SuPAR is associated with death and adverse cardiovascular outcomes in patients with suspected coronary artery disease

Prognostic performance of soluble urokinase plasminogen activator receptor for heart failure or mortality in Western and Asian patients with acute breathlessness

AIMS

The performance of circulating soluble urokinase plasminogen activator receptor (suPAR) for predicting the composite endpoint of subsequent heart failure (HF) hospitalisation and/or death at 1 year was assessed in (i) patients with undifferentiated breathlessness, and generalisability was compared in (ii) disparate Western versus Asian sub-cohorts, and in (iii) the sub-cohort adjudicated with HF.

METHODS AND RESULTS

Patients with acute breathlessness were recruited from the emergency departments in New Zealand (NZ, n = 612) and Singapore (n = 483). suPAR measured in the presentation samples was higher in patients incurring the endpoint (n = 281) compared with survivors (5.2 ng/mL vs 3.1 ng/mL, P < 0.0001). The discriminative power of suPAR for endpoint prediction was c-statistic of 0.77 in the combined population, but was superior in Singapore than NZ (c-statistic: 0.83 vs 0.71, P < 0.0001). Although the highest suPAR tertile (>4.37 ng/mL) was associated with risks of >4-fold in NZ, >20-fold in Singapore, and ≥3-fold in HF for incurring the outcome, there was no interaction between country and suPAR levels after adjustment. Multivariable analysis indicated suPAR to be robust in predicting HF/death at 1-year [hazard ratio: 1.9 (95% CI:1.7 to 2.0) per SD increase] and improved risk discrimination for outcome prediction in HF (∆0.06) and for those with NT-proBNP >1000 pg/mL (∆0.02).

CONCLUSION

suPAR is a strong independent predictor of HF and/or death at 1 year in acutely breathless patients, in both Asian and Western cohorts, and in HF. suPAR may improve stratification of acutely breathless patients, and in acute HF, for risk of later onset of heart failure or mortality.

Immune Activation Mediates the Association of Advanced Hepatic Fibrosis With Adverse Outcomes in Patients With Coronary Artery Disease

BACKGROUND

Literature suggests a bidirectional association between advanced hepatic fibrosis (AHF) and coronary artery disease (CAD). We evaluated the association of AHF with immune activation, systemic inflammation, and adverse outcomes in patients with CAD.

METHODS AND RESULTS

A fibrosis-4 index cutoff value ≥2.67 was used to define AHF. Circulating levels of soluble urokinase plasminogen activator receptor and hsCRP (high-sensitivity C-reactive protein) were measured as markers for immune activation and systemic inflammation, respectively. The relationship of AHF with soluble urokinase plasminogen activator receptor, hsCRP, and adverse cardiovascular outcomes was evaluated. Among 3406 participants with CAD, 479 had AHF. Participants with AHF were older; were less likely to be Black individuals; and had a lower body mass index, worse renal function, and a prior history of heart failure. In multivariable linear regression models adjusted for clinical and demographic confounders, participants with AHF had 15.6% higher soluble urokinase plasminogen activator receptor and 24.0% higher hsCRP levels. They were more likely to experience the following adverse outcomes: all-cause death (adjusted hazard ratio [HR], 1.57 ([95% CI, 1.29-1.92]; P<0.001) and cardiovascular death: (subdistribution HR, 1.50 [95% CI, 1.14-1.95]; P=0.003). Mediation analysis showed that 47.0% (95% CI, 13.6%-81.2%]; P=0.006) of the indirect effect of AHF on cardiovascular death was mediated by circulating soluble urokinase plasminogen activator receptor levels.

CONCLUSIONS

AHF is independently associated with immune activation, systemic inflammation, and adverse cardiovascular outcomes in patients with CAD. The association of AHF with adverse outcomes is partly mediated by immune activation, and targeting this pathway may help reduce the residual risk in patients with CAD.

Role of Soluble Urokinase-Type Plasminogen Activator Receptor in Cardiovascular Disease

PURPOSE OF REVIEW

Chronic inflammation is a major contributor to cardiovascular disease (CVD) risk. Soluble urokinase plasminogen activator receptor (suPAR) is an immune-derived glycoprotein that is strongly associated with atherosclerotic disease. This review summarizes evidence on suPAR's role in CVD pathogenesis and its potential as a prognostic indicator and therapeutic target.

RECENT FINDINGS

Clinical, genetic, and experimental evidence supports suPAR's role as a pathogenic factor in atherosclerosis. suPAR promotes atherosclerosis through modulation of monocyte activation and function. Clinically, elevated suPAR levels are linked to increased cardiovascular risk across diverse populations. Ongoing clinical trials are evaluating therapies targeting suPAR signaling. Current evidence positions suPAR as a regulator of myeloid cell function that contributes to vascular inflammation and subsequent cardiovascular events. Additional research is needed to determine whether suPAR measurement can improve CVD risk prediction and enable personalized management. Overall, suPAR is a promising immune-derived biomarker and target for reducing inflammation and cardiovascular risk.

Prognostic value of soluble urokinase-type plasminogen activator receptor in coronary artery disease: A meta-analysis

BACKGROUND

A potential inflammatory biomarker, soluble urokinase-type plasminogen activator receptor (suPAR) has been utilized to assist the prognostic assessment of coronary artery disease (CAD) patients; however, outcomes have been inconsistent. The prognostic relevance of suPAR as a predictor of CAD patient adverse outcomes was therefore examined.

METHODS

Research articles published as of 1 January 2022 were retrieved from PubMed, Embase, the Web of Science and the Cochrane Library. All-cause mortality, cardiovascular mortality and other major cardiovascular events (nonfatal myocardial infarction, heart failure or stroke) were analysed as a subset of relevant studies' results. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for each study. The broad EQUATOR guidelines were conformed. Risk of bias was assessed with ROBINS-I tool.

RESULTS

In total, this analysis included nine studies including 14,738 CAD patients. All included studies made a correction for certain potential confounders. However, risk of bias ranged from moderate to critical. When the ROBINS-I tool was used. Patients with CAD that exhibited increased suPAR levels had a substantially higher risk of all-cause mortality (HR = 2.24; 95% CI 1.97-2.55) or cardiovascular mortality (HR = 2.02; 95% CI 1.58-2.58), but not of developing other major cardiovascular events (HR = 1.63; 95% CI 0.86-3.11). Considerable heterogeneity across studies was observed in our meta-analyses, but no significant publication bias was detected.

CONCLUSION

In patients with coronary disease, suPAR may have prognostic value for both all-cause and cardiovascular mortality but not for other major cardiovascular events.

Acute and Long-Term Treatment With Dapagliflozin and Association With Serum Soluble Urokinase Plasminogen Activator Receptor

Background: Elevated soluble urokinase plasminogen activator receptor (suPAR) is highly associated with increased risk of diabetic complications. Dapagliflozin is a drug inhibiting the sodium-glucose co-transporter 2 in the kidney to decrease blood glucose, while also decreasing risk of kidney disease, heart failure, and death. Therefore, we have investigated suPAR as a monitor for treatment effect with dapagliflozin in diabetes. Methods: suPAR was measured in two double-blinded randomized clinical cross-over trials. The first trial investigated the effect of a single dose dapagliflozin 50 mg or placebo 12 h after intake, in individuals with type 1 diabetes and albuminuria. The second trial investigated the effect of a daily dose dapagliflozin 10 mg or placebo for 12 weeks, in individuals with type 2 diabetes and albuminuria. suPAR was measured in serum samples taken, in the acute trial, after treatment with dapagliflozin and placebo, and in the long-term trial, before and after treatment with dapagliflozin and placebo. Effect of dapagliflozin on suPAR levels were assessed using paired t-test. Results: 15 participants completed the acute trial and 35 completed the long-term trial. Mean difference in suPAR between dapagliflozin and placebo in the acute trial after 12 h was 0.70 ng/ml (95% CI: 0.66; 1.33, p = 0.49). In the long-term trial the mean difference was 0.06 ng/ml (95% CI -0.15; 0.27, p = 0.57). Conclusion: Based on our findings we conclude that suPAR is not a feasible marker to monitor the effect of treatment with dapagliflozin. Thus, a further search of suitable markers must continue.

Specific Combinations of Inflammatory, Angiogenesis and Vascular Integrity Biomarkers Are Associated with Clinical Severity, Coma and Mortality in Beninese Children with Plasmodium Falciparum Malaria

Malaria-related deaths could be prevented if powerful diagnostic and reliable prognostic biomarkers were available to allow rapid prediction of the clinical severity allowing adequate treatment. Using quantitative ELISA, we assessed the plasma concentrations of Procalcitonin, Pentraxine-3, Ang-2, sTie-2, suPAR, sEPCR and sICAM-1 in a cohort of Beninese children with malaria to investigate their potential association with clinical manifestations of malaria. We found that all molecules showed higher levels in children with severe or cerebral malaria compared to those with uncomplicated malaria (p-value < 0.005). Plasma concentrations of Pentraxine-3, Procalcitonin, Ang-2 and the soluble receptors were significantly higher in children with coma as defined by a Blantyre Coma Score < 3 (p < 0.001 for Pentraxine-3, suPAR, and sTie-2, p = 0.004 for PCT, p = 0.005 for sICAM-1, p = 0.04 for Ang-2). Moreover, except for the PCT level, the concentrations of Pentraxine-3, suPAR, sEPCR, sICAM-1, sTie-2 and Ang-2 were higher among children who died from severe malaria compared to those who survived (p = 0.037, p = 0.035, p < 0.0001, p= 0.0008, p = 0.01 and p = 0.02, respectively). These findings indicate the ability of these molecules to accurately discriminate among clinical manifestations of malaria, thus, they might be potentially useful for the early prognostic of severe and fatal malaria, and to improve management of severe cases.

Soluble urokinase plasminogen activator receptor and functionally relevant coronary artery disease: a prospective cohort study

BACKGROUND

Soluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker associated with anatomical CAD burden and cardiovascular outcomes including myocardial infarction (MI) and death. We aimed at validating previous findings of the prognostic value of suPAR and evaluated its diagnostic potential for functional relevant CAD (fCAD).

METHODS

Consecutive patients with suspected fCAD were enrolled. Adjudication of fCAD was performed blinded to suPAR concentrations by myocardial perfusion single photon emission tomography (MPI-SPECT) and coronary angiography. Prognostic outcome measures included all-cause, cardiovascular death, and incident MI during 2-year follow-up.

RESULTS

Among consecutive 968 patients, SuPAR concentrations were higher in patients with fCAD compared to those without (3.45ng/mL versus 3.20ng/mL, p = 0.007), without acceptable diagnostic accuracy (area under the curve [AUC]: 0.56, 95%CI 0.52-0.60). SuPAR correlated with high-sensitivity cardiac-troponin (hs-cTn) T (Spearman's rho (ρ) 0.393, p < 0.001), NT-proBNP (ρ = 0.327, p < 0.001), age (ρ = 0.364, p < 0.001) and very weakly with coronary atherosclerosis (ρ = 0.123, p < 0.001). Prognostic discrimination of suPAR was moderate for cardiovascular death (AUC =0.72, 95%CI 0.62-0.81) and all-cause death (AUC =0.72, 95%CI 0.65-0.79) at 2-years. SuPAR remained a significant predictor for all-cause death in the full model (HR =1.96, p = 0.001).

CONCLUSIONS

SuPAR was an independent predictor of all-cause death, without diagnostic utility for fCAD.

Experimental and Clinical Evidence Supports the Use of Urokinase Plasminogen Activation System Components as Clinically Relevant Biomarkers in Gastroesophageal Adenocarcinoma

Simple Summary

Patients with gastric and oesophageal adenocarcinomas (GOCs) have short life expectancies as their tumours spread to other sites early. This is facilitated by the increased expression of the urokinase plasminogen activation system (uPAS); a feature of the majority of GOCs. There is increasing appreciation of the importance of uPAS expression in a range of cell types within the tumour microenvironment. Abundant clinical evidence indicates that altered expression of uPAS proteins is associated with worse outcomes, including time to tumour recurrence and patient survival. Emerging technologies, including liquid biopsy, suggest a role of uPAS for the detection of circulating tumour cells, which are responsible for the dissemination of cancers. We review and summarise pre-clinical and clinical data that supports the use of uPAS as a biomarker in GOC.

Abstract

Gastric and oesophageal cancers (GOCs) are lethal cancers which metastasise early and recur frequently, even after definitive surgery. The urokinase plasminogen activator system (uPAS) is strongly implicated in the invasion and metastasis of many aggressive tumours including GOCs. Urokinase plasminogen activator (uPA) interaction with its receptor, urokinase plasminogen activator receptor (uPAR), leads to proteolytic activation of plasminogen to plasmin, a broad-spectrum protease which enables tumour cell invasion and dissemination to distant sites. uPA, uPAR and the plasminogen activator inhibitor type 1 (PAI-1) are overexpressed in some GOCs. Accumulating evidence points to a causal role of activated receptor tyrosine kinase pathways enhancing uPAS expression in GOCs. Expression of these components are associated with poorer clinicopathological features and patient survival. Stromal cells, including tumour-associated macrophages and myofibroblasts, also express the key uPAS proteins, supporting the argument of stromal involvement in GOC progression and adverse effect on patient survival. uPAS proteins can be detected on circulating leucocytes, circulating tumour cells and within the serum; all have the potential to be developed into circulating biomarkers of GOC. Herein, we review the experimental and clinical evidence supporting uPAS expression as clinical biomarker in GOC, with the goal of developing targeted therapeutics against the uPAS.

Promising Novel Biomarkers in Cardiovascular Diseases

Cardiovascular diseases remain the most common causes of death globally, according to the World Health Organization. In recent years, a great number of biomarkers have been investigated, whereas only some have gained value in the diagnosis, prognosis, and risk stratification of different cardiovascular illnesses. As numerous studies have investigated the diagnostic yield of novel biomarkers in various disease entities every year, this review aims to provide an overview of the current status of four promising representatives. In particular, this manuscript refers to soluble suppression of tumorigenicity 2 (sST2), heart-type fatty acid binding protein (H-FABP), growth differentiation factor (GDF-15) and soluble urokinase-type plasminogen activator receptor (suPAR). These markers are of special interest as they are thought to provide an accurate estimate of cardiovascular risk in certain patient populations, especially those with pre-existing diseases, such as obesity or diabetes mellitus. We sought to give an overview of their function, individual diagnostic and predictive value and determination in the laboratory. A review of the literature regarding the aforementioned cardiovascular biomarkers yielded manifold results with respect to their individual diagnostic and prognostic value. Yet, the clinical relevance of these findings remains unclear, warranting further studies to identify their optimal use in clinical routine.

Prognostic value of soluble urokinase plasminogen activator receptor in patients presenting to the emergency department with chest pain suggestive of acute coronary syndrome

INTRODUCTION

Soluble urokinase plasminogen activator receptor (suPAR) is a prognostic biomarker of cardiovascular disease.

OBJECTIVES

We aimed to evaluate the early prognostic value of suPAR in patients presenting to the emergency department (ED) with chest pain suggestive of acute coronary syndrome (ACS).

PATIENTS AND METHODS

In a post-hoc analysis from a multicenter study including patients with a chest pain < 6 h, suPAR concentrations at ED admission were studied according to the outcome at 30-days.

RESULTS

198 patients (median age 56 years) in whom 16% had an ACS, were included. Fifteen (7.3%) patients presented a 30-day event. At ED admission, median (IQR) suPAR concentrations were higher in patients with a 30-day event in comparison to patients without event (4.54 (3.09-8.61) vs. 2.72 (2.10-3.43) ng/mL, p < 0.001). The ROC curve AUC of suPAR for the prediction of a 30-days event was 0.775 [95%CI: 0.710-0.831]. The optimal threshold was 3.3 ng/mL, with a sensitivity of 73 [45-92] % and a specificity of 72 [65-79] %. The association of a suPAR < 3.3 ng/mL AND a NT-proBNP < 160 ng/L AND a HEART score < 4 had a negative predictive value of 99 [91-100] %. A suPAR value at admission above 3.3 ng/mL was independently and significantly associated with a 30-day event in chest pain emergency patients (OR 4.87 [1.35-17.51], p = 0.015).

CONCLUSION

suPAR is a promising biomarker for early prediction of events in chest pain emergency patients.

Soluble urokinase-type plasminogen activator receptor predicts peripheral artery disease severity and outcomes

Soluble urokinase-type plasminogen activator receptor (suPAR) is associated with chronic kidney disease (CKD) severity and peripheral artery disease (PAD). We hypothesize an association of PAD severity and suPAR in patients without advanced CKD and further risk stratification according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. For study purposes, suPAR was measured in 334 PAD patients (34% women, age 69 (62-78) years, eGFR 68 ± 20 mL/min/1.72 m2) by commercial ELISA. Patients were followed for 10 years to assess long-term all-cause survival by Cox regression. Higher suPAR levels were associated with lower ankle-brachial index (R = -0.215, p = 0.001) in patients with PAD without media-sclerosis (n = 236). suPAR levels inversely correlated with decreased glomerular filtration rate (R = -0.476, p < 0.001) and directly correlated with urinary albumin-to-creatinine ratio (R = 0.207, p < 0.001). Furthermore, higher suPAR levels associated with a higher KDIGO risk score (p < 0.001). Baseline suPAR was significantly associated with all-cause mortality (HR 1.40 (95% CI 1.16-1.68), p < 0.001) over 10 years. suPAR remained associated with mortality (HR 1.29 (1.03-1.61), p = 0.026) after multivariable adjustment for age, sex, cardiovascular risk factors, and eGFR. Future research may define a standard role for suPAR assessment in PAD's work-up and treatment, especially in patients with CKD.