The role of natriuretic peptide testing in guiding chronic heart failure management: review of available data and recommendations for use

Biomarkers in heart failure: the past, current and future

Despite the enhanced knowledge of the pathophysiology of heart failure (HF), it still remains a serious syndrome with substantial morbidity, mortality, and frequent hospitalizations. These are due to the current improvements in other cardiovascular diseases (like myocardial infarction), the aging population, and growing prevalence of comorbidities. Biomarker-guided management has brought a new dimension in prognostication, diagnosis, and therapy options. Following the recommendation of natriuretic peptides (B-type natriuretic peptide and N-terminal-proBNP), many other biomarkers have been thoroughly studied to reflect different pathophysiological processes (such as fibrosis, inflammation, myocardial injury, and remodeling) in HF and some of them (like cardiac troponins, soluble suppression of tumorigenesis-2, and galectin 3) have subsequently been recommended to aid in the diagnosis and prognostication in HF. Consequently, multi-marker approach has also been approved owing to the varied nature of HF syndrome. In this review, we discussed the guidelines available for HF biomarkers, procedures for evaluating novel markers, and the utilities of both emerging and established biomarkers for risk stratification, diagnosis, and management of HF in the clinics. We later looked at how the rapidly emerging field-OMICs, can help transform HF biomarkers discoveries and establishment.

Targeting Natriuretic Peptide Levels in Heart Failure with Therapy: Does "X" Really Mark the Spot?

PURPOSE OF REVIEW

Explore controversial biomarker-guided management of patients with heart failure (HF) with reduced ejection fraction.

RECENT FINDINGS

Natriuretic peptides (e.g., BNP, NT-proBNP) are elevated in HF as a result of end-diastolic stress and are used in the diagnosis and prognosis of heart failure. Natriuretic peptide levels decrease with guideline-directed medical therapy (GDMT). Multiple small studies examined whether the use of biomarker-guided therapy would be beneficial to guide HF care and potentially improve outcomes. Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT), the largest randomized control study seeking to answer that question, did not find biomarker guided therapy to be more effective than usual care in improving the primary endpoints of HF hospitalization or cardiovascular mortality in HF patients. Natriuretic peptides are important for diagnosis and prognosis in HF. GUIDE-IT showed that patients with HF and reduced ejection did not benefit from biomarker-guided strategy in terms of clinical outcomes. Future studies could focus on additional routine clinical care settings and take into account other HF phenotypes including preserved ejection fraction.

Increased Plasma Soluble Fractalkine in Patients with Chronic Heart Failure and Its Clinical Significance

Fractalkine has been reported to play an important role in the pathophysiology of various cardiovascular disorders. This research aims to study the change of soluble fractalkine (sFKN) in plasma level of patients with chronic heart failure (CHF) and evaluate its prognostic value.A total of 96 patients with CHF and 45 healthy subjects were included in this study. The plasma levels of sFKN, brain natriuretic peptide (BNP), and Interleukin-18 (IL-18) were determined by ELISA kits when they were first admitted to the hospital. Left ventricular ejection fraction (LVEF) was measured by echocardiogram. Rehospitalization status within 1 year after the first hospitalization was also recorded.The plasma levels of sFKN, BNP, and IL-18 in patients with CHF were significantly higher than in the control group (P < 0.05). The concentrations of sFKN and BNP were increased with the severity of heart failure classified by NYHA classification (P < 0.05). There were no statistical differences among all CHF subgroups classified by etiology (P > 0.05). Plasma sFKN level in CHF group was positively correlated with BNP (r = 0.441, P < 0.001) and IL-18 (r = 0.592, P < 0.001). Receiver operating characteristic curve analysis showed that area under the curve values of FKN, BNP, and IL-18 were 0.885 (95%CI: 0.810 to 0.960, P < 0.001), 0.889 (95%CI: 0.842 to 0.956, P < 0.001), and 0.878 (95%CI: 0.801-0.954, P < 0.001), respectively. The concentrations of sFKN and BNP were increased in patients readmitted more than once within 1 year (P < 0.05).

CRP genetic variants are associated with mortality and depressive symptoms in chronic heart failure patients

OBJECTIVE

Heart failure (HF) is a complex medical condition with a multitude of genetic and other factors being involved in the pathogenesis. Emerging evidence points to an involvement of inflammatory mechanisms at least in subgroups of patients. The same is true for depression and depressive symptoms, which have a high prevalence in HF patients and are risk factors for the development and outcomes of cardiovascular disease.

METHODS

In 936 patients of the Interdisciplinary Network Heart Failure (INH) program, CRP and IL-6 protein blood levels were measured and genetic variants (single nucleotide polymorphisms) of the CRP and IL6 gene analyzed regarding their influence on mortality.

RESULTS

Less common recessive genotypes of two single nucleotide polymorphisms in the CRP gene (rs1800947 and rs11265263) were associated with significantly higher mortality risk (p < 0.006), higher CRP levels (p = 0.029, p = 0.006) and increased depressive symptoms in the PHQ-9 (p = 0.005, p = 0.003). Variants in the IL-6 gene were not associated with mortality.

CONCLUSION

Our results hint towards an association of less common CRP genetic variants with increased mortality risk, depressive symptoms and peripheral CRP levels in this population of HF patients thereby suggesting a possible role of the inflammatory system as link between poor prognosis in HF and depressive symptoms.

Developing Drugs for Heart Failure With Reduced Ejection Fraction: What Have We Learned From Clinical Trials?

There remains a large unmet need for new therapies in the treatment of heart failure with reduced ejection fraction (HFrEF). In the early drug development phase, the therapeutic potential of a drug is not yet fully understood and trial endpoints other than mortality are needed to guide drug development decisions. While a true surrogate marker for mortality in heart failure (HF) remains elusive, the successes and failures of previous trials can reveal markers that support clinical Go/NoGo decisions.

Clinical Phenotyping of Heart Failure with Biomarkers: Current and Future Perspectives

INTRODUCTION

Heart failure (HF) is a complex clinical syndrome with diverse risk factors and etiologies, differing underlying pathophysiology, and large phenotypic heterogeneity.

RECENT FINDINGS

Advances in imaging techniques coupled with clinical trials that targeted only in those with impaired left ventricular ejection fraction (LVEF) have largely shaped the current management strategy for HF that focuses predominantly in patients with systolic HF. In contrast, there are no effective treatments for HF with preserved ejection fraction (HFpEF). Instead of this "one-size-fits-all" approach to treatment, better precision to define HF phenotypic classifications may lead to more efficient and effective HF disease management.

CONCLUSION

Integrating variables-including clinical variables, HF biomarkers, imaging, genotypes, metabolomics, and proteomics-can identify different pathophysiologies, lead to more precise phenotypic classification, and warrant investigation in future clinical trials.

Evaluation of NT-proBNP in children with heart failure younger than 3 years old

INTRODUCTION

Heart failure (HF) is characterized by neuroendocrine activation. The cardiac natriuretic hormones, including atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), together with their related pro-peptides (proANP and proBNP) represent a group of peptide hormones produced by the heart. A normal NT-proBNP level has a high negative predictive value for heart failure. The use of NT-proBNP testing is helpful in diagnosing acute HF in the emergency care setting, allowing an early and optimal treatment. The purpose of this study is to assess the prognostic value of NT-proBNP in heart failure in children younger than 3 years old and to establish whether it correlates with the NYHA/Ross functional class and left ventricle systolic function.

METHODS

We enrolled 24 consecutive children with HF due to congenital heart diseases and dilated cardiomyopathy. The serum levels of NT-proBNP were measured, all patients underwent echocardiography and left ventricle ejection fraction was calculated.

RESULTS

The highest median value of NT-proBNP was recorded in patients with cyanotic heart diseases (248.0 fmol/mL), p = 0.610. NT-proBNP had a negative correlation with the ejection fraction of the left ventricle: Spearman's rank correlation coefficient was -0.165.

CONCLUSIONS

NT-proBNP levels correlate with the severity of HF in infants and small children younger than 3 years old with heart failure due to congenital heart diseases and dilated cardiomyopathy.

ANALYSIS OF CHANGE IN NT-proBNP AFTER ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY IN PATIENT WITH HEART FAILURE

NT-proBNP is an inactive fragment of BNP secreted by stretched ventricle as response to wall stress in patients with heart failure. As a specific cardiac marker, elevated NT-proBNP correlates well with heart failure severity. The principle of heart failure therapy is modulation on neurohormonal activation. ARB can modulate neurohormon on RAA system, that result in decreasing NT-proBNP level and favorable outcomes. Reduction in NT-proBNP more than biologic variability (> 25%) shows a therapy response.This study was to analyze change of NT-proBNP after ARB therapy in ambulatory HF patients. This observational prospective study was carried from September to December 2015. Blood sampling was performed on patients who meet the inclusion criteria of the study at first visit and after 2 months therapy. NT-proBNP was measured by IMMULITE® as primary parameter and creatinin as secondary parameter. There are 14 patients met the inclusion criteria of the study (11 males and 3 females). ARB therapy used in patients were Valsartan (64%), Telmisartan (22%) and Candesartan (14%). After 2 months ARB therapy, a decrease in level of NT-proBNP with initial median 3092.5 (216 – 32112) pg/ml to 2135.5 (350 – 16172) pg/ml respectively were statistically significant (p=0.003). And the secondary parameter creatinin serum convert to eGFR shows a change in eGFR with initial median 73.33 (37.05 – 266.68) ml/minute to 81.04 (39.31 – 167.02) ml/minute respectively were statistically not significant (p=0.657). There were 7 patients (50%) have a decrease > 25%. In this study, we found that ARB therapy can change NT-proBNP level significantly after 2 months therapy.

NT-proBNP LEVEL CHANGES AFTER COMBINATION THERAPY WITH BISOPROLOL AND ACE-INHIBITOR IN PATIENT WITH HEART FAILURE

Heart failure (HF) is the final common stage of many diseases of the heart. NT-proBNP levels are increased in HF and correlate well with ventricular wall stress and severity of HF. Combination therapy with Bisoprolol and ACE-inhibitor decreases NT-proBNP level in patient with HF. The use of Bisoprolol as a combination with ACE-inhibitor is still dominate in outpatient setting at Dr. Soetomo teaching hospital. The objective of this study is to analyze NT-proBNP level changes as an indicator in cardiac function after combination therapy with Bisoprolol and ACE-inhibitor in patient with HF.Methods: This study was prospective, observational and conducted in outpatient setting. Consecutive patients who meet the inclusion criteria of the study were included. Blood samples were taken at pre and 2 months post combination therapy with Bisoprolol and ACE-inhibitor, then NT-proBNP level was measured with IMMULITE®. There were 14 patients enrolled in this study (7 males, 7 females). The result showed that NT-proBNP 2 months post combination therapy with Bisoprolol and ACE-inhibitor is significantly decreased than baseline with mean baseline of NT-proBNP level is 4191.43 ± 4367.277 pg/ml to 2786.79 ± 2485.199 pg/ml (p=0.025). From a total 14 patients, 9 patients had NT-proBNP decreases >20% (20.1% – 56.4%) and 3 patients had NT-proBNP decreases <20% (1.8%, 6.6%, and 12.4%). There were 2 patients with NT-proBNP increases >40% (43.4% and 40.4%). In conclusion, there was a significant decreases in NT-proBNP level after 2 months combination therapy with Bisoprolol and ACE-inhibitor in patient with HF.

Prognostic Implications of Changes in N-Terminal Pro-B-Type Natriuretic Peptide in Patients With Heart Failure

BACKGROUND

Natriuretic peptides (NP) have prognostic value in heart failure (HF), although the clinical importance of changes in NP from baseline is unclear.

OBJECTIVES

The authors assessed whether a reduction in N-terminal pro-B-type NP (NT-proBNP) was associated with a decrease in HF hospitalization and cardiovascular mortality (primary endpoint) in patients with HF and reduced ejection fraction, whether treatment with sacubitril/valsartan reduced NT-proBNP below specific partition values more than enalapril, and whether the relationship between changes in NT-proBNP and changes in the primary endpoint were dependent on assigned treatment.

METHODS

In PARADIGM-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial), baseline NT-proBNP was measured in 2,080 patients; 1,292 had baseline values >1,000 pg/ml and were reassessed at 1 and 8 months. We related change in NT-proBNP to outcomes.

RESULTS

One month after randomization, 24% of the baseline NT-proBNP levels >1,000 pg/ml had fallen to ≤1,000 pg/ml. Risk of the primary endpoint was 59% lower in patients with a fall in NT-proBNP to ≤1,000 pg/ml than in those without such a fall. In sacubitril/valsartan-treated patients, median NT-proBNP was significantly lower 1 month after randomization than in enalapril-treated patients, and it fell to ≤1,000 pg/ml in 31% versus 17% of patients treated with sacubitril/valsartan and enalapril, respectively. There was no significant interaction between treatment and the relationship between change in NT-proBNP and the subsequent risk of the primary endpoint.

CONCLUSIONS

Patients who attained a significant reduction in NT-proBNP had a lower subsequent rate of cardiovascular death or HF hospitalization independent of the treatment group. Treatment with sacubitril/valsartan was nearly twice as likely as enalapril to reduce NT-proBNP to values ≤1,000 pg/ml. (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ACEI [Angiotensin-Converting-Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) [PARADIGM-HF]; NCT01035255.).

Diastolic dysfunction in hypertension

Hypertension and coronary heart disease, often coexisting, are the most common risk factors for heart failure. The progression of hypertensive heart disease involves myocardial fibrosis and alterations in the left ventricular geometry that precede the functional change, initially asymptomatic. The left ventricular diastolic dysfunction is part of this continuum being defined by the presence of left ventricular diastolic dysfunction without signs or symptoms of heart failure or poor left ventricular systolic function. It is highly prevalent in hypertensive patients and is associated with increased cardiovascular morbidity and mortality. Despite its growing importance in clinical practice it remains poorly understood. This review aims to present the epidemiological fundamentals and the latest developments in the pathophysiology, diagnosis and treatment of left ventricular diastolic dysfunction.

Myocardial dimensions and hemodynamics during 24-h ultraendurance ergometry

PURPOSE

This study aimed to evaluate cardiorespiratory and hemodynamic responses during 24 h of continuous cycle ergometry in ultraendurance athletes.

METHODS

Eight males (mean ± SD; age = 39 ± 8 yr, height = 179 ± 7 cm, body weight [Wt] = 77.1 ± 6.0 kg) were monitored during 24 h at a constant workload,∼25% below the first lactate turn point at 162 ± 23 W. Measurements included Wt, HR, oxygen consumption (V˙O2), cardiac output (Q), and stroke volume (SV) determined by a noninvasive rebreathing technique (Innocor; Innovision, Odense, Denmark). Myocardial dimensions were evaluated using a two-dimensional echocardiogram. [M-mode measurement]-left atrial (LAD), ventricular end-diastolic (LVEDD), and end-systolic diameters (LVESD) were obtained over the left parasternal area. Venous blood samples were analyzed for hematocrit (Hct%), albumin (g·L(-1)), aldosterone (pg·mL(-1)), CK, CK-MB (U·L(-1)), and N-terminal pro-brain natriuretic peptide (NT-proBNP) (pg·mL(-1)).

RESULTS

HR (bpm) significantly increased (P < 0.01) from 1 h (132 ± 11) to 6 h (143 ± 10) and significantly decreased (P < 0.001) from 6 to 24 h (116 ± 10). V˙O2 and (Q were unchanged during the 24 h. Wt (76.6 ± 5.6 vs 78.7 ± 5.4), SV (117 ± 13 vs 148 ± 19), LVEDD (4.9 ± 0.3 vs 5.6 ± 0.2), and LAD (3.6 ± 0.5 vs 4.3 ± 0.7) significantly increased between 6 and 24 h (P < 0.001). No significant changes were observed for LVESD. Hct (45.1 ± 1.3 vs 41.3 ± 1.2) significantly decreased (P < 0.05) and CK (181 ± 60/877 ± 515), aldosterone (48 ± 17 vs 661 ± 172), and NT-proBNP (23 ± 13 vs 583 ± 449) significantly increased (P < 0.05). The increase in SV (ΔSV) was significantly related to changes in Wt (ΔWt), and HR (ΔHR) and ΔWt were significantly related to ΔLAD and ΔLVEDD.

CONCLUSION

Our findings suggest that the decrease in HR during 24 h of ultraendurance exercise was due to hypervolemia and the associated ventricular loading, increasing left ventricular diastolic dimensions because of increased SV and LVEDD, resulting in an increase in NT-proBNP.

Correlation between impedance cardiography and 6 min walk distance in atrial fibrillation patients

Background

The correlation between impedance cardiography (ICG) and 6 min walk distance (6MWD) in atrial fibrillation (AF) patients remains unknown.

Methods

We recruited 49 subjects in the study (21 AF patients and 28 patients without AF) and estimated hemodynamic parameters: cardiac output (CO), stroke volume (SV), stroke volume index (SVI), left stroke work (LSW), left stroke work index (LSWI), stroke systemic vascular resistance (SSVR), stroke systemic vascular resistance index (SSVRI); 6MWD, left ventricle ejection fraction (LVEF), NT-pro brain natriuretic peptide (NT-pro BNP) for the two groups.

Results

The AF group have apparently lower CO (2.26 ± 0.14 VS 4.11 ± 0.20 L/min, p = 0.039) and distinctly higher SVR (677.60 ± 69.10 VS 344.41 ± 22.98 dynes/cm⁵, p = 0.001), SSVRI (396.97 ± 36.80 VS 199.01 ± 11.72 dynes/cm⁵/m², p < 0.001) than the control group. NT-pro BNP (1409.48 ± 239.90 VS 332.59 ± 68.85 pg/ml, p = 0.001) in the AF group was significantly higher than the control group and 6MWD (264.33 ± 14.55 VS 428.79 ± 29.98 m, p < 0.001) in the AF group was lower than the control group. There was no significant difference in LVEF between the two groups (62.67 ± 7.62 % VS 63.93 ± 5.03 %, p = 0.470). Pearson correlation analysis revealed that CO (R = 0.494, p = 0.023), SV (R = 0.633, p = 0.002), LSW (R = 0.615, p = 0.003) and LSWI (R = 0.491, p = 0.024) significantly correlated positively with 6MWD in AF patients.

Conclusions

AF patients had lower cardiac output, shorter 6MWD and higher NT-pro BNP than patients with sinus rhythm. The cardiac output measured by impedance cardiography significantly correlated positively with 6MWD in AF patients.

The search for efficient diagnostic and prognostic biomarkers of heart failure

Several biomarkers have been tested for screening, diagnosis and prognosis purposes, as well as to guide treatment in heart failure, but only the assay of circulating B-type natriuretic peptides has widely recognized applications for clinical decision-making. Natriuretic peptides are sensitive in detecting the clinically overt or subclinical myocardial damage, but their plasma levels are increased following every generic insult to the cardiovascular system. Novel biomarkers are required to identify specific pathways of disease progression, such as diverse neurohormonal axes activation, inflammation and fibrogenesis, and to act as a tool for therapeutic tailoring. In this view, Gal-3 and ST-2 assays seem very promising, given their involvement in mechanisms of cardiac fibrosis and their prognostic value.

How B-Type Natriuretic Peptide (BNP) and Body Weight Changes Vary in Heart Failure With Preserved Ejection Fraction Compared With Reduced Ejection Fraction: Secondary Results of the HABIT (HF Assessment With BNP in the Home) Trial

BACKGROUND

Heart failure is a common cause of hospitalization and can be divided into types with preserved and reduced ejection fraction (HFpEF and HFrEF, respectively). In this subanalysis of the HABIT (Heart Failure Assessment With BNP in the Home) trial, we examined the differences between home B-type natriuretic peptide (BNP) testing and weight monitoring in patients with HFpEF and with HFrEF before decompensation.

METHODS AND RESULTS

This was a retrospective review of patients with HFpEF and HFrEF from the HABIT trial. The HFpEF patients compared with HFrEF patients were older and more obese and had lower baseline BNP values. Intra-individual BNP dispersion (spread of distribution over time) was greater in HFpEF than in HFrEF owing to rapid fluctuations (within 3 days). Slowly varying changes in BNP (estimated by a moving average) were equally predictive of ADHF risk in both HFpEF and HFrEF. However, in HFpEF, a rapid rise in BNP >200 pg/mL within 3 days was associated with an increased risk of acute decompensated heart failure (ADHF; hazard ratio 4.0), whereas a similar association was not observed in HFrEF. Weight gain ≥5 lb in 3 days had a high specificity but low sensitivity for ADHF in both HFpEF and HFrEF, whereas a lower threshold of ≥2 lb weight gain over 3 days in patients with HFpEF (but not HFrEF) was a moderately sensitive cutoff associated with decompensation (60% sensitivity).

CONCLUSIONS

Patients with HFpEF and HFrEF have variations in their BNP and weight before decompensation. The rapid time scale behaves differently between the groups. In those with HFpEF, a 3-day period characterized by ≥2 lb weight gain and/or >200 pg/mL BNP rise was significantly associated with decompensation. Future prospective studies investigating different weight and BNP cutoffs for home monitoring of HFpEF and HFrEF patients should be performed to fully learn the value of BNP changes before clinical deompensation.

Subclinical elevation of high-sensitive troponin T levels at the convalescent stage is associated with increased 5-year mortality after ST-elevation myocardial infarction

BACKGROUND

It is unclear whether serum high-sensitive troponin T (hs-TnT) levels at the convalescent stage of ST-elevation myocardial infarction (STEMI) are associated with long-term mortality.

METHODS

This study enrolled a total of 2944 consecutive STEMI patients who were registered in the Osaka Acute Coronary Insufficiency Study between 2000 and 2009, and whose hs-TnT levels were evaluated at the convalescent stage. Patients were divided into four hs-TnT category groups according to the results of survival classification and regression tree (CART) analysis. The impact of hs-TnT levels on 5-year mortality was evaluated using multivariate Cox regression analysis.

RESULTS

Only one patient had hs-TnT level below the detection limit of the assay (<0.003ng/mL). The median hs-TnT level was 0.025 (quartile 0.011-0.083)ng/mL. During the median follow-up period of 1782 days, 188 patients died. Survival CART analysis revealed that the 1st, 2nd, and 3rd discriminating hs-TnT levels to discern 5-year mortality were 0.028, 0.008, and 1.340ng/mL, respectively. The adjusted hazard ratios for the medium-low (0.009-0.028ng/mL), medium-high (0.029-1.340ng/mL), and high-risk (≥1.341ng/mL) groups were 3.03 (95% confidence interval 1.18-7.77, p=0.021), 4.29 (1.63-11.28, p=0.003), and 8.68 (2.20-34.27, p=0.002), respectively. Integrated discrimination improvement (IDI) analysis revealed that incorporation of this hs-TnT classification scheme with other clinical variables statistically improved the discriminatory accuracy for 5-year mortality, with a time-dependent IDI of 0.0076 (p=0.033).

CONCLUSIONS

hs-TnT levels at the convalescent stage were associated with long-term mortality in STEMI patients. Even subclinical elevation of hs-TnT levels was associated with increased 5-year mortality.

Rationale and design of a randomized, double-blind, event-driven, multicentre study comparing the efficacy and safety of oral rivaroxaban with placebo for reducing the risk of death, myocardial infarction or stroke in subjects with heart failure and significant coronary artery disease following an exacerbation of heart failure: the COMMANDER HF trial

AIMS

Thrombin is a critical element of crosstalk between pathways contributing to worsening of established heart failure (HF). The aim of this study is to explore the efficacy and safety of rivaroxaban 2.5 mg bid compared with placebo (with standard care) after an exacerbation of HF in patients with reduced ejection fraction (HF-rEF) and documented coronary artery disease.

METHODS

This is an international prospective, multicentre, randomized, double-blind, placebo-controlled, event-driven study of approximately 5000 patients for a targeted 984 events. Patients must have a recent symptomatic exacerbation of HF, increased plasma concentrations of natriuretic peptides (B-type natriuretic peptide ≥200 pg/mL or N-terminal pro-B-type natriuretic peptide ≥800 pg/mL), with left ventricular ejection fraction ≤40% and coronary artery disease. Patients requiring anticoagulation for atrial fibrillation or other conditions will be excluded. After an index event (overnight hospitalization, emergency department or observation unit admission, or unscheduled outpatient parenteral treatment for worsening HF), patients will be randomized 1:1 to rivaroxaban or placebo (with standard of care). The primary efficacy outcome event is a composite of all-cause mortality, myocardial infarction or stroke. The principal safety outcome events are the composite of fatal bleeding or bleeding into a critical space with potential permanent disability, bleeding events requiring hospitalization and major bleeding events according to International Society on Thrombosis and Haemostasis bleeding criteria.

CONCLUSION

COMMANDER HF is the first prospective study of a target-specific oral antithrombotic agent in HF. It will provide important information regarding rivaroxaban use following an HF event in an HF-rEF patient population with coronary artery disease.

Evolution of biomarker guided therapy for heart failure: current concepts and trial evidence

Optimizing management of patients with heart failure remains quite challenging despite many significant advances in drug and device therapy for this syndrome. Although a large body of evidence from robust clinical trials supports multiple thera-pies, utilization of these well-established treatments remains inconsistent and outcomes suboptimal in “real-world” patients with heart failure. Disease management programs may be effective, but are difficult to implement due to cost and logistical issues. Another approach to optimizing therapy is to utilize biomarkers to guide therapeutic choices. Natriuretic peptides pro-vide additional information of significant clinical value in the diagnosis and estimation of risk inpatients with heart failure. Ongoing research suggests a potential important added role for natriuretic peptides in heart failure. Guiding therapy based on serial changes in these biomarkers may be an effective strategy to optimize treatment and achieve better outcomes in this syn-drome. Initial, innovative, proof-of-concept studies have provided encouraging results and important insights into key as-pects of this strategy, but well designed, large-scale, multicenter, randomized, outcome trials are needed to definitively estab-lish this novel approach to management. Given the immense and growing public health burden of heart failure, identification of cost-effective ways to decrease the morbidity and mortality due to this syndrome is critical.

The effect of carvedilol on B-type natriuretic peptide and cardiac function in patients with heart failure and persistent atrial fibrillation

OBJECTIVES

We sought to determine the relationship between changes in natriuretic peptides and symptoms as a consequence of introducing beta-blocker therapy, in patients with chronic heart failure (CHF) and persistent atrial fibrillation (AF).

METHODS

In a randomised, double-blind, placebo-controlled study involving 47 patients with CHF and persistent AF (mean age 68 years and 62% men), we analysed the individual change (Δ) in B-type natriuretic peptide (BNP) level to the introduction of carvedilol (titrated to a target dose of 25 mg twice daily, group A) or placebo (group B) in addition to background treatment with digoxin. Symptoms score, 6-min walk distance, New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), heart rate (24-hour ECG) and BNP were measured at baseline and at 4 months.

RESULTS

LVEF (Δ median +5 vs. +0.4, p = 0.048), symptoms score (Δ median -4 vs. 0, p = 0.04), NYHA class (Δ median -33% vs. +3% in NYHA class 3-4, p = 0.046) and heart rate [Δ median 24-hour ventricular rate (VR) -19 vs. -2, p < 0.0001] improved with combination therapy of digoxin and carvedilol compared to digoxin alone, but BNP (Δ median +28 vs. -6 , p = 0.11) trended in the opposite direction. There was no relationship between the degree of symptomatic improvement or VR control and BNP response.

CONCLUSION

After the introduction of carvedilol, clinical outcome appears unrelated to BNP changes in patients with CHF and AF. Changes in BNP cannot be used as a marker of clinical response in terms of symptoms or cardiac function in this setting.

Troponin T and N-terminal pro B-Type natriuretic peptide and presence of coronary artery disease

BACKGROUND

We tested the effects of exercise intensity, sampling intervals, degree of coronary artery stenosis, and demographic factors on circulating N-terminal pro B-Type natriuretic peptide (NT-pro-BNP) and cardiac Troponin T (cTnT) in subjects suspected of coronary artery disease (CAD).

MATERIALS AND METHODS

A total of 242 subjects referred for diagnostic evaluation of possible CAD had blood samples obtained before, 5 min after, and again 20 h after a symptom-limited exercise test.

RESULTS

Totally 40 subjects had CAD with ≥ 50% stenosis, 115 subjects had no stenosis and 87 subjects served as controls. In univariate analysis CAD-subjects had higher median baseline NT-pro-BNP-levels (85.3 ng/L) compared with non-CAD-subjects (41.3 ng/L) and controls (40.1 ng/L), both p < 0.001, but the association disappeared in multivariate analysis adjusted for age and gender. NT-pro-BNP increased similarly after exercise in CAD-subjects, non-CAD-subjects, and controls (median increase 8.14 ng/L) and the increase was positively associated with baseline NT-pro-BNP but not presence of CAD. Median baseline cTnT was 6.25 ng/L in CAD-subjects and 3.00 ng/L in non-CAD-subjects as well as controls, both p < 0.0001. Median ΔcTnT (baseline to 20 h after exercise) was higher in CAD-subjects than non-CAD-subjects and controls (0.62 ng/L vs. 0.0 ng/L, p < 0.001). A linear relationship between ΔcTnT and 'percent of predicted maximal heart rate achieved' was found in subjects with ≥ 70% stenosis (n = 24, r = 0.4067 p = 0.046).

CONCLUSIONS

Baseline cTnT and ΔcTnT were found to be independently associated with CAD and also with exercise intensity in stable chest pain subjects. These properties were not identified for NT-pro-BNP.

Is chronic inhibition of phosphodiesterase type 5 cardioprotective and safe? A meta-analysis of randomized controlled trials

BACKGROUND

The myocardial effects of phosphodiesterase type 5 inhibitors (PDE5i) have recently received consideration in several preclinical studies. The risk/benefit ratio in humans remains unclear.

METHODS

We performed a meta-analysis of randomized, placebo-controlled trials (RCTs) to evaluate the efficacy and safety of PDE5i on cardiac morphology and function. From March 2012 to December 2013 (update: May 2014), we searched English-language studies from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and SCOPUS-selecting RCTs of continuous PDE5i administration that reported cardiovascular outcomes: cardiac geometry and performance, afterload, endothelial function and safety. The pooled estimate of a weighted mean difference between treatment and placebo was obtained for all outcomes using a random effects model. A test for heterogeneity was performed and the I2 statistic calculated.

RESULTS

Overall, 1,622 subjects were treated, with 954 randomized to PDE5i and 772 to placebo in 24 RCTs. According to our analysis, sustained PDE5 inhibition produced: (1) an anti-remodeling effect by reducing cardiac mass (-12.21 g/m2, 95% confidence interval (CI): -18.85; -5.57) in subjects with left ventricular hypertrophy (LVH) and by increasing end-diastolic volume (5.00 mL/m2; 95% CI: 3.29; 6.71) in non-LVH patients; (2) an improvement in cardiac performance by increasing cardiac index (0.30 L/min/m2, 95% CI: 0.202; 0.406) and ejection fraction (3.56%, 95% CI: 1.79; 5.33). These effects are parallel to a decline of N-terminal-pro brain natriuretic peptide (NT-proBNP) in subjects with severe LVH (-486.7 pg/ml, 95% CI: -712; -261). PDE5i administration also produced: (3) no changes in afterload parameters and (4) an improvement in flow-mediated vasodilation (3.31%, 95% CI: 0.53; 6.08). Flushing, headache, epistaxis and gastric symptoms were the commonest side effects.

CONCLUSIONS

This meta-analysis suggests for the first time that PDE5i have anti-remodeling properties and improve cardiac inotropism, independently of afterload changes, with a good safety profile. Given the reproducibility of the findings and tolerability across different populations, PDE5i could be reasonably offered to men with cardiac hypertrophy and early stage heart failure. Given the limited gender data, a larger trial on the sex-specific response to long-term PDE5i treatment is required.

Clinical and prognostic implications of plasma NGAL and NT-proBNP in adult patients with congenital heart disease

BACKGROUND

Prognostic value of NT-proBNP is well established in patients with congenital heart disease. Growing evidence suggests that plasma NGAL is elevated in heart failure but data is limited in congenital heart disease. This study investigates the combined prognostic value of plasma NGAL with plasma NT-proBNP in adult patients with congenital heart disease.

METHODS

Plasma levels of NT-proBNP and NGAL were measured in 76 consecutive adult patients (33 men, mean age 31.7 ± 14 yrs) with congenital heart disease and normal values of serum creatinine. Patients were divided in three groups: A: simple cardiac lesions, B: complex cardiac lesions and C: cyanotic lesions. Patients were also monitored for long-term major cardiovascular events: death, hospitalization, NYHA class worsening, new onset of arrhythmias, surgical or percutaneous intervention.

RESULTS

NGAL value was significantly different between groups: In group A median NGAL value was 64.5 ± 36.7 ng/ml, in group B median NGAL value was 88.77 ± 36.17 ng/ml and in group C median NGAL value was 121 ± 40 ng/ml (group A vs. group B: p = 0.048, group B vs. group C: p = 0.037, group A vs. group C: p = 0.003). Plasma NT-proBNP predicted all events (HR = 1.001, CI = 1.001-1.002, p = 0.0006) as well as cardiovascular death alone (HR = 1.001, CI = 1.001-1.002, p = 0.0004); plasma NGAL was the only predictor of cardiovascular death (HR = 1.017, CI = 1.001-1.033, p = 0.037).

CONCLUSION

Plasma NGAL levels were lower in patients with simple congenital disease compared to patients with complex congenital heart disease and cyanotic congenital heart disease. Plasma NGAL levels correlated with NT-proBNP and could predict cardiovascular death in this small cohort of patients.

Rationale and design of the GUIDE-IT study: Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure

OBJECTIVES

The GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) study is designed to determine the safety, efficacy, and cost-effectiveness of a strategy of adjusting therapy with the goal of achieving and maintaining a target N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of <1,000 pg/ml compared with usual care in high-risk patients with systolic heart failure (HF).

BACKGROUND

Elevations in natriuretic peptide (NP) levels provide key prognostic information in patients with HF. Therapies proven to improve outcomes in patients with HF are generally associated with decreasing levels of NPs, and observational data show that decreases in NP levels over time are associated with favorable outcomes. Results from smaller prospective, randomized studies of this strategy thus far have been mixed, and current guidelines do not recommend serial measurement of NP levels to guide therapy in patients with HF.

METHODS

GUIDE-IT is a prospective, randomized, controlled, unblinded, multicenter clinical trial designed to randomize approximately 1,100 high-risk subjects with systolic HF (left ventricular ejection fraction ≤40%) to either usual care (optimized guideline-recommended therapy) or a strategy of adjusting therapy with the goal of achieving and maintaining a target NT-proBNP level of <1,000 pg/ml. Patients in either arm of the study are followed up at regular intervals and after treatment adjustments for a minimum of 12 months. The primary endpoint of the study is time to cardiovascular death or first hospitalization for HF. Secondary endpoints include time to cardiovascular death and all-cause mortality, cumulative mortality, health-related quality of life, resource use, cost-effectiveness, and safety.

CONCLUSIONS

The GUIDE-IT study is designed to definitively assess the effects of an NP-guided strategy in high-risk patients with systolic HF on clinically relevant endpoints of mortality, hospitalization, quality of life, and medical resource use. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT]; NCT01685840).

Heart failure in patients with chronic kidney disease: a systematic integrative review

Introduction. Heart failure (HF) is highly prevalent in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) and is strongly associated with mortality in these patients. However, the treatment of HF in this population is largely unclear. Study Design. We conducted a systematic integrative review of the literature to assess the current evidence of HF treatment in CKD patients, searching electronic databases in April 2014. Synthesis used narrative methods. Setting and Population. We focused on adults with a primary diagnosis of CKD and HF. Selection Criteria for Studies. We included studies of any design, quantitative or qualitative. Interventions. HF treatment was defined as any formal means taken to improve the symptoms of HF and/or the heart structure and function abnormalities. Outcomes. Measures of all kinds were considered of interest. Results. Of 1,439 results returned by database searches, 79 articles met inclusion criteria. A further 23 relevant articles were identified by hand searching. Conclusions. Control of fluid overload, the use of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimization of dialysis appear to be the most important methods to treat HF in CKD and ESRD patients. Aldosterone antagonists and digitalis glycosides may additionally be considered; however, their use is associated with significant risks. The role of anemia correction, control of CKD-mineral and bone disorder, and cardiac resynchronization therapy are also discussed.

BNP predicts chemotherapy-related cardiotoxicity and death: comparison with gated equilibrium radionuclide ventriculography

Cardiotoxicity is a dose-limiting side-effect of cancer chemotherapeutics such as anthracyclines. The drug-induced cardiac toxicity is currently monitored with repeated assessments of the left ventricular ejection fraction (LVEF) using multigated equilibrium radionuclide ventriculography (MUGA) or echocardiography. However, the plasma cardiac biomarker B-type natriuretic peptide (BNP) has been suggested for early identification of cardiac dysfunction. The aim of the study was to compare LVEF obtained by MUGA and plasma BNP as predictors of developing congestive heart failure (CHF) or death in a population of anthracycline-treated cancer patients.

Methods

We prospectively followed 333 cancer patients referred to our department for routine monitoring of LVEF with MUGA and measurement of BNP, January-December 2004. Study end points were hospitalization for CHF and death during follow-up 2004-2010. Data were obtained from the Danish National Patient Registry.

Results

During follow-up (mean 1,360 days), 21 of the patients were admitted to hospital with a diagnosis of CHF and 194 of the patients died. BNP levels were significantly higher and LVEF lower in the group of patients that developed CHF. Using cut-off points of BNP>100 pg/ml (HR 5.5; CI 1.8–17.2; p = 0.003) and LVEF <50% (HR 7.9; CI 3.0–21.4; p<0.001) both significantly predicted CHF. Using the same cut-off points only BNP (HR 1.9; CI 1.3-2.9; p = 0.002) and not LVEF (HR 1.1; CI 0.7–1.8; p = 0.58) was predictive of overall death. In multivariate Cox analysis both BNP and LVEF were independent predictors of CHF while age remained the only independent predictor of overall death.

Conclusion

In cancer patients treated with cardiotoxic chemotherapy both BNP and LVEF can significantly predict subsequent hospitalization with CHF. In addition, BNP and not LVEF has a prognostic value in detecting overall death. This prospective study based on the hitherto largest study population supports BNP as a clinical relevant method for monitoring chemotherapy-related cardiac failure and death.

Importance of Bnp changes during the follow-up in elderly outpatients with heart failure

BACKGROUND

The aim of the present study was to analyze whether absolute BNP and relative BNP change values during follow-up of elderly patients with chronic HF could predict the development of acute decompensated episodes.

METHODS AND RESULTS

A total population of 108 elderly outpatients with the diagnosis of HF was retrospectively reviewed. Available BNP levels after at least one stable visit and one acute decompensated episode were required. Follow-up period was 12 months (343 visits, 42.6% decompensated HF episodes). Relative BNP changes were analyzed: "CC period" (patients who remained stable) and "CD period" (patient who suffered from a decompensated HF episode). Changes in BNP levels were significantly higher in CD than in CC periods (mean and median differences 138% and 85%, vs 16% and 0%, respectively; p<0.001). The clinical model (AUC=0.83) had a sensitivity of 67.06%, and a specificity of 80.36%. Relative BNP change (29%) showed by itself, a similar AUC (0.83) and specificity (79%) and an improved sensitivity (0.80) than the clinical model. When relative BNP change was introduced at the clinical model, a similar specificity was obtained and the diagnostic accuracy, AUC (0.89 vs 0.83, p=0.01) and sensitivity were improved. Absolute BNP changes showed worse AUC than that derived from relative BNP changes or clinical assessment.

CONCLUSIONS

Percent BNP change values during the follow-up showed better results than absolute BNP values and improved the clinical assessment for diagnostic of decompensated HF episodes in elderly outpatients.

Biomarkers in outpatient heart failure management; Are they correlated to and do they influence clinical judgment?

AIMS

Heart failure (HF) management is complicated by difficulties in clinical assessment. Biomarkers may help guide HF management, but the correspondence between clinical evaluation and biomarker serum levels has hardly been studied. We investigated the correlation between biomarkers and clinical signs and symptoms, the influence of patient characteristics and comorbidities on New York Heart Association (NYHA) classification and the effect of using biomarkers on clinical evaluation.

METHODS AND RESULTS

This post-hoc analysis comprised 622 patients (77 ± 8 years, 76 % NYHA class ≥3, 80 % LVEF ≤45 %) participating in TIME-CHF, randomising patients to either NT-proBNP-guided or symptom-guided therapy. Biomarker measurements and clinical evaluation were performed at baseline and after 1, 3, 6, 12 and 18 months. NT-proBNP, GDF-15, hs-TnT and to a lesser extent hs-CRP and cystatin-C were weakly correlated to NYHA, oedema, jugular vein distension and orthopnoea (ρ-range: 0.12-0.33; p < 0.01). NT-proBNP correlated more strongly to NYHA class in the NT-proBNP-guided group compared with the symptom-guided group. NYHA class was significantly influenced by age, body mass index, anaemia, and the presence of two or more comorbidities.

CONCLUSION

In HF, biomarkers correlate only weakly with clinical signs and symptoms. NYHA classification is influenced by several comorbidities and patient characteristics. Clinical judgement seems to be influenced by a clinician's awareness of NT-proBNP concentrations.

The use of biomarkers in the patient with heart failure

Heart failure is a major burden to the health care system in terms of not only cost, but also morbidity and mortality. Appropriate use of biomarkers is critically important to allow rapid identification and optimal risk stratification and management of patients with both acute and chronic heart failure. This review will discuss the biomarkers that have the most diagnostic, prognostic, and therapeutic value in patients with heart failure. We will discuss established biomarkers such as natriuretic peptides as well as emerging biomarkers reflective of myocyte stress, myocyte injury, extracellular matrix injury, and both neurohormonal and cardio-renal physiology.

Lung ultrasound for the evaluation of pulmonary congestion in outpatients: a comparison with clinical assessment, natriuretic peptides, and echocardiography

OBJECTIVES

The aim of this study was to define the performance of lung ultrasound (LUS) compared with clinical assessment, natriuretic peptides, and echocardiography, to evaluate decompensation in patients with systolic heart failure (HF) in an outpatient clinic.

BACKGROUND

Evaluation of pulmonary congestion in chronic HF is challenging. LUS has been recently proposed as a reliable tool for the semiquantification of extravascular lung water through assessment of B-lines.

METHODS

This was a cohort study of patients with moderate to severe systolic HF. Receiver-operating characteristic (ROC) analyses were performed to compare LUS with a previously validated clinical congestion score (CCS), amino-terminal portion of B-type natriuretic peptide (NT-proBNP), E/e' ratio, chest x-ray, and 6-min walk test.

RESULTS

Ninety-seven patients were enrolled. Decompensation was present in 57.7% of patients when estimated by CCS, 68% by LUS, 53.6% by NT-proBNP, and 65.3% by E/e' ≥15. The number of B-lines was correlated to NT-proBNP (r = 0.72; p < 0.0001), E/e' (r = 0.68; p < 0.0001), and CCS (r = 0.43; p < 0.0001). In ROC analyses, considering as reference for decompensation a combined method (E/e' ≥ 15 and/or NT-proBNP >1,000 pg/ml), LUS yielded a C-statistic of 0.89 (95% confidence interval: 0.82 to 0.96), providing the best accuracy with a cutoff ≥ 15 B-lines (sensitivity 85%, specificity 83%). A systematic approach using CCS, E/e', NT-proBNP, chest x-ray, and 6-min walk test in different combinations as reference for decompensation also corroborated this cutoff and found a similar accuracy for LUS.

CONCLUSIONS

In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. A B-line ≥15 cutoff could be considered for a quick and reliable assessment of decompensation in outpatients with HF.

The role of B-type natriuretic Peptide testing in guiding outpatient heart failure treatment

OPINION STATEMENT

While heart failure (HF) treatment guidelines exist, there are significant gaps in their implementation owing in part to the lack of objective data to help guide clinicians in their medical decision-making. B-type natriuretic peptide (BNP) and its amino-terminal equivalent (NT-proBNP) are objective markers of HF prognosis, are useful to monitor response to treatment in outpatients with HF, and may have a role in "guiding" HF care as well. Successful BNP or NT-proBNP guided HF treatment requires regular attempts to reach and maintain target values (BNP ≤ 125 pg/mL or NT-proBNP ≤ 1000 pg/mL). This may be achieved through lifestyle modifications, exercise programs, medication adjustments, and therapeutic interventions shown to reduce morbidity and mortality in HF patients. Failure to achieve biomarker targets portends a worse prognosis, proportional to the lowest achieved natriuretic peptide concentration; in those with significant biomarker "nonresponse," prognosis is poor, and alternative therapeutic strategies should be considered.

N-TproBNP as biomarker in systemic sclerosis

Systemic sclerosis (SSc) is a connective tissue disorder characterized by tissue fibrosis affecting the skin and internal organs, fibroproliferative vasculopathy, and autoimmune activation. SSc still heralds a poor prognosis with significant morbidity and mortality. Early detection of organ involvement is critical as currently available treatments are most effective when started early. Many candidate biomarkers have been investigated in the past two decades. However, despite the enormous efforts, no accurate tool to predict the pattern of organ involvement and to assess disease activity has been yet identified. The N-terminal fragment of probrain natriuretic peptide (N-TproBNP) is a neurohormone released by ventricular myocytes in response to pressure overload. N-TproBNP is highly relevant for diagnosis, prognosis, and prediction of pulmonary arterial hypertension in SSc. Moreover, several studies support its potential benefit for cardiac assessment of scleroderma patients. Conversely, the role of N-TproBNP as surrogate marker of pulmonary fibrosis and skin involvement is much less clear. We provide an extensive review of the studies that have previously investigated the role of N-TproBNP as candidate biomarker in scleroderma manifestations, presenting also the findings of a recent study we conducted in a cohort of 87 SSc patients.

Amino terminal pro-B-type natriuretic peptide, secondary stroke prevention, and choice of antithrombotic therapy

BACKGROUND AND PURPOSE

Because of its association with atrial fibrillation and heart failure, we hypothesized that amino terminal pro-B-type natriuretic peptide (NT-proBNP) would identify a subgroup of patients from the Warfarin-Aspirin Recurrent Stroke Study, diagnosed with inferred noncardioembolic ischemic strokes, where anticoagulation would be more effective than antiplatelet agents in reducing risk of subsequent events.

METHODS

NT-proBNP was measured in stored serum collected at baseline from participants enrolled in Warfarin-Aspirin Recurrent Stroke Study, a previously reported randomized trial. Relative effectiveness of warfarin and aspirin in preventing recurrent ischemic stroke or death over 2 years was compared based on NT-proBNP concentrations.

RESULTS

About 95% of 1028 patients with assays had NT-proBNP below 750 pg/mL, and among them, no evidence for treatment effect modification was evident. For 49 patients with NT-proBNP >750 pg/mL, the 2-year rate of events per 100 person-years was 45.9 for the aspirin group and 16.6 for the warfarin group, whereas for 979 patients with NT-proBNP ≤750 pg/mL, rates were similar for both treatments. For those with NT-proBNP >750 pg/mL, the hazard ratio was 0.30 (95% confidence interval: 0.12-0.84; P=0.021) significantly favoring warfarin over aspirin. A formal test for interaction of NT-proBNP with treatment was significant (P=0.01).

CONCLUSIONS

For secondary stroke prevention, elevated NT-proBNP concentrations may identify a subgroup of ischemic stroke patients without known atrial fibrillation, about 5% based on the current study, who may benefit more from anticoagulants than antiplatelet agents. Clinical Trial Registration- This trial was not registered because enrollment began before 2005.

Cardiac biomarkers: new tools for heart failure management

The last decade has seen exciting advances in the field of biomarkers used in managing patients with heart failure (HF). Biomarker research has broadened our knowledge base, shedding more light on the underlying pathophysiological mechanisms occurring in patients with both acute and chronic HF. The criterion required by an ideal cardiovascular biomarker has been progressively changing to an era of sensitive assays that can be used to guide treatment. Recent technological advances have made it possible to rapidly measure even minute amounts of these proteins by means of higher sensitivity assays. With a high prevalence of comorbidities associated with HF, an integrated approach utilizing multiple biomarkers have shown promise in predicting mortality, better risk stratification and reducing re-hospitalizations, thus lowering health-care costs. This review provides a brief insight into recent advances in the field of biomarkers currently used in the diagnosis and prognosis of patients with acute and chronic HF.