be used as an imaging tool for the assessment and treatment of MI patients.

Beneficial effects of renal sympathetic denervation on cardiovascular inflammation and remodeling in essential hypertension

BACKGROUND

Renal sympathetic denervation (RSD) represents a potential treatment option for certain patients with resistant arterial hypertension (HT). HT is associated with chronic vascular inflammation and remodeling, contributing to progressive vascular damage, and atherosclerosis. The present study aimed to evaluate the influence of RSD on cardiovascular inflammation and remodeling by determining serum levels of interleukin-6 (IL-6), high-sensitive C-reactive protein (hsCRP), matrix metalloproteinases (MMP), and tissue inhibitor of metalloproteinases (TIMP).

METHODS

A total of 60 consecutive patients (age 67.9 ± 9.6 years) undergoing RSD were included. A therapeutic response was defined as an office systolic blood pressure (SBP) reduction of >10 mmHg 6 months after RSD. Venous serum samples for measurement of hsCRP, IL-6, MMP-2, MMP-9, and TIMP-1 were collected prior to and 6 months after RSD.

RESULTS

A significant reduction in office SBP of 26.4 mmHg [SBPbaseline 169.3 mmHg (SD 11.3), p < 0.001] was documented 6 months after RSD. The serum levels of hsCRP (p < 0.001) and the pro-inflammatory cytokine IL-6 (p < 0.001) were significantly decreased compared to baseline values. The levels of MMP-9 (p = 0.024) and MMP-2 (p < 0.01) were significantly increased compared to baseline values.

CONCLUSION

In addition to the effective blood pressure reduction in response to RSD, this study demonstrates a positive effect of RSD on biomarkers reflecting vascular inflammation and remodeling. These results suggest a possible prognostic benefit of RSD in high-risk patients for endothelial dysfunction and cardiovascular remodeling as well as end-organ damage.

Inflammatory cytokines as biomarkers in heart failure

Inflammation has been implicated in the pathogenesis of heart failure (HF). In addition to their direct involvement as mediators in the pathogenesis of HF, inflammatory cytokines and related mediators could also be suitable markers for risk stratification and prognostication in HF patients. Many reports have suggested that inflammatory cytokines may predict adverse outcome in these patients. However, most studies have been limited in sample size and lacking full adjustment with the most recent and strongest biochemical predictor such as NT-proBNP and high sensitivity troponins. Furthermore, a number of pre-analytical and analytical aspects of cytokine measurements may limit their use as biomarkers. This review focuses on technical, informative and practical considerations concerning the clinical use of inflammatory cytokines as prognostic biomarkers in HF. We focus on the predictive value of tumor necrosis factor (TNF) α, the TNF family receptors sTNFR1 and osteoprotegerin, interleukin (IL)-6 and its receptor gp130, the chemokines MCP-1, IL-8, CXCL16 and CCL21 and the pentraxin PTX-3 in larger prospective fully adjusted studies. No single inflammatory cytokine provides sufficient discrimination to justify the transition to everyday clinical use as a prognosticator in HF. However, while subjecting potential new HF markers to rigorous comparisons with "gold-standard" markers, such as NT-proBNP, using receiver operating characteristics (ROCs) and HF risk models, makes sense from a clinical standpoint, it may pose a threat to a broadening of mechanistic insight if the new markers are dismissed solely on account of lower statistical power.

Factors associated with increased risk for dementia in individuals age 80 years or older with congestive heart failure

BACKGROUND AND RESEARCH OBJECTIVE

An increasing body of evidence shows that individuals diagnosed with congestive heart failure (CHF) are at a higher risk for dementia. However, the prevalence rate of dementia among persons with CHF in very old individuals has not been previously reported, and little is known about the comorbidities that place old persons with CHF at a higher risk for dementia. The aim of this study was to compare the prevalence of dementia in individuals 80 years or older who have CHF with that in individuals without CHF and to identify factors related to dementia in individuals diagnosed with CHF.

METHODS

A total of 702 participants from a Swedish population-based longitudinal study (Octogenerian Twin) were included. The group consisted of same-sex twin pairs, age 80 years or older, and 138 participants had CHF. Dementia was diagnosed according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Generalized estimating equations including gender, age and educational level, waist circumference, diabetes, hypertension, smoking, depression, and blood values were used in a case-control analysis.

RESULTS

Individuals with CHF had a significantly higher prevalence of vascular dementia, 16% vs 6% (P < 0.001), and of all types of dementia, 40% vs 30% (P < 0.01), than those not diagnosed with CHF. The generalized estimating equation models showed that depression, hypertension, and/or increased levels of homocysteine were all associated with a higher risk for dementia in individuals with CHF. Diabetes was specifically associated with an increased risk for vascular dementia.

CONCLUSIONS

The prevalence of dementia was higher among individuals with CHF than in those without CHF. Diabetes, depression, and hypertension in patients with CHF require special attention from healthcare professionals because these conditions are associated with an elevated risk for dementia. Higher levels of homocysteine were also found to be a marker of dementia in patients with CHF. Further research is needed to identify the factors related to dementia in individuals 80 years or older diagnosed with CHF.

Old and newer biomarkers in heart failure: from pathophysiology to clinical significance

Heart failure is a complex disease in which a careful clinical examination and the measurement of cardiac function may not always be sufficient for making a correct diagnosis. Measuring plasma levels of natriuretic peptides may assist in this process, also offering a good tool for accurate risk stratification. Other alternative biomarkers may give insight into the different pathways of heart failure genesis and pathophysiology, and may help to identify those patients with overt heart failure and a more adverse outcome, or distinguish between those at risk of developing heart failure. Despite a high number of potentially useful biomarkers, only a few will likely be introduced routinely into clinical practice. However, a multi-marker approach might increase the diagnostic accuracy and it might identify different phenotypes of heart failure patients who might benefit from individualized therapy in the future.

A modified approach to induce predictable congestive heart failure by volume overload in rats

The model of infrarenal aortocaval fistula (ACF) has recently gained new interest in its use to investigate cardiac pathophysiology. Since in previous investigations the development of congestive heart failure (CHF) was inconsistent and started to develop earliest 8–10 weeks after fistula induction using a 18G needle, this project aimed to induce a predictable degree of CHF within a definite time period using a modified approach. An aortocaval fistula was induced in male Wistar rats using a 16G needle as a modification of the former 18G needle-technique described by Garcia and Diebold. Results revealed within 28±2 days of ACF significantly increased heart and lung weight indices in the ACF group accompanied by elevated filling pressure. All hemodynamic parameters derived from a pressure-volume conductance-catheter in vivo were significantly altered in the ACF consistent with severe systolic and diastolic left ventricular dysfunction. This was accompanied by systemic neurohumoral activation as demonstrated by elevated rBNP-45 plasma concentrations in every rat of the ACF group. Furthermore, the restriction in overall cardiac function was associated with a β1- and β2-adrenoreceptor mRNA downregulation in the left ventricle. In contrast, β3-adrenoreceptor mRNA was upregulated. Finally, electron microscopy of the left ventricle of rats in the ACF group showed signs of progressive subcellular myocardial fragmentation. In conclusion, the morphometric, hemodynamic and neurohumoral characterization of the modified approach revealed predictable and consistent signs of congestive heart failure within 28±2 days. Therefore, this modified approach might facilitate the examination of various questions specific to CHF and allow for pharmacological interventions to determine pathophysiological pathways.

Associates of an elevated natriuretic peptide level in stable heart failure patients: implications for targeted management

Background. Persistently elevated natriuretic peptide (NP) levels in heart failure (HF) patients are associated with impaired prognosis. Recent work suggests that NP-guided therapy can improve outcome, but the mechanisms behind an elevated BNP remain unclear. Among the potential stimuli for NP in clinically stable patients are persistent occult fluid overload, wall stress, inflammation, fibrosis, and ischemia. The purpose of this study was to identify associates of B-type natriuretic peptide (BNP) in a stable HF population. Methods. In a prospective observational study of 179 stable HF patients, the association between BNP and markers of collagen metabolism, inflammation, and Doppler-echocardiographic parameters including left ventricular ejection fraction (LVEF), left atrial volume index (LAVI), and E/e prime (E/e′) was measured. Results. Univariable associates of elevated BNP were age, LVEF, LAVI, E/e′, creatinine, and markers of collagen turnover. In a multiple linear regression model, age, creatinine, and LVEF remained significant associates of BNP. E/e′ and markers of collagen turnover had a persistent impact on BNP independent of these covariates. Conclusion. Multiple variables are associated with persistently elevated BNP levels in stable HF patients. Clarification of the relative importance of NP stimuli may help refine NP-guided therapy, potentially improving outcome for this at-risk population.

Connective tissue growth factor (CTGF/CCN2): diagnostic and prognostic value in acute heart failure

BACKGROUND

As a mediator of ECM homeostasis, connective tissue growth factor (CTGF) appears to be involved in adverse structural remodeling processes in the heart. However, the diagnostic and prognostic value of CTGF levels in acute heart failure (AHF) in addition to natriuretic peptide testing has not yet been evaluated.

METHODS AND RESULTS

A total of 212 patients presenting with acute dyspnea and/or peripheral edema to the Emergency Department were evaluated. CTGF and NT-proBNP plasma levels were measured at the initial presentation. All patients were followed up to 1 and 5 years. The first endpoint tested was the diagnostic non-inferiority of combined CTGF plus NT-proBNP compared to NT-proBNP alone for AHF diagnosis. Afterwards, the additional diagnostic value of CTGF plus NT-proBNP was tested. CTGF levels were higher in NYHA class III/IV and AHA/ACC class C/D patients compared to lower class patients (p = 0.04). Patients with HFREF revealed highest CTGF levels (median 93.3 pg/ml, IQR 18.2-972 pg/ml, n = 48) compared to patients with a normal heart function (i.e., without HFREF and HFPEF) (median 25.9, IQR <1-82.2 pg/ml, n = 37) (p < 0.05), followed by patients with HFPEF (median 82.2 pg/ml, IQR 11.5-447 pg/ml, n = 32) as assessed by echocardiography. Finally, CTGF levels were higher in patients with AHF (median 77.3 pg/ml, IQR 22.5-1012 pg/ml, n = 66) compared to those without (p = 0.002). CTGF plus NT-proBNP was non-inferior to NT-proBNP testing alone for AHF diagnosis (AUC difference 0.01, p > 0.05). CTGF plus NT-proBNP improved the diagnostic capacity for AHF (accuracy 82 %, specificity 83 %, positive predictive value 66 %, net reclassification improvement +0.11) compared to NT-proBNP alone (p = 0.0001). CTGF levels were not able to differentiate prognostic outcomes after 1 and 5 years.

CONCLUSIONS

Additional CTGF measurements might lead to a better discrimination of higher functional and structural heart failure stages and might identify patients of an increased risk for an acute cardiac decompensation.

B-type natriuretic peptide: distribution in the general population and the association with major cardiovascular and coronary events--the Heinz Nixdorf Recall Study

BACKGROUND

A B-type natriuretic peptide (BNP) threshold of 100 pg/ml is used in practice for identification of heart failure, but data about the "normal" distribution of BNP in a large population in primary prevention are rare. We aimed to characterize the BNP distribution in a healthy subset of a population-based cohort and to evaluate the association of elevated BNP levels with major events.

METHODS

In a first step, we determined gender-specific distribution and 90th percentiles of BNP in participants who were at baseline free from known determinants of increased BNP, i.e. cardiovascular disease, hypertension or chronic kidney disease. Consecutively, the association of BNP levels above these 90th percentiles with subsequent cardiovascular and coronary events was assessed in the entire cohort.

RESULTS

In the BNP-normal sub-sample (n = 1,639), we defined gender-specific 90th percentile of BNP (31.3 pg/ml for men, 45.5 pg/ml for women). From overall 3,697 subjects (mean age 59.4, 52.4 % female), 194 subjects developed a major cardiovascular event and 122 myocardial infarction during a mean follow-up period of 8.0 ± 1.5 years. The 90th percentiles derived from the normal subset as threshold showed strong associations with major events in the entire cohort even after adjusting for traditional risk factors: hazard ratio (95% CI): 1.86 (1.37; 2.53), p < 0.0001 for cardiovascular, and 1.77 (1.19; 2.62), p = 0.005 for coronary events.

CONCLUSION

The gender-specific 90th percentile of BNP (31 pg/ml for males and 45 pg/ml for females) obtained from a BNP-normal sub-sample is associated with incident major cardiovascular and coronary events, suggesting that even BNP values lower than 100 pg/ml could imply prognostic information in the general population.

Trends in laboratory test volumes for Medicare Part B reimbursements, 2000-2010

CONTEXT

Changes in reimbursements for clinical laboratory testing may help us assess the effect of various variables, such as testing recommendations, market forces, changes in testing technology, and changes in clinical or laboratory practices, and provide information that can influence health care and public health policy decisions. To date, however, there has been no report, to our knowledge, of longitudinal trends in national laboratory test use.

OBJECTIVE

To evaluate Medicare Part B-reimbursed volumes of selected laboratory tests per 10,000 enrollees from 2000 through 2010.

DESIGN

Laboratory test reimbursement volumes per 10,000 enrollees in Medicare Part B were obtained from the Centers for Medicare & Medicaid Services (Baltimore, Maryland). The ratio of the most recent (2010) reimbursed test volume per 10,000 Medicare enrollees, divided by the oldest data (usually 2000) during this decade, called the volume ratio, was used to measure trends in test reimbursement. Laboratory tests with a reimbursement claim frequency of at least 10 per 10,000 Medicare enrollees in 2010 were selected, provided there was more than a 50% change in test reimbursement volume during the 2000-2010 decade. We combined the reimbursed test volumes for the few tests that were listed under more than one code in the Current Procedural Terminology (American Medical Association, Chicago, Illinois). A 2-sided Poisson regression, adjusted for potential overdispersion, was used to determine P values for the trend; trends were considered significant at P < .05.

RESULTS

Tests with the greatest decrease in reimbursement volumes were electrolytes, digoxin, carbamazepine, phenytoin, and lithium, with volume ratios ranging from 0.27 to 0.64 (P < .001). Tests with the greatest increase in reimbursement volumes were meprobamate, opiates, methadone, phencyclidine, amphetamines, cocaine, and vitamin D, with volume ratios ranging from 83 to 1510 (P < .001).

CONCLUSIONS

Although reimbursement volumes increased for most of the selected tests, other tests exhibited statistically significant downward trends in annual reimbursement volumes. The observed changes in reimbursement volumes may be explained by disease prevalence and severity, patterns of drug use, clinical or laboratory practices, and testing recommendations and guidelines, among others. These data may be useful to policy makers, health systems researchers, laboratory directors, and industry scientists to understand, address, and anticipate trends in laboratory testing in the Medicare population.

Assessment of a multimarker strategy for prediction of mortality in older heart failure patients: a cohort study

OBJECTIVE

Primarily to develop a multimarker score for prediction of 3-year mortality in older patients with decompensated heart failure (HF).

DESIGN

Prospective cohort study.

SETTING

Secondary care. Single centre. PATIENTS AND BIOMARKERS: 131 patients, aged ≥65 years, with decompensated HF were included. Assessment of biomarkers was performed at discharge.

PRIMARY OUTCOME MEASURE

3-year mortality.

RESULTS

Mean age was 73±11 years; mean left ventricular ejection fraction , 43±14%; 53% were male. The 3-year mortality was 53.4%. The following N-terminal brain natriuretic peptide (NTproBNP) levels could optimally stratify mortality: <2000 ng/l (n=39), 30.8% mortality; 2000-8000 ng/l (n=58), 51.7% mortality; and >8000 ng/l (n=34), 82.4% mortality. However, in the 2000-8000 ng/l range, NTproBNP levels had low-prognostic capacity, based on the area under the receiver operating characteristic curve (AUC=0.53; 95% CI 0.40 to 0.67). In this group, multivariate analysis identified age, cystatin C (CysC), and troponin T (TnT) levels as independent risk factors. A risk score based on these three risk factors separated a high-risk and low-risk groups within the NTproBNP range of 2000-8000 ng/l. The score exhibited a significantly higher AUC (0.75; 95% CI 0.62 to 0.86) than NTproBNP alone (p=0.03) in this NTproBNP group and had similar prognostic capacity as NTproBNP in patients below or above this NTproBNP range (p=0.57). Net reclassification improvement and integrated discriminatory improvement in the group with NTproBNP levels between 2000 and 8000 ng/l was 54% and 23%, respectively, and in the whole cohort 22% and 11%, respectively.

CONCLUSIONS

Our results suggested that, to assess risk in HF, older patients required significantly higher levels of NTproBNP than younger patients. Furthermore, a risk score that included TnT and CysC at discharge, and age could improve risk stratification for mortality in older patients with HF in particular when NTproBNP was moderately elevated.

[Diastolic heart failure: heart failure with preserved ejection fraction]

The prognosis for patients with diastolic heart failure--heart failure with preserved ejection fraction--has not improved in the last few decades despite improvement of prognosis for all patients with heart failure. Diastolic dysfunction is a typical finding in elderly patients with heart failure. The diagnostic process is a challenge for clinicians who are often faced with comorbidities like COPD, osteoarthritis, sarcopenia, and diabetes. Classical treatment options fail to improve patients with diastolic heart failure; thus, a comprehensive and specific treatment plan is necessary.

Galectin-3 is an independent marker for ventricular remodeling and mortality in patients with chronic heart failure

BACKGROUND

Galectin-3 (Gal-3) is a recently discovered marker for myocardial fibrosis and elevated levels are associated with an impaired outcome after short-term follow-up in heart failure (HF) patients. However, whether Gal-3 is related to cardiac remodeling and outcome after long-term follow-up is unknown. Therefore, we determined the utility of Gal-3 as a novel biomarker for left ventricular remodeling and long-term outcome in patients with severe chronic HF.

METHODS AND RESULTS

A total of 240 HF patients with New York Heart Association (NYHA) Class III and IV were included. Patients were followed for 8.7 ± 1 years, had a mean age of 71 ± 0.6 years and 73 % of the study population was male. Circulating levels of NT-proBNP and Gal-3 were measured. Serial echocardiography was performed at baseline and at 3 months. At baseline median left ventricular end-diastolic volume (LVEDV) was 267 mL [interquartile range 232-322]. Patients were divided into three groups according to the change in LVEDV. Patients in whom the LVEDV decreased over time had significant lower levels of Gal-3 at entry compared to patients in whom the LVEDV was stable or increased (14.7 vs. 17.9 vs. 19.0 ng/mL; p = 0.004 for trend), whereas no significant differences were seen in levels of NT-proBNP (p = 0.33). Multivariate linear regression analyses revealed that Gal-3 levels were positively correlated to change in LVEDV (p = 0.007). In addition, Gal-3 was a significant predictor of mortality after long-term follow-up (p = 0.001).

CONCLUSION

Gal-3 is associated with left ventricular remodeling determined by serial echocardiography and predicts long-term mortality in patients with severe chronic HF.

Right ventricular hypertrophy after atrial switch operation: normal adaptation process or risk factor? A cardiac magnetic resonance study

Background

Systemic right ventricle (RV) hypertrophy and impaired function occur after atrial switch for dextro-transposition of the great arteries (d-TGA). Echocardiography is limited in its ability to assess the RV. We sought to evaluate systemic RV myocardial-mass index (MMI) and function after atrial switch and to analyse the role of hypertrophy for ventricular function with special consideration of the interventricular septal (IVS) movement.

Methods

Thirty-seven consecutive patients (median age 22.9 years) after atrial switch were studied using cardiac magnetic resonance imaging (1.5T Intera, Philips) with a dedicated 5-channel phased-array surface cardiac coil. Cine steady-state free-precession sequences were acquired to obtain myocardial masses and function. The systolic movement of the IVS was defined as positive when moving towards the centroid of the RV and was defined as non-positive otherwise. Patient parameters were compared to controls.

Results

The systemic RVs were significantly larger (p < 0.001) than the left ventricles of the control group, systolic function was significantly impaired (p < 0.001) and MMI including the IVS was comparable (p = n.s.). RV-MMI excluding the IVS and RV ejection fraction (EF) demonstrated a quadratic correlation (r = 0.6, p < 0.001), meaning that patients with RV-MMI ≤29 g/m² and >68 g/m² had a reduced level of systolic function. Positive septal movement improved RV function compared with non-positive septal movement (p = 0.024).

Conclusions

There seems to be a range of beneficial RV hypertrophy after atrial switch in which a sufficient RV-EF can be expected. A positive septal movement, probably the result of hypertrophic septal RV fibres, improves RV function and might be regarded as a beneficial contraction pattern.