Effect of cardiac resynchronization therapy on broad neurohormone biomarkers in heart failure

Effects of Cardiac Resynchronization Therapy on Cardio-Respiratory Coupling

In this study, the effect of cardiac resynchronization therapy (CRT) on the relationship between the cardiovascular and respiratory systems in heart failure subjects was examined for the first time. We hypothesized that alterations in cardio-respiratory interactions, after CRT implantation, quantified by signal complexity, could be a marker of a favorable CRT response. Sample entropy and scaling exponents were calculated from synchronously recorded cardiac and respiratory signals 20 min in duration, collected in 47 heart failure patients at rest, before and 9 months after CRT implantation. Further, cross-sample entropy between these signals was calculated. After CRT, all patients had lower heart rate and CRT responders had reduced breathing frequency. Results revealed that higher cardiac rhythm complexity in CRT non-responders was associated with weak correlations of cardiac rhythm at baseline measurement over long scales and over short scales at follow-up recording. Unlike CRT responders, in non-responders, a significant difference in respiratory rhythm complexity between measurements could be consequence of divergent changes in correlation properties of the respiratory signal over short and long scales. Asynchrony between cardiac and respiratory rhythm increased significantly in CRT non-responders during follow-up. Quantification of complexity and synchrony between cardiac and respiratory signals shows significant associations between CRT success and stability of cardio-respiratory coupling.

Biomarkers to predict the response to cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an established non-pharmacological treatment for selected heart failure patients with wide QRS duration. However, there is a persistent number of non-responders throughout. The prediction of the CRT response is paramount to adequately select the correct patients for CRT. One of the expanding fields of research is the development of biomarkers that predict the response to CRT. A review of the available literature on biomarkers in CRT patients has been performed to formulate a critical appraisal of the available data. The main conclusion of our review is that biomarker research in this patient population is very fragmented and broad. This results in the use of non-uniform endpoints to define the CRT response, which precludes an in-depth comparison of the available data. To improve research development in this field, a uniform definition of the CRT response and relevant endpoints is necessary to better predict the CRT response.

Usefulness of Biomarkers for Predicting Response to Cardiac Resynchronization Therapy

Cardiac Resynchronization Therapy (CRT) is an effective treatment strategy for heart failure. It significantly improves clinical symptoms and decreases mortality and long-term morbidity. However, some patients do not respond properly to this treatment. In this review, the role of different biomarkers in predicting response to CRT is discussed. Some biomarkers, including natriuretic peptides and inflammatory markers have promising results but further trials are needed for more evaluation.

Gender in cardiac resynchronisation therapy

Introduction: Gender differences in cardiac resynchronisation therapy (CRT) response are not clear enough. This study aimed to assess gender influence on systemic inflammation, neurohormonal activation, fibrosis in patients with congestive heart failure (CHF) and CRT.

Methods: We compared group I (61 men) and group II (16 women) of patients undergoing CRT. Plasma levels of Nt-proBNP, interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor alpha (TNF-α), C-reactive protein, galectin-3 (Gal-3), metalloproteinase-9 (MMP-9), tissue inhibitors of metalloproteinase 1 and 4 (TIMP-1, TIMP-4), ratio MMP-9/TIMP-1, MMP-9/TIMP-4 were measured. According to dynamics of left ventricular end-systolic volume patients were classified into non-responders, responders, super-responders.

Results: Women more likely had left bundle branch block (81.3 vs 47.5%, P = 0.016), were more super-responders (66.7 vs 30.5%). Both groups showed decrease of IL-6 (P < 0.05), TNF-α (P < 0.001; P < 0.05), NT-proBNP (P = 0.001; P < 0.05), Gal-3 (P < 0.05). In women there was decrease of IL-6 by 44.4 vs 23.5% in men (PP = 0.029), TNF-α by 41.4 vs 30.9%, NT-proBNP by 73.3 vs 46% (P = 0.002), Gal-3 by 82.3 vs 64.9% (P < 0.05). Group I also showed decrease of IL-10 by 34.2% (P < 0.05). Group dynamics of TIMP-1 was opposite: men showed tendency to reduction of TIMP-1 (P = 0.054), women showed increase of TIMP-1 (P < 0.05). Besides, men showed decrease of MMP-9 (P < 0.05) and ratio MMP-9/TIMP-4 (P < 0.05).

Conclusion: The best response to CRT is associated with female gender explained by greater decrease of neurohormonal activation, systemic inflammation and fibrosis. The revealed opposite dynamics of TIMP-1 in the groups can demonstrate the existence of gender features of matrix metalloproteinase system activity and their tissue inhibitors.

Extracellular cardiac matrix biomarkers in patients with reduced ejection fraction heart failure as predictors of response to cardiac resynchronisation therapy: a systematic review

OBJECTIVE

Cardiac resynchronisation therapy (CRT) is an effective therapy for selected patients with heart failure (HF); however, a significant non-response rate exists. We examined current evidence on extracellular cardiac matrix (ECM) biomarkers in predicting response following CRT.

METHODS

Complete literature review of PubMed, Ovid SP MEDLINE, Cochrane Library and TRIP, reference lists, international cardiology conferences and ongoing studies between December 1999 and December 2015 conducted according to prospectively registered study selection and analysis criteria (PROSPERO:CRD42016025864) was performed. All observational and randomised control trials (RCT) were included if they tested prespecified ECM biomarkers' ability to predict CRT response. Risk of bias assessment and data extraction determined pooling of included studies was not feasible due to heterogeneity of the selected studies.

RESULTS

A total of 217 studies were screened; six (five prospective cohort and one RCT substudy) were included in analysis with 415 participants in total. Study sizes varied (n=55-260), cohort characteristics contrasted (male: 67.8%-83.6%, ischaemic aetiology: 40.2%-70.3%) and CRT response definitions differed (three clinical/functional, three echocardiographic). Consistent observation in all ECM biomarker behaviour before and after CRT implantation was not observed between studies. Lower type I and type III collagen synthesis biomarkers (N-terminal propeptides of type I and III procollagens) expression demonstrated replicated ability to predict reverse left ventricular remodelling.

CONCLUSION

Collagen synthesis biomarkers offer the most potential as ECM biomarkers for predicting CRT response. Heterogeneity between these studies was large and limited the ability to pool and compare results numerically. Use of different response definitions was one of the biggest challenges.

Prognostic value of collagen turnover biomarkers in cardiac resynchronization therapy: A subanalysis of the TRUST CRT randomized trial population

BACKGROUND

A substantial proportion of patients do not respond to cardiac resynchronization therapy (CRT). Various echocardiographic and biochemical markers including collagen turnover biomarkers were suggested to predict CRT results. However, pathological significance of collagen turnover biomarkers in CRT remains controversial.

OBJECTIVE

The aim of the present study was to evaluate the relationship between levels of collagen turnover biomarkers (amino-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III [PIIINP]), N-terminal of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, and matrix metalloproteinases (metalloproteinase-2 and metalloproteinase-9) and echocardiographic response to CRT and clinical outcomes.

METHODS

The study population consisted of patients enrolled in the Triple Site Versus Standard Cardiac Resynchronization Therapy trial. Blood samples were obtained before implantation of a CRT with defibrillator. The levels of PIIINP, amino-terminal propeptide of procollagen type I, metalloproteinase-2, and metalloproteinase-9 were determined using commercially available ELISA kits. High-sensitivity C-reactive protein and NT-proBNP levels were determined in a standard way.

RESULTS

Samples were collected from 74 of 100 enrolled patients. The multivariate logistic regression analysis demonstrated that low PIIINP levels (odds ratio [OR] 3.56; 95% confidence interval [CI] 1.23-10.24; P = .017) and baseline ejection fraction (OR 2.14; 95% CI 1.11-4.11; P = .02) were favorably associated with echocardiographic response. PIIINP and NT-proBNP levels appeared to be independent predictors of all-cause mortality (PIIINP: OR 3.11; 95% CI 1.21-7.89; P = .033; NT-proBNP: OR 2.05; 95% CI 1.11-4.96; P = .039) and risk of major cardiac adverse event (PIIINP: OR 3.56; 95% CI 1.53-9.15; P = .007; NT-proBNP: OR 4.51; 95% CI 1.75-11.6; P = .001). PIIINP levels showed significant additive value in predicting mortality as compared with NT-proBNP levels, but they were not superior to ejection fraction in predicting response. Survival analysis with cutoff values identified by receiver operating characteristic analysis confirmed a significant benefit associated with low baseline PIIINP levels.

CONCLUSION

Low PIIINP levels are associated with favorable echocardiographic response and long-term survival in CRT recipients.

Association between brain natriuretic peptide, markers of inflammation and the objective and subjective response to cardiac resynchronization therapy

INTRODUCTION

Studies suggest that cardiac resynchronization therapy (CRT) can induce a decrease in brain natriuretic peptide (BNP) and systemic inflammation, which may be associated with CRT-response. However, the evidence is inconclusive. We examined levels of BNP and inflammatory markers from pre-CRT implantation to 14months follow-up in CRT-responders and nonresponders, defined by two response criteria.

METHODS

We studied 105 heart failure patients implanted with a CRT-defibrillator (68% men; age=65.4±10.1years). The objective CRT-response was defined as a reduction of ⩾15% in left ventricular end systolic volume; subjective CRT-response was defined as an improvement of ⩾10 points in patient-reported health status assessed with the Kansas City Cardiomyopathy Questionnaire. Plasma BNP and markers of inflammation (CRP, IL-6, TNFα, sTNFr1 and sTNFr2) were measured at three time points.

RESULTS

Pre-implantation concentrations of TNFα were significantly lower for subjective responders compared to nonresponders (p=.05), but there was no difference in BNP and the other inflammatory markers at baseline. Objective CRT-response was significantly associated with lower BNP levels over time (F=27.31, p<.001), and subjective CRT-response with lower TNFα levels (F=5.67, p=.019).

CONCLUSION

Objective and subjective response to CRT was associated with lower levels of BNP and TNFα, respectively, but not with other markers of inflammation. This indicates that response to CRT is not automatically related to a stronger overall decrease in inflammation. Large-scale studies are warranted that further examine the relation between the clinical effects of CRT on inflammatory markers, as the latter have been associated with poor prognosis in heart failure.