Effect of Serum Growth Differentiation Factor-15 and the Syntax Score on 2-Year Outcomes in Patients With Acute Coronary Syndrome

Growth differentiation factor-15 predicts all-cause death and major adverse cardiovascular events in patients with coronary heart disease: a prospective cohort study

The prognostic value of growth differentiation factor-15 (GDF-15) in predicting long-term adverse outcomes in coronary heart disease (CHD) patients remains limited. Our study examines the association between GDF-15 and adverse outcomes over an extended period in CHD patients and firstly assesses the incremental prognostic effect of incorporating GDF-15 into the Framingham risk score (FRS)-based model. This single-center prospective cohort study included 3,321 patients with CHD categorized into 2,479 acute coronary syndrome (ACS) (74.6%) and 842 non-ACS (25.4%) groups. The median age was 61.0 years (range: 53.0-70.0), and 917 (27.6%) were females. Mortality and major adverse cardiovascular events (MACEs) included cardiovascular mortality, myocardial infarction (MI), stroke, and heart failure (HF) (inclusive of HF episodes requiring outpatient treatment and/or hospital admission). Cox regression models assessed the associations between GDF-15 and the incidence of all-cause mortality and MACEs. Patients were stratified into three groups based on GDF-15 levels: the first tertile group (< 1,370 ng/L), the second tertile group (1,370-2,556 ng/L), and the third tertile group (> 2,556 ng/L). The C-index, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA) were used to assess incremental value. Over a median 9.4-year follow-up, 759 patients (22.9%) died, and 1,291 (38.9%) experienced MACEs. The multivariate Cox model indicated that GDF-15 was significantly associated with all-cause mortality (per ln unit increase, HR = 1.49, 95% CI: 1.36-1.64) and MACEs (per ln unit increase, HR = 1.29, 95% CI: 1.20-1.38). These associations persisted when GDF-15 was analyzed as an ordinal variable (p for trend < 0.05). Subgroup analysis of ACS and non-ACS for the components of MACEs separately showed a significant association between GDF-15 and both cardiovascular mortality and HF, but no association was observed between GDF-15 and MI /stroke in both ACS and non-ACS patients. The addition of GDF-15 to the FRS-based model enhanced the discrimination for both all-cause mortality (∆ C-index = 0.009, 95% CI: 0.005-0.014; IDI = 0.030, 95% CI: 0.015-0.047; continuous NRI = 0.631, 95% CI: 0.569-0.652) and MACEs (∆ C-index = 0.009, 95% CI: 0.006-0.012; IDI = 0.026, 95% CI: 0.009-0.042; continuous NRI = 0.593, 95% CI: 0.478-0.682). DCA suggested that incorporating GDF-15 into the FRS-based model demonstrated higher net benefits compared to FRS-based models alone (All-cause mortality: FRS-based model: area under the curve of DCA (AUDC) = 0.0903, FRS-based model + GDF-15: AUDC = 0.0908; MACEs: FRS-based model: AUDC = 0.1806, FRS-based model + GDF-15: AUDC = 0.1833). GDF-15 significantly associates with the long-term prognosis of all-cause mortality and MACEs in CHD patients and significantly improves the prognostic accuracy of the FRS-based model for both outcomes.

GDF-15, a future therapeutic target of glucolipid metabolic disorders and cardiovascular disease

Growth and differentiation factor 15 (GDF-15) was discovered as a member of the transforming growth factor β (TGF-β) superfamily and the serum level of GDF-15 was significantly correlated with glucolipid metabolic disorders (GLMD) and cardiovascular diseases. In 2017, a novel identified receptor of GDF-15-glial-derived neurotrophic factor receptor alpha-like (GFRAL) was found to regulate energy homeostasis (such as obesity, diabetes and non-alcoholic fatty liver disease (NAFLD)). The function of GDF-15/GFRAL in suppressing appetite, enhancing glucose/lipid metabolism and vascular remodeling has been gradually revealed. These effects make it a potential therapeutic target for GLMD and vascular diseases. In this narrative review, we included and reviewed 121 articles by screening 524 articles from literature database. We primarily focused on the function of GDF-15 and its role in GLMD/cardiovascular diseases and discuss its potential clinical application.

Association of GDF-15 and Syntax Score in Patient with Acute Myocardial Infarction

Aims

GDF-15 is considered to be an important biomarker for cardiovascular events, but the differences in serum GDF-15 levels between acute myocardial infarction (AMI) patients and non-AMI patients warrant further investigation.

Methods

A cohort of 409 subjects was enrolled in the current study. The Syntax score was calculated from the baseline coronary angiography results by using online methods. Blood samples were obtained at the start of the study for an assessment of GDF-15 by using ELISA methods.

Results

Patients with AMI had significantly higher levels of serum GDF-15 (Wilcox test, P < 0.001), Syntax scores (Wilcox test, P = 0.006), and left ventricular ejection fractions (LEVF, Wilcox test, P< 0.001). However, no significant differences were present among the other clinical characteristics. The logistical regression analysis indicated that serum GDF-15 levels (P=0.01534) were independent predictors of non-AMI and AMI after adjusting for age, sex, smoking status, and LVEF.

Conclusions

Elevated serum levels of GDF-15 are independently associated with the risk of MI, and GDF-15 may serve as a protective factor for MI in the cardiovascular system.

Growth differentiation factor 15 and geriatric conditions in acute coronary syndrome

BACKGROUND

Growth differentiation factor 15 (GDF-15) is a marker of cell senescence. Age is a well-known determinant of GDF-15 levels, yet no study has analyzed the relationship between geriatric conditions and GDF-15. We hypothesize that geriatric conditions reflecting biological age might be stronger determinants of GDF-15 than chronological age in elderly patients with acute coronary syndrome.

METHODS

A total of 208 patients (mean age = 78.3 ± 7.0 years) were included. Prior to discharge, a thorough geriatric assessment was performed and GDF-15 measured. Predictors of GDF-15 (transformed by its natural logarithm) were determined with linear regression. Furthermore, Cox regression was used for the analysis of all-cause mortality. The median follow-up was 728 days.

RESULTS

Median GDF-15 concentration was 2432 pg/ml. In multivariate analysis, frailty (Fried score, p = 0.001), and comorbidity (Charlson index, p = 0.003) were independent determinants of lnGDF-15 while age was not significant (p = 0.17). Other covariates included in the model were male gender (p = 0.017), diabetes (p = 0.169), Killip class ≥2 (p = 0.046) and glomerular filtration rate (p = 0.001). The Fried score and Charlson index provided significant incremental value in the R² model (0.362 vs 0.447; p = 0.0001). A total of 66 (32%) patients died. LnGDF-15 was a significant mortality predictor (HR = 1.82, 95% CI 1.12-2.94, p = 0.015) along with the Fried score (p = 0.013) and the Charlson index (p = 0.030).

CONCLUSIONS

Geriatric conditions are strong determinants of GDF-15 levels on top of age in acute coronary syndromes. Furthermore, GDF-15 was associated with mortality independently of geriatric status. Geriatric assessment and GDF-15 are complementary tools.

Prognostic Value of the Clinical SYNTAX Score on 2-Year Outcomes in Patients With Acute Coronary Syndrome Who Underwent Percutaneous Coronary Intervention

This prospective, single-center, observational study evaluated prognostic value of clinical SYNTAX score (CSS) on 2-year outcomes in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). The SYNTAX score (SS) is a scoring system based on the complexity and severity of coronary lesions and is thought to be a prognostic tool to predict long-term outcomes. However, SS was a sole angiographic grading tool only with no consideration for clinical factors. There are few studies investigating the prognostic value of CSS in patients with ACS who underwent PCI. From January 2013 to December 2013, 6,099 consecutive patients with ACS admitted to FuWai hospital and underwent PCI were enrolled in this study. Based on CSS, patients were divided into low CSS group (CSS ≤ 6.5; 2,012 patients), mid-CSS group (6.5 < CSS < 13.8; 2,056 patients), and high CSS group (CSS ≥ 13.8; 2,031 patients). At 2-year follow-up, rates of cardiac death and major adverse cardiac events (MACE) were significantly higher in the high CSS group. Compared with baseline SS, CSS demonstrated significantly improved performance for 2-year cardiac death (receiver-operating characteristic curve C-statistic: 0.74 vs 0.62, p <0.001) but not for MACE (receiver-operating characteristic curve C-statistic: 0.60 vs 0.59, p = 0.29). By multivariable analysis, the CSS combined with PCI history and hypertension were strong predictors for cardiac death and CSS, intra-aortic balloon pump support, diabetes, and successful PCI were independent predictors for MACE. In conclusion, compared with the anatomic SS, CSS was suitable in risk stratifying and predicting 2-year clinical outcome among ACS population.

Prognostic biomarkers in acute coronary syndrome

The acute coronary syndrome (ACS) is a leading cause of death around the globe. Beside a still high mortality rate, additional complications of ACS include arrhythmias, left ventricular mural thrombus, cardiac fibrosis, heart failure (HF), cardiogenic shock, mitral valve dysfunction, aneurysms, up to cardiac rupture. Despite many prognostic tools have been developed over the past decades, efforts are still ongoing to identify reliable and predictive biomarkers, which may help predict the prognosis of these patients and especially the risk of HF. Recent evidence suggests that the value of a discrete number of biomarkers of myocardial fibrosis, namely the soluble form of suppression of tumorigenicity 2 (sST2) and galectin-3 (GAL-3), may be predictive of HF and death in patients with ACS. Interestingly, the already promising predictive value of these biomarkers when measured alone was shown to be consistently magnified when combined with other and well-established cardiac biomarkers such natriuretic peptides and cardiac troponins. This article is hence aimed to review the current knowledge about cardiac biomarkers of fibrosis and adverse remodeling.