Usefulness of cardiac biomarkers for prognosis of better outcomes in chronic heart failure: Retrospective 18-year follow-up study

Association between serum alkaline phosphatase and cardiovascular events in patients with atrial fibrillation

High alkaline phosphatase (ALP) levels are reported to be associated with an increased risk of cardiovascular events in patients with chronic kidney disease (CKD). Given the pathological link with CKD, a similar relationship may exist in patients with atrial fibrillation (AF). We retrospectively evaluated 1,719 patients with AF and normal hepatic function who were registered in the Shinken Database between November 2011 and March 2017. Study patients were divided into three groups according to ALP value tertiles with cut-offs of 175 and 227 IU/L (normal range: 95-350 IU/L). Each group's incidence rate was recorded, and the risks of cardiovascular events and each component for patients in the middle and high ALP tertiles were compared with those in the low tertile and evaluated using Cox regression models. The additional predictive value of the high ALP tertile over the existing risk scores for the components of cardiovascular events was evaluated via receiver operating characteristic (ROC) curve analysis. During the median follow-up of 731 days (IQR: 444-1095 days), 137 cardiovascular events occurred, with incidence rates of 2.94%, 3.44%, and 6.19%/person-year for the low, middle, and high ALP tertiles, respectively. Of these cardiovascular events, heart failure had the highest incidence rates (1.34%, 1.89%, and 4.29%/person-year for the low, middle, and high ALP tertiles, respectively) and the incidence rates of the other components of cardiovascular event were similar in each ALP groups. Multivariate Cox regression analysis yielded hazard ratios of 1.22 (95% confidence interval [CI] 0.70-1.96) and 1.62 (95% CI 1.06-2.48) for cardiovascular events and 1.66 (95% CI 0.87-3.15) and 2.50 (95% CI 1.39-4.48) for heart failure admission in the middle and high ALP tertiles, respectively. By ROC curve analysis for heart failure admission showed that the high ALP tertile lacked significant additive predictive value over the existing risk scores. High serum ALP levels, even those in the normal range, were significantly associated with an increased risk of cardiovascular events, especially heart failure admission in patients with AF.

Prognostic value of the liver fibrosis marker fibrosis-5 index in patients with acute heart failure

Aims

Recently, liver fibrosis markers, such as the fibrosis‐4 index (FIB‐4), have been shown to be associated with prognosis in patients with heart failure. The fibrosis‐5 (FIB‐5) index, which assesses albumin, alkaline phosphatase, aspartate transaminase, alanine aminotransferase and platelet count, is a simple liver fibrosis marker that was reported to be superior to FIB‐4 for differentiation of liver fibrosis. This study aimed to compare the prognostic value of FIB‐4 and FIB‐5 in patients with heart failure.

Methods and results

The FIB‐4 and FIB‐5 scores were calculated at discharge in 906 patients hospitalized with heart failure. The patients were stratified into three groups based on their FIB‐5 scores: low (n = 303), middle (n = 301), and high (n = 302) FIB‐5 groups. The primary endpoint was a composite of cardiac death or rehospitalization for heart failure. The low FIB‐5 group was older and had larger inferior vena cava diameters and higher brain natriuretic peptide levels than the other two groups. The primary endpoint occurred in 156 (51.5%), 110 (36.5%), and 54 patients (17.9%) in the low, middle, and high FIB‐5 groups, respectively (P < 0.001). On Cox proportional hazard analysis, the low FIB‐5 was independently associated with the primary endpoint after adjustment for confounding factors. The association was consistent in both patients with preserved and reduced left ventricular ejection fraction (LVEF), and there was no significant interaction between LVEF phenotypes in terms of the prognostic impact of FIB‐5 (P for interaction = 0.311). FIB‐5 was superior to FIB‐4 as a prognostic indicator of the primary endpoint (continuous net reclassification improvement, 0.530; 95% confidence interval [CI], 0.399–0.662; P < 0.001; integrated discrimination improvement, 0.072; 95% CI, 0.057–0.088; P < 0.001).

Conclusions

The FIB‐5 is a useful risk stratification marker with better prognostic value than FIB‐4 in patients hospitalized with heart failure.