Potentials of cystatin C and uric acid for predicting prognosis of heart failure

Heart failure risk estimation based on novel biomarkers

Introduction: Despite advances in medical care, heart failure (HF)-associated morbidity and mortality remains high. Consequently, there is increased effort to find better ways for predicting, screening, and prognosticating HF in order to facilitate effective primary and secondary prevention.Areas covered: In this review, we describe the various biomarkers associated with different etiologic pathways implicated in HF, and discuss their roles in screening, diagnosing, prognosticating and predicting HF. We explore the emerging role of multi-omic approaches. We performed electronic searches in databases (PubMed and Google Scholar) through December 2020, using the following key terms: biomarker, novel, heart failure, risk, prediction, and estimation.Circulating BNP and troponin concentrations have been established in clinical care as key biomarkers for diagnosing and prognosticating HF. Emerging biomarkers (such as galectin-3 and ST-2) have gained further recognition for use in evaluating prognosis of HF patients. Promising biomarkers that are yet to be part of clinical recommendations include biomarkers of cardiorenal disease.Expert opinion: Increasing recognition of the complex and interdependent nature of pathophysiological pathways of HF has led to the application of multi-marker approaches including multi-omic high throughput assays. These newer approaches have the potential for new therapeutic discoveries and improving precision medicine in HF.

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.

Circulating Biomarkers in Heart Failure

Biological markers have served for diagnosis, risk stratification and guided therapy of heart failure (HF). Our knowledge regarding abilities of biomarkers to relate to several pathways of HF pathogenesis and reflect clinical worsening or improvement in the disease is steadily expanding. Although there are numerous clinical guidelines, which clearly diagnosis, prevention and evidence-based treatment of HF, a strategy regarding exclusion of HF, as well as risk stratification of HF, nature evolution of disease is not well established and requires more development. The aim of the chapter is to discuss a role of biomarker-based approaches for more accurate diagnosis, in-depth risk stratification and individual targeting in treatment of patients with HF.

Association between cardiac, renal, and hepatic biomarkers and outcomes in patients with acute heart failure

OBJECTIVES

Myocardial injury, worsening renal function, and hepatic impairment are independent risk factors for poor patient acute heart failure (AHF) outcomes. Biomarkers of organ damage may be useful in identifying patients at risk for poor outcomes. The objective of this analysis was to assess the relationship between abnormal AHF biomarkers and outcomes in AHF patients.

METHODS

AHF admissions (N = 104,794) data from the Cerner Health Facts® inpatient database were analyzed retrospectively. Multivariate predictive models determined the impact of biomarkers on mortality, readmission, length of stay (LOS), and cost from index admission through 180 days post discharge. Thirty and 60 day time windows are reported but 180 day results were consistent with 60 day outcomes. Biomarkers evaluated were aspartate transaminase (AST), estimated glomerular filtration rate (eGFR), high sensitivity cardiac troponin, bilirubin, alanine transaminase (ALT), sodium, high sensitivity C-reactive protein (hs-CRP), uric acid, B-type natriuretic peptide (BNP), NT-ProBNP, blood urea nitrogen (BUN), serum creatinine (SCr), and hemoglobin.

RESULTS

All biomarkers evaluated except hs-CRP, uric acid, and NT-ProBNP were significant (p < 0.0001) predictors of mortality at all timepoints; non-significance for these 3 biomarkers is likely due to low patient counts (1%-2%). Odds ratios for significant biomarkers of mortality ranged from 1.168-2.076 at index admission, 1.205-1.946 at 30 days post-discharge, and 1.233-1.991 at 60 days post-discharge. AST, eGFR, troponin, ALT, BNP, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of readmission risk at all timepoints. AST, eGFR, troponin, bilirubin, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of cumulative LOS at all timepoints. AST, eGFR, troponin, ALT, sodium, BUN, and hemoglogin were significant (p < 0.0001) cost predictors at 30 and 60 days post-discharge.

CONCLUSIONS

Renal function measures were associated with outcomes in patients hospitalized for AHF. Increased vigilance of renal biomarkers may be warranted to assess risk and promote proactive clinical management to improve outcomes.

Clinical Risk Stratification Optimizes Value of Biomarkers to Predict New-Onset Heart Failure in a Community-Based Cohort

Background—

We aim to identify and quantify the value of biomarkers for incident new-onset heart failure (HF) in a community-based cohort and subgroups based on cardiovascular risk and evaluate the prognostic value of 13 biomarkers for HF with reduced and preserved ejection fraction.

Methods and Results—

Thirteen biomarkers reflecting diverse pathophysiologic domains were examined in 8569 HF-free participants in Prevention of Vascular and Renal Endstage Disease (mean age, 49 years; 50% men). Subjects were categorized in 2 risk groups based on cardiovascular history. Incremental value per biomarker was assessed using Harrell C-indices. One hundred sixty-eight subjects (2.4%) were diagnosed with new-onset HF in the low-risk group (n=6915; Framingham Risk Score, 5.9%) and 206 (12.2%) subjects in the high-risk group (n=1654; Framingham Risk Score, 18.6%). The association of natriuretic peptides, adrenomedullin, endothelin, and galectin-3 with new-onset HF was stronger in the high-risk group (all P <0.05). Troponin-T, high-sensitive C-reactive protein, urinary albumin excretion, and cystatin-C had similar risk for new-onset HF between both risk groups. The best model for new-onset HF included the combination of N-terminal pro-B-type natriuretic peptide, troponin-T, and urinary albumin excretion, increasing model accuracy to 0.81 (9.5%, P <0.001) in the high-risk group. Except for a modest effect of cystatin-C, no biomarker was associated with increased risk for HF with preserved ejection fraction.

Conclusions—

Risk stratification increases the incremental value per biomarker to predict new-onset HF, especially HF with reduced ejection fraction. We suggest that routine biomarker testing should be limited to the use of natriuretic peptides and troponin-T in patients with increased cardiovascular risk.

Evaluation of patients with heart failure

Heart failure is one of the most prevalent cardiovascular diseases in the United States, and is associated with significant morbidity, mortality, and costs. Prompt diagnosis may help decrease mortality, hospital stay, and costs related to treatment. A complete heart failure evaluation comprises a comprehensive history and physical examination, echocardiogram, and diagnostic tools that provide information regarding the etiology of heart failure, related complications, and prognosis in order to prescribe appropriate therapy, monitor response to therapy, and transition expeditiously to advanced therapies when needed. Emerging technologies and biomarkers may provide better risk stratification and more accurate determination of cause and progression.