The diagnostic accuracy of the natriuretic peptides in heart failure: systematic review and diagnostic meta-analysis in the acute care setting

Screening for Heart Failure: Biomarkers to Detect Heightened Risk in the General Population

PURPOSE OF REVIEW

Heart failure (HF) represents a growing global burden of morbidity and mortality. Identifying individuals at risk for HF development is increasingly important, particularly given the advent of disease-modifying therapies for HF as well as its major risk factors such as obesity actalnd diabetes. We aim to review the key circulating biomarkers associated with future HF which may contribute to HF risk prediction.

RECENT FINDINGS

While current guidelines recommend the use of natriuretic peptides and cardiac troponins in HF risk stratification, there are a diverse array of other emerging protein, metabolic, transcriptomic, and genomic biomarkers of future HF development. These biomarkers not only lend insight into the underlying pathophysiology of HF, which spans inflammation to cardiac fibrosis, but also offer an opportunity to further refine HF risk in addition to established biomarkers. As evolving techniques in molecular biology enable an increased understanding of the complex biologic contributions to HF pathophysiology, there is an important opportunity to construct integrated clinical and multi-omic models to best capture HF risk. Moving forward, future studies should seek to understand the contributions of sex differences, underlying comorbidity burden, and HF subtypes to an individual's HF risk. Further studies are necessary to fully define the clinical utility of biomarker screening approaches to refine HF risk assessment, as well as to link risk assessment directly to preventive strategies for HF.

Peripartum cardiomyopathy: a comprehensive and contemporary review

Cardiovascular disease is a major non-communicable disease globally, with increasing prevalence, posing a significant public health challenge. It is the leading non-obstetric cause of perinatal morbidity and mortality, with a substantial number of cardiac fatalities occurring in individuals without any known pre-existing cardiovascular disease. Peripartum cardiomyopathy is a type of de novo heart failure that occurs in pregnant women in the late stages of pregnancy or following delivery. Despite extensive research, diagnosing and managing peripartum cardiomyopathy remains challenging, resulting in significant morbidity and mortality. Recent advancements and novel approaches have been made to better understand and manage peripartum cardiomyopathy, including molecular and non-molecular biomarkers, genetic predisposition and risk prediction, targeted therapies, multidisciplinary care, and improved patient education. This narrative review provides a comprehensive overview and new perspectives on peripartum cardiomyopathy, covering its epidemiology, updated pathophysiological mechanisms, diagnosis, management, and future research directions for healthcare professionals, researchers, and clinicians.

Impact of first-line antihypertensive drug class and intensity on NT-proBNP improvement and cardiovascular outcomes among hypertensive patients with pre-heart failure: findings from SPRINT trial

Five first-line classes of antihypertensive drugs are recommended for hypertension treatment. However, it is unclear which class should be chosen for hypertensive patients with pre-heart failure (pre-HF). The study aimed to investigate the association between antihypertensive drug classes and intensity with probability of NT-proBNP (N-terminal pro-B-type natriuretic peptide) improvement and risk of cardiovascular events among pre-HF hypertensive patients. Utilizing the data from SPRINT, we included pre-HF hypertensive patients, identified by NT-proBNP ≥125 pg/mL at baseline. NT-proBNP improvement is defined as a reduction of ≥50% to a level below 125 pg/mL. A total of 3293 patients (mean age: 71.9 years; female: 43.8%) were included. NT-proBNP improvement was observed in 415 patients (12.6%) over 1-year follow up. Thiazide-type diuretics users were associated with a higher likelihood of NT-proBNP improvement (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.05-1.70), a lower risk of HF (hazard ratio [HR], 0.54; 95% CI, 0.37-0.78) and primary composite outcome (HR, 0.72; 95% CI, 0.57-0.89). ACEI/ARB users were only associated with a lower risk of primary composite outcome (HR, 0.80; 95% CI, 0.63-0.99). In contrast, beta-blockers users were associated with a lower likelihood of NT-proBNP improvement (OR, 0.43; 95% CI, 0.34-0.55), while a higher risk of HF (HR, 1.79; 95% CI, 1.21-2.64) and primary composite outcome (HR, 1.48; 95% CI, 1.18-1.87). These associations varied across subgroups of different drug intensities. This post hoc analysis supports the use of thiazide-type diuretics and ACEI/ARB for prevention of cardiovascular events. The use of beta-blockers is associated with an increased risk of HF and primary outcomes, which requires further validation. Association between antihypertensive drug classes and intensity with NT-proBNP improvement and long-term clinical outcome.

Use of artificial intelligence-powered ECG to differentiate between cardiac and pulmonary pathologies in patients with acute dyspnoea in the emergency department

BACKGROUND

Acute dyspnoea is common in acute care settings. However, identifying the origin of dyspnoea in the emergency department (ED) is often challenging. We aimed to investigate whether our artificial intelligence (AI)-powered ECG analysis reliably distinguishes between the causes of dyspnoea and evaluate its potential as a clinical triage tool for comparing conventional heart failure diagnostic processes using natriuretic peptides.

METHODS

A retrospective analysis was conducted using an AI-based ECG algorithm on patients ≥18 years old presenting with dyspnoea at the ED from February 2006 to September 2023. Patients were categorised into cardiac or pulmonary origin groups based on initial admission. The performance of an AI-ECG using a transformer neural network algorithm was assessed to analyse standard 12-lead ECGs for accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Additionally, we compared the diagnostic efficacy of AI-ECG models with N-terminal probrain natriuretic peptide (NT-proBNP) levels to identify cardiac origins.

RESULTS

Among the 3105 patients included in the study, 1197 had cardiac-origin dyspnoea. The AI-ECG model demonstrated an AUC of 0.938 and 88.1% accuracy for cardiac-origin dyspnoea. The sensitivity, specificity and positive and negative predictive values were 93.0%, 79.5%, 89.0% and 86.4%, respectively. The F1 score was 0.828. AI-ECG demonstrated superior diagnostic performance in identifying cardiac-origin dyspnoea compared with NT-proBNP. True cardiac origin was confirmed in 96 patients in a sensitivity analysis of 129 patients with a high probability of cardiac origin initially misdiagnosed as pulmonary origin predicted by AI-ECG.

CONCLUSIONS

AI-ECG demonstrated superior diagnostic accuracy over NT-proBNP and showed promise as a clinical triage tool. It is a potentially valuable tool for identifying the origin of dyspnoea in emergency settings and supporting decision-making.

Reference intervals of circulating secretoneurin concentrations determined in a large cohort of community dwellers: the HUNT study

OBJECTIVES

Secretoneurin (SN) is a novel cardiac biomarker that associates with the risk of mortality and dysfunctional cardiomyocyte Ca2+ handling in heart failure patients. Reference intervals for SN are unknown.

METHODS

SN was measured with a CE-marked ELISA in healthy community dwellers from the fourth wave of the Trøndelag Health Study (HUNT4) conducted in 2017-2019. The common, sex and age specific 90th, 95th, 97.5th and 99th percentiles were calculated using the non-parametric method and outlier exclusion according to the Reed test. The applicability of sex and age specific reference intervals were investigated using Harris and Boyd test. We also estimated the percentiles in a subset with normal findings on echocardiographic screening.

RESULTS

The total cohort included 887 persons (56.4 % women). After echocardiographic screening 122 persons were excluded, leaving a total of 765 persons (57.8 % women). The 97.5th percentile (95 % CI in brackets) of SN was 59.7 (57.5-62.1) pmol/L in the total population and 58.6 (57.1-62.1) pmol/L after echocardiography screening. In general, slightly higher percentiles were found in women and elderly participants, but less than 4 % in these subgroups had concentrations deviating from the common 97.5th percentile. Low BMI or eGFR was also associated with higher concentrations of SN.

CONCLUSIONS

Upper reference limits for SN were similar amongst healthy adult community dwellers regardless of prescreening including cardiac echocardiography or not. Women and elderly showed higher concentrations of SN, but the differences were not sufficiently large to justify age and sex stratified upper reference limits.

A discrete time-to-event model for the meta-analysis of full ROC curves

The development of new statistical models for the meta-analysis of diagnostic test accuracy studies is still an ongoing field of research, especially with respect to summary receiver operating characteristic (ROC) curves. In the recently published updated version of the "Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy", the authors point to the challenges of this kind of meta-analysis and propose two approaches. However, both of them come with some disadvantages, such as the nonstraightforward choice of priors in Bayesian models or the requirement of a two-step approach where parameters are estimated for the individual studies, followed by summarizing the results. As an alternative, we propose a novel model by applying methods from time-to-event analysis. To this task we use the discrete proportional hazard approach to treat the different diagnostic thresholds, that provide means to estimate sensitivity and specificity and are reported by the single studies, as categorical variables in a generalized linear mixed model, using both the logit- and the asymmetric cloglog-link. This leads to a model specification with threshold-specific discrete hazards, avoiding a linear dependency between thresholds, discrete hazard, and sensitivity/specificity and thus increasing model flexibility. We compare the resulting models to approaches from the literature in a simulation study. While the estimated area under the summary ROC curve is estimated comparably well in most approaches, the results depict substantial differences in the estimated sensitivities and specificities. We also show the practical applicability of the models to data from a meta-analysis for the screening of type 2 diabetes.

Associations of fear of physical activity, coping style and self-reported exercise behavior in patients with chronic heart failure

AIMS

Fear of physical activity (PA) is discussed as a barrier to regular exercise in patients with heart failure (HF), but HF-specific theoretical concepts are lacking. This study examined associations of fear of PA, heart-focused anxiety and trait anxiety with clinical characteristics and self-reported PA in outpatients with chronic HF. It was also investigated whether personality-related coping styles for dealing with health threats impact fear of PA via symptom perception.

METHODS AND RESULTS

This cross-sectional study enrolled 185 HF outpatients from five hospitals (mean age 62 ± 11 years, mean ejection fraction 36.0 ± 12%, 24% women). Avoidance of PA, sports/exercise participation (yes/no) and the psychological characteristics were assessed by self-reports. Fear of PA was assessed by the Fear of Activity in Situations-Heart Failure (FActS-HF15) questionnaire. In multivariable regression analyses higher NYHA class (b = 0.26, p = 0.036) and a higher number of HF drugs including antidepressants (b = 0.25, p = 0.017) were independently associated with higher fear of PA, but not with heart-focused fear and trait anxiety. Of the three anxiety scores only increased fear of PA was independently associated with more avoidance behavior regarding PA (b = 0.45, SE = 0.06, p < 0.001) and with increased odds of no sports/exercise participation (OR = 1.34, 95% CI 1.03-1.74, p = 0.028). Attention towards cardiac symptoms and symptom distress were positively associated with fear of PA (p < 0.001), which explained higher fear of PA in patients with a vigilant (directing attention towards health threats) coping style (p = 0.004).

CONCLUSIONS

Fear of PA assessed by the FActS-HF15 is a specific type of anxiety in patients with HF. Attention towards and being distressed by HF symptoms appear to play a central role in fear of PA, particularly in vigilant patients who are used to direct their attention towards health threats. These findings provide approaches for tailored interventions to reduce fear of PA and to increase PA in patients with HF.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02898246.

A Comprehensive Review of Cardiovascular Disease Management: Cardiac Biomarkers, Imaging Modalities, Pharmacotherapy, Surgical Interventions, and Herbal Remedies

Cardiovascular diseases (CVDs) continue to be a major global health concern, representing a leading cause of morbidity and mortality. This review provides a comprehensive examination of CVDs, encompassing their pathophysiology, diagnostic biomarkers, advanced imaging techniques, pharmacological treatments, surgical interventions, and the emerging role of herbal remedies. The review covers various cardiovascular conditions such as coronary artery disease, atherosclerosis, peripheral artery disease, deep vein thrombosis, pulmonary embolism, cardiomyopathy, rheumatic heart disease, hypertension, ischemic heart disease, heart failure, cerebrovascular diseases, and congenital heart defects. The review presents a wide range of cardiac biomarkers such as troponins, C-reactive protein, CKMB, BNP, NT-proBNP, galectin, adiponectin, IL-6, TNF-α, miRNAs, and oxylipins. Advanced molecular imaging techniques, including chest X-ray, ECG, ultrasound, CT, SPECT, PET, and MRI, have significantly enhanced our ability to visualize myocardial perfusion, plaque characterization, and cardiac function. Various synthetic drugs including statins, ACE inhibitors, ARBs, β-blockers, calcium channel blockers, antihypertensives, anticoagulants, and antiarrhythmics are fundamental in managing CVDs. Nonetheless, their side effects such as hepatic dysfunction, renal impairment, and bleeding risks necessitate careful monitoring and personalized treatment strategies. In addition to conventional therapies, herbal remedies have garnered attention for their potential cardiovascular benefits. Plant extracts and their bioactive compounds, such as flavonoids, phenolic acids, saponins, and alkaloids, offer promising cardioprotective effects and enhanced cardiovascular health. This review underscores the value of combining traditional and modern therapeutic approaches to improve cardiovascular outcomes. This review serves as a vital resource for researchers by integrating a broad spectrum of information on CVDs, diagnostic tools, imaging techniques, pharmacological treatments and their side effects, and the potential of herbal remedies.

Effects of serial NT-proBNP measurements in patients with acute decompensated heart failure: Results of the POC-HF pilot trial

INTRODUCTION

Serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements have proven to be useful for therapy monitoring in patients hospitalized for acute decompensated heart failure (ADHF). The POC-HF pilot study investigated whether serial NT-proBNP measurements influenced treatment decisions in these patients.

METHODS

Patients hospitalized for ADHF were randomly assigned to an intervention group (serial NT-proBNP measurements made available to treating physicians) or a control group (care as usual). HF therapy was administered at the discretion of the treating physician. The primary endpoint was dose changes in HF therapy during hospitalization. Secondary endpoints included changes in NT-proBNP levels, recovery from HF symptoms, length of hospital stay, and quality of life.

RESULTS

52 patients (35% female; mean age 81.8 years) were included. The availability of serial NT-proBNP values was associated with higher dosages of ACE inhibitors (relative treatment effect (RTE) day 11:0.74, p = 0.007) and loop diuretics (RTE day 11:0.77, p = 0.005), and lower dosages of beta-blockers (RTE day 11:0.43, p  =  0.002). NT-proBNP levels decreased (-752 pg/ml, p = 0.162) and recovery rates from ADHF symptoms were more pronounced in the intervention group, but without statistical significance. No differences were found in terms of the length of hospital stay and quality of life.

CONCLUSION

The results of this pilot trial indicate that serial NT-proBNP measurements are possibly associated with faster up-titration of HF medication, more pronounced NT-proBNP decrease, and faster recovery from symptoms than symptom-guided therapy in patients hospitalized for ADHF. These preliminary findings require further validation through larger studies.

TRIAL REGISTRATION

http://www.swissethics.ch BASEC-ID 2017-01030, registered on 28 December 2017.

Assessment of cardiovascular risk and physical activity: the role of cardiac-specific biomarkers in the general population and athletes

The first part of this Inter-Society Document describes the mechanisms involved in the development of cardiovascular diseases, particularly arterial hypertension, in adults and the elderly. It will also examine how consistent physical exercise during adolescence and adulthood can help maintain blood pressure levels and prevent progression to symptomatic heart failure. The discussion will include experimental and clinical evidence on the use of specific exercise programs for preventing and controlling cardiovascular diseases in adults and the elderly. In the second part, the clinical relevance of cardiac-specific biomarkers in assessing cardiovascular risk in the general adult population will be examined, with a focus on individuals engaged in sports activities. This section will review recent studies that suggest a significant role of biomarkers in assessing cardiovascular risk, particularly the presence of cardiac damage, in athletes who participate in high-intensity sports. Finally, the document will discuss the potential of using cardiac-specific biomarkers to monitor the effectiveness of personalized physical activity programs (Adapted Physical Activity, APA). These programs are prescribed for specific situations, such as chronic diseases or physical disabilities, including cardiovascular diseases. The purposes of this Inter-Society Document are the following: 1) to discuss the close pathophysiological relationship between physical activity levels (ranging from sedentary behavior to competitive sports), age categories (from adolescence to elderly age), and the development of cardiovascular diseases; 2) to review in detail the experimental and clinical evidences supporting the role of cardiac biomarkers in identifying athletes and individuals of general population at higher cardiovascular risk; 3) to stimulate scientific societies and organizations to develop specific multicenter studies that may take into account the role of cardiac biomarkers in subjects who follow specific exercise programs in order to monitor their cardiovascular risk.

Midregional Proatrial Natriuretic Peptide (MRproANP) is associated with vertebral fractures and low bone density in patients with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Patients with COPD are often affected by loss of bone mineral density (BMD) and osteoporotic fractures. Natriuretic peptides (NP) are known as cardiac markers, but have also been linked to fragility-associated fractures in the elderly. As their functions include regulation of fluid and mineral balance, they also might affect bone metabolism, particularly in systemic disorders such as COPD.

RESEARCH QUESTION

We investigated the association between NP serum levels, vertebral fractures and BMD assessed by chest computed tomography (CT) in patients with COPD.

METHODS

Participants of the COSYCONET cohort with CT scans were included. Mean vertebral bone density on CT (BMD-CT) as a risk factor for osteoporosis was assessed at the level of TH12 (AI-Rad Companion), and vertebral compression fractures were visually quantified by two readers. Their relationship with N-terminal pro-B-type natriuretic peptide (NT-proBNP), Mid-regional pro-atrial natriuretic peptide (MRproANP) and Midregional pro-adrenomedullin (MRproADM) was determined using group comparisons and multivariable analyses.

RESULTS

Among 418 participants (58% male, median age 64 years, FEV1 59.6% predicted), vertebral fractures in TH12 were found in 76 patients (18.1%). Compared to patients without fractures, these had elevated serum levels (p ≤ 0.005) of MRproANP and MRproADM. Using optimal cut-off values in multiple logistic regression analyses, MRproANP levels ≥ 65 nmol/l (OR 2.34; p = 0.011) and age (p = 0.009) were the only significant predictors of fractures after adjustment for sex, BMI, smoking status, FEV1% predicted, SGRQ Activity score, daily physical activity, oral corticosteroids, the diagnosis of cardiac disease, and renal impairment. Correspondingly, MRproANP (p < 0.001), age (p = 0.055), SGRQ Activity score (p = 0.061) and active smoking (p = 0.025) were associated with TH12 vertebral density.

INTERPRETATION

MRproANP was a marker for osteoporotic vertebral fractures in our COPD patients from the COSYCONET cohort. Its association with reduced vertebral BMD on CT and its known modulating effects on fluid and ion balance are suggestive of direct effects on bone mineralization.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01245933, Date of registration: 18 November 2010.

Comprehensive Quality Analysis of Conventional and Novel Biomarkers in Diagnosing and Predicting Prognosis of Coronary Artery Disease, Acute Coronary Syndrome, and Heart Failure, a Comprehensive Literature Review

Coronary artery disease (CAD), acute coronary syndrome (ACS), and heart failure (HF) are major global health issues with high morbidity and mortality rates. Biomarkers like cardiac troponins (cTn) and natriuretic peptides (NPs) are crucial tools in cardiology, but numerous new biomarkers have emerged, proving increasingly valuable in CAD/ACS. These biomarkers are classified based on their mechanisms, such as fibrosis, metabolism, inflammation, and congestion. The integration of established and emerging biomarkers into clinical practice is an ongoing process, and recognizing their strengths and limitations is crucial for their accurate interpretation, incorporation into clinical settings, and improved management of CVD patients. We explored established biomarkers like cTn, NPs, and CRP, alongside newer biomarkers such as Apo-A1, IL-17E, IgA, Gal-3, sST2, GDF-15, MPO, H-FABP, Lp-PLA2, and ncRNAs; provided evidence of their utility in CAD/ACS diagnosis and prognosis; and empowered clinicians to confidently integrate these biomarkers into clinical practice based on solid evidence.

Thiol/Disulfide Homeostasis: A New Oxidative Marker in Heart Failure Patients with Preserved Ejection Fraction

BACKGROUND

It is suggested that myocardial dysfunction in heart failure patients may result from increased oxidative stress-related membrane changes. Thiol/disulfide homeostasis is a new oxidative stress indicator. The aim of this study was to evaluate serum thiol levels and thiol/disulfide homeostasis in patients with heart failure with preserved ejection fraction (HFpEF).

METHODS

Eighty-four overweight patients who applied to our clinic between November 2016 and February 2018 and diagnosed with hypertension and left ventricule concentric hypertrophy with normal systolic function are included in the study. Forty-two patients who were asymptomatic and had normal N terminal pro-B type natriuretic peptide (NT-proBNP) levels (≤125) were in the control group. Forty-two patients who have cardiac failure symptoms and have high NT-roBNP levels (>125) were in the patient group.

RESULTS

Native thiol, total thiol, and disulfide values of the patient group are found to be significantly lower than the control group (P =.001; P <.001; P =.041 respectively). There is a statictically significant negative correlation between native thiol, total thiol values, and NT-proBNP. There is a statictically significant negative correlation between native thiol, total thiol values, and carbohydrate antigen 125 (CA-125) values.

CONCLUSION

As far as we know from literature, this is the first study on HFpEF and thiol/disulfide homeostasis. It is found that native, total thiol, and disulfide values are low in HFpEF patients and that there is a negative correlation between native, total thiol values and NT-proBNP, CA-125 values. It can be said that oxidant/antioxidant balance is impaired in patients with HFpEF and that larger, randomized studies are needed in order to use oxidant/antioxidant balance in diagnosis and treatment of HFpEF.

Sacubitril/Valsartan Improves Cardiac Function in Dialysis Patients

Heart failure (HF) is characterized by the activation of adverse neurohormonal systems and a high mortality rate. Noteworthy, HF is a well-known complication of chronic kidney disease (CKD), especially in end-stage kidney disease (ESKD), where dialysis patients are seven to eight times more likely to encounter cardiac arrest than the general population. Therefore, it is important to develop efficient treatments to improve cardiac function in dialysis patients and eventually reduce the cardiovascular death toll. Sacubitril/valsartan (Sac/Val) is a dual inhibitor/blocker of the neprilysin and angiotensin II receptors, which exert cardioprotective effects among patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved EF (HFpEF). Unfortunately, the drug is not approved for subjects with advanced CKD or dialysis patients due to safety concerns. The current study examined the cardiac effects of Sac/Val in HD patients. Administration of Sac/Val (100-400 mg/day) to 12 hemodialysis (HD) patients with HFrEF for six months gradually improved ejection fraction (EF) independently of morphological changes in cardiac geometry, as assessed by echocardiography (ECHO), and hemodynamic alterations. Interestingly, the Cardiomyopathy Questionnaire (Kansas City KCCQ-12) revealed that quality of life significantly improved after Sac/Val treatment. No major adverse effects were reported in the present study, supporting the safety of Sac/Val at least in these patients and for the applied follow-up period. Collectively, these findings support the use of Sac/Val as a cardioprotective agent in both HD and peritoneal dialysis (PD) patients. Yet, a more comprehensive study is required to establish these findings and to extend the follow-up period for 12 months in order to solidify these encouraging results.

Biomarkers in heart failure: a focus on natriuretic peptides

While progress has been made in the management of most aspects of cardiovascular disease, the incidence and prevalence of heart failure (HF) remains high. HF affects around a million people in the UK and has a worse prognosis than most cancers. Patients with HF are often elderly with complex comorbidities, making accurate assessment of HF challenging. A timely diagnosis and initiation of evidence-based treatments are key to prevent hospitalisation and improve outcomes in this population. Biomarkers have dramatically impacted the way patients with HF are evaluated and managed. The most studied biomarkers in HF are natriuretic peptides (NPs). Since their discovery in the 1980s, there has been an explosion of work in the field of NPs and they have become an important clinical tool used in everyday practice to guide diagnosis and prognostic assessment of patients with HF. In this article, we will review the physiology of NPs and study their biological effects. Then, we will discuss the role of NPs in the diagnosis, management and prognostication of patients with HF. We will also explore the role of NPs as a potential therapeutic agent.

Importance of B-Type Natriuretic Peptide in the Detection of Patients With Structural Heart Disease in a Primary Care Setting

BACKGROUND

Early detection and intervention for preclinical heart failure (HF) are crucial for restraining the potential increase in patients with HF. Thus, we designed and conducted a single-center retrospective cohort study to confirm the efficacy of B-type natriuretic peptide (BNP) for the early detection of preclinical HF in a primary care setting.

METHODS AND RESULTS

We investigated 477 patients with no prior diagnosis of HF who were under the care of general practitioners. These patients were categorized into 4 groups based on BNP concentrations: Category 1, 0 pg/mL≤BNP≤35 pg/mL; Category 2, 35 pg/mL200 pg/mL. There was a marked and statistically significant increase in the prevalence of preclinical HF with increasing BNP categories: 19.9%, 57.9%, 87.5%, and 96.0% in Categories 1, 2, 3, and 4, respectively. Compared with Category 1, the odds ratio of preclinical HF in Categories 2, 3, and 4 was determined to be 5.56 (95% confidence interval [CI] 3.57-8.67), 23.70 (95% CI 8.91-63.11), and 171.77 (95% CI 10.31-2,861.93), respectively.

CONCLUSIONS

Measuring BNP is a valuable tool for the early detection of preclinical HF in primary care settings. Proactive testing in patients at high risk of HF could play a crucial role in addressing the impending HF pandemic.

Insights into the Novel Cardiac Biomarker in Acute Heart Failure: Mybp-C

(1) Background: Given its high cardiac specificity and its capacity to directly assess the cardiac function, cardiac myosin-binding protein (MyBP-C) is a promising biomarker in patients with acute heart failure (AHF). The aim of our study was to investigate the clinical utility of this novel marker for diagnosis and short-term prognosis in subjects with AHF. (2) Methods: We measured plasma levels of MyBP-C at admission in 49 subjects (27 patients admitted with AHF and 22 controls). (3) Results: The plasma concentration of MyBP-C was significantly higher in patients with AHF compared to controls (54.88 vs. 0.01 ng/L, p < 0.001). For 30-day prognosis, MyBP-C showed significantly greater AUC (0.972, p < 0.001) than NT-proBNP (0.849, p = 0.001) and hs-TnI (0.714, p = 0.047). In a multivariate logistic regression analysis, an elevated level of MyBP-C was the best independent predictor of 30-day mortality (OR = 1.08, p = 0.039) or combined death/recurrent 30-days rehospitalization (OR = 1.12, p = 0.014). (4) Conclusions: Our data show that circulating MyBP-C is a sensitive and cardiac-specific biomarker with potential utility for the accurate diagnosis and prognosis of AHF.

Review of the National Institute for Health and Care Excellence guidelines on chronic heart failure

Guidelines are more accessible than ever and represent an important tool in clinical practice. The National Institute for Health and Care Excellence (NICE) has developed recommendations for heart failure diagnosis and management based not only on morbidity and mortality trial outcome data but also in-depth economic analysis, with a focus on generalisability to UK National Health Service clinical practice. There is broad consistency in structure and content between NICE guidelines and those produced by major cardiovascular organisations such as the American College of Cardiology/American Heart Association and the European Society of Cardiology. However, important differences do exist-largely attributable to publication timing-a factor that is enhanced by the rapid pace of heart failure research. This article reviews the most recent iteration of NICE chronic heart failure guidelines and compares them with major guidelines on an international scale. Variations in recommendations will be explored including implications for NICE guideline updates in the future.

Use of the energy waveform electrocardiogram to detect subclinical left ventricular dysfunction in patients with type 2 diabetes mellitus

BACKGROUND

Recent guidelines propose N-terminal pro-B-type natriuretic peptide (NT-proBNP) for recognition of asymptomatic left ventricular (LV) dysfunction (Stage B Heart Failure, SBHF) in type 2 diabetes mellitus (T2DM). Wavelet Transform based signal-processing transforms electrocardiogram (ECG) waveforms into an energy distribution waveform (ew)ECG, providing frequency and energy features that machine learning can use as additional inputs to improve the identification of SBHF. Accordingly, we sought whether machine learning model based on ewECG features was superior to NT-proBNP, as well as a conventional screening tool-the Atherosclerosis Risk in Communities (ARIC) HF risk score, in SBHF screening among patients with T2DM.

METHODS

Participants in two clinical trials of SBHF (defined as diastolic dysfunction [DD], reduced global longitudinal strain [GLS ≤ 18%] or LV hypertrophy [LVH]) in T2DM underwent 12-lead ECG with additional ewECG feature and echocardiography. Supervised machine learning was adopted to identify the optimal combination of ewECG extracted features for SBHF screening in 178 participants in one trial and tested in 97 participants in the other trial. The accuracy of the ewECG model in SBHF screening was compared with NT-proBNP and ARIC HF.

RESULTS

SBHF was identified in 128 (72%) participants in the training dataset (median 72 years, 41% female) and 64 (66%) in the validation dataset (median 70 years, 43% female). Fifteen ewECG features showed an area under the curve (AUC) of 0.81 (95% CI 0.787-0.794) in identifying SBHF, significantly better than both NT-proBNP (AUC 0.56, 95% CI 0.44-0.68, p < 0.001) and ARIC HF (AUC 0.67, 95%CI 0.56-0.79, p = 0.002). ewECG features were also led to robust models screening for DD (AUC 0.74, 95% CI 0.73-0.74), reduced GLS (AUC 0.76, 95% CI 0.73-0.74) and LVH (AUC 0.90, 95% CI 0.88-0.89).

CONCLUSIONS

Machine learning based modelling using additional ewECG extracted features are superior to NT-proBNP and ARIC HF in SBHF screening among patients with T2DM, providing an alternative HF screening strategy for asymptomatic patients and potentially act as a guidance tool to determine those who required echocardiogram to confirm diagnosis. Trial registration LEAVE-DM, ACTRN 12619001393145 and Vic-ELF, ACTRN 12617000116325.

Identification of novel endogenous control miRNAs in heart failure for normalization of qPCR data

MicroRNAs (miRNAs), a class of non-coding RNAs, are utilized as biomarkers for a wide range of disorders. Circulating miRNAs are proposed as potential markers in the clinical identification of heart failure (HF). However, identifying miRNA biomarkers in HF requires identification of robust endogenous control miRNAs for normalization in differential expression analysis. Hence, this study aimed to identify circulating miRNAs that can be utilized as endogenous controls in HF. We evaluated the expression of eight miRNAs, which were previously reported as endogenous controls in different pathological conditions. Total RNA, including miRNA, was extracted from the serum samples of 30 HF patients (15 HFrEF and 15 HFpEF) and their matched controls (n = 15). We used quantitative PCR to determine the miRNA expression. The stability of the selected endogenous miRNAs was assessed and compared using a standard set of criteria with the RefFinder software. Six of the eight miRNAs analyzed showed consistent expression among all sample groups. Stability analysis ranked hsa-let-7i-5p, hsa-miR-148b-3p, and hsa-miR-484 as the most stable miRNAs, indicating their potential as reliable endogenous controls.

A Software Tool for Estimating Uncertainty of Bayesian Posterior Probability for Disease

The role of medical diagnosis is essential in patient care and healthcare. Established diagnostic practices typically rely on predetermined clinical criteria and numerical thresholds. In contrast, Bayesian inference provides an advanced framework that supports diagnosis via in-depth probabilistic analysis. This study's aim is to introduce a software tool dedicated to the quantification of uncertainty in Bayesian diagnosis, a field that has seen minimal exploration to date. The presented tool, a freely available specialized software program, utilizes uncertainty propagation techniques to estimate the sampling, measurement, and combined uncertainty of the posterior probability for disease. It features two primary modules and fifteen submodules, all designed to facilitate the estimation and graphical representation of the standard uncertainty of the posterior probability estimates for diseased and non-diseased population samples, incorporating parameters such as the mean and standard deviation of the test measurand, the size of the samples, and the standard measurement uncertainty inherent in screening and diagnostic tests. Our study showcases the practical application of the program by examining the fasting plasma glucose data sourced from the National Health and Nutrition Examination Survey. Parametric distribution models are explored to assess the uncertainty of Bayesian posterior probability for diabetes mellitus, using the oral glucose tolerance test as the reference diagnostic method.

Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Pioglitazone and barriers to effective post-stroke comorbidity management in stroke survivors with diabetes

OBJECTIVES

To explore the barriers preventing pioglitazone use in stroke survivors and primary and secondary stroke care services.

METHODS

A qualitative grounded theory approached design was used to assess post-stroke diabetes treatments and to assess clinical applicability of pioglitazone as a preventive treatment to minimize its side effects (SEs) associated. Three focus groups were established with 48 participants from Scotland and Wales health board centers during January 2019 to July 2022.

RESULTS

A qualitative grounded theory approached design was used to assess post-stroke diabetes treatments and to assess clinical applicability of pioglitazone as a preventive treatment to minimize its SEs associated. Three focus groups were established with 48 participants from Scotland and Wales health board centers during January 2019 to July 2022.

CONCLUSION

These strategies might allow greater treatment adherence by stroke survivors and increased confidence of the health care professionals in their practice. The findings suggest that further research will be needed to facilitate wider usage of pioglitazone in treating people with stroke and health education is necessitate when using diabetes drugs post-stroke.

Impact of recombinant human brain natriuretic peptide on emergency dialysis and prognosis in end-stage renal disease patients with type 4 cardiorenal syndrome

Recombinant human brain natriuretic peptide (rhBNP) effects on type 4 cardiorenal syndrome (CRS) and adverse events such as heart failure rehospitalization and all-cause mortality have not been assessed in large-scale research. This study evaluated the impact of rhBNP on emergency dialysis and prognosis in end-stage renal disease (ESRD) patients with type 4 CRS, and the risk factors of emergency dialysis. This retrospective cohort study included patients with type 4 CRS and ESRD admitted for decompensated heart failure between January 2016 and December 2021. Patients were divided into the rhBNP and non-rhBNP cohorts, according to whether they were prescribed rhBNP. The primary outcomes were emergency dialysis at first admission and cardiovascular events within a month after discharge. A total of 77 patients were included in the rhBNP cohort (49 males and 28 females, median age 67) and 79 in the non-rhBNP cohort (47 males and 32 females, median age 68). After adjusting for age, residual renal function, and primary diseases, Cox regression analysis showed that rhBNP was associated with emergency dialysis (HR = 0.633, 95% CI 0.420-0.953) and cardiovascular events (HR = 0.410, 95% CI 0.159-0.958). In addition, multivariate logistic regression analysis showed that estimated glomerular filtration rate (eGFR) (OR = 0.782, 95% CI 0.667-0.917, P = 0.002) and procalcitonin (PCT) levels (OR = 1.788, 95% CI 1.193-2.680, P = 0.005) at the first visit were independent risk factors for emergency dialysis while using rhBNP was a protective factor for emergency dialysis (OR = 0.195, 95% CI 0.084-0.451, P < 0.001). This study suggests that RhBNP can improve cardiac function and reduce the occurrence of emergency dialysis and cardiovascular events in ESRD patients with type 4 CRS.

Plasma N-terminal pro-B-type natriuretic peptide in the detection of aortic valve stenosis

BACKGROUND

Systolic murmur suggestive of aortic valve origin is a common accidental finding, particularly in the elderly. Usually, it is due to aortic stenosis (AS) or aortic sclerosis (ASc). Currently, echocardiography is used to differentiate AS from ASc. Plasma N-terminal (NT)-prohormone BNP (NT-proBNP) is known to correlate with the severity of AS. We assessed whether NT-proBNP separates AS from ASc.

METHODS

The study population consisted of three groups: AS (n = 87, age 77 ± 7 years), ASc (n = 76, age 72 ± 10 years), and healthy controls (n = 101, age 55 ± 10 years). All subjects underwent transthoracic echocardiography and measurement of plasma NT-proBNP. Patients with diseases known to increase NT-proBNP were excluded.

RESULTS

The crude plasma NT-proBNP (median; IQR) in AS patients (413; 165-1055 ng/l) was significantly higher compared to ASc patients (96; 53-237 ng/l, p < 0.001) and healthy controls (50; 29-76 ng/l, p < 0.001). After adjusting for the confounding factors (age, coronary artery disease, renal function and diastolic blood pressure), plasma NT-proBNP remained significantly higher in AS patients as compared to ASc (p < 0.002) and controls (p < 0.0001). In the receiver-operating characteristic curve for NT-proBNP to identify AS from ASc and controls, the area under the curve was 0.878 with optimal cutoff of 115 ng/l. In addition, using 115 ng/l to separate AS from ASc yielded sensitivity of 0.885, and negative predictive value of 0.808.

CONCLUSIONS

NT-proBNP was sensitive to identify AS and useful to rule out AS in patients with systolic murmur in the left ventricular outflow tract provided the patient does not have coexisting disease known to impact NT-proBNP.

To support the use of NT-proBNP to better detect heart failure in patients with type 2 diabetes

PURPOSE

Heart failure (HF) is a chronic disease that causes approximately 300,000 and 250,000 deaths per year in Europe and United States, respectively. Type 2 Diabetes Mellitus (T2DM) is one the major risk factors of HF, and the investigation of NT-proBNP might support the early identification of HF in T2DM sufferers. Nevertheless, this parameter is poorly investigated. Thus, we aimed to demographically and clinically characterize diabetic patients which were prescribed with NT-proBNP in the primary care setting.

METHODS

Using a primary care database, we formed a cohort of patients aged ≥18 years diagnosed with T2DM between 2002 and 2021. A multivariate Cox model was adopted to assess the determinants associated with the prescription of NT-proBNP.

RESULTS

Among 167,961 T2DM patients, 7558 (4.5%, 95% CI: 4.4-4.6) were prescribed with NT-proBNP. Males and increasing age were expectedly associated with a higher propensity to be prescribed with NT-proBNP. In addition, a significant association was found for those suffering from obesity, ischemic cardiomyopathy, stroke, atrial fibrillation, hypertension, and with a Charlson Index of 2+.

CONCLUSION

These determinants might contribute to investigate the NT-proBNP in T2DM sufferers. A decision support system to appropriately ease the prescription of NT-proBNP might be therefore implemented in primary care settings.

Diagnostic accuracy of plasma brain natriuretic peptide for evaluation of dyspnea NYHA-III and NYHA-IV in emergency department of tertiary care hospital

Objective

To determine the diagnostic accuracy of breathing not properly (BNP) for evaluation of dyspnea NYHA III and IV due to systolic heart failure in emergency department patients keeping echocardiography as the gold standard.

Study design

Cross-sectional validation study. Setting: Department of Accident and Emergency Duration of Study: 25 July 2022-25 January 2023.

Subjects and methods

A total of 115 of both sexes presenting with acute onset of dyspnea and having NYHA Class III and IV were included. Emergency nursing staff had immediately taken a single venous blood sample for BNP and creatinine levels and a 2D echo was performed. Ejection fraction was recorded, and the diagnosis of systolic heart failure on the basis of an ejection fraction, that is less than or equal to 45% was documented.

Results

The age range in this study was from 18 to 65 years, with a mean age of 49.147±8.73 years. Mean BNP levels were 139.452±84.04 pg/ml. Patients with NYHA class III was 67.8 and 32.2% belongs to NYHA class IV. BNP levels greater than or equal to 100 pg/ml diagnosed 76 (66.1%) and echocardiography has diagnosed 68 (59.1%) patients with heart failure. BNP levels greater than or equal to 100 pg/ml had shown sensitivity 94.1%, specificity 74.5%, and diagnostic accuracy 86%, positive predictive value 84.21%, negative prediction value 89.74%, likelihood positive ratio 3.68 and likelihood negative ratio was 0.08 in diagnosis of heart failure.

Conclusion

BNP estimation is a sensible and particular procedure for diagnosing CHF in patients who present to the emergency department with acute dyspnea and may add extra advantages to the administration of patients with congestive heart failure (CHF) in our population.

Echocardiography for Volume Assessment in Acute Myocardial Infarction

Background Errors caused by improper volume estimation increase acute mortality rates in acute myocardial infarction (AMI). We aimed to determine volume status in AMI patients using echocardiography and to correlate the findings with clinical outcomes. Methods This cross-sectional, single-center study was performed at a tertiary care center in India between August 2017 and September 2020 involving AMI patients. We performed echocardiography for all patients. Parameters such as left ventricle (LV) and atrium size, LV end-diastolic pressure, inferior vena cava (IVC) size and size variation, velocity stroke volume, and velocity time integral variation were measured. B-lines were recorded by scanning 32 regions on the anterior chest in the supine position using cardiac probes of echocardiography. Results A total of 184 patients were enrolled in the study with male predominance (82.1%). The mean age of patients was 58.2 ± 10.7 years. Dilated (>2.1 cm) and collapsible (<50%) IVC, and B-lines were significantly associated with heart failure (HF) (p<0.001; r=0.87 and p<0.001; r=0.74, respectively). The area under receiver operating characteristics (AUROC) curve to diagnose HF at a cut-off value of >10 for B-lines was 0.897 (0.842-0.951). AUROC curve for IVC size in diagnosing hypovolemia was 0.063 (0.000-0.130). Conclusions Volume status based on IVC size and B-lines detected by echocardiography has a strong prognostic value in AMI patients and should be included in the routine assessment of these patients.

Identification of crucial genes related to heart failure based on GEO database

BACKGROUND

The molecular biological mechanisms underlying heart failure (HF) remain poorly understood. Therefore, it is imperative to use innovative approaches, such as high-throughput sequencing and artificial intelligence, to investigate the pathogenesis, diagnosis, and potential treatment of HF.

METHODS

First, we initially screened Two data sets (GSE3586 and GSE5406) from the GEO database containing HF and control samples from the GEO database to establish the Train group, and selected another dataset (GSE57345) to construct the Test group for verification. Next, we identified the genes with significantly different expression levels in patients with or without HF and performed functional and pathway enrichment analyses. HF-specific genes were identified, and an artificial neural network was constructed by Random Forest. The ROC curve was used to evaluate the accuracy and reliability of the constructed model in the Train and Test groups. Finally, immune cell infiltration was analyzed to determine the role of the inflammatory response and the immunological microenvironment in the pathogenesis of HF.

RESULTS

In the Train group, 153 significant differentially expressed genes (DEGs) associated with HF were found to be abnormal, including 81 down-regulated genes and 72 up-regulated genes. GO and KEGG enrichment analyses revealed that the down-regulated genes were primarily enriched in organic anion transport, neutrophil activation, and the PI3K-Akt signaling pathway. The upregulated genes were mainly enriched in neutrophil activation and the calcium signaling. DEGs were identified using Random Forest, and finally, 16 HF-specific genes were obtained. In the ROC validation and evaluation, the area under the curve (AUC) of the Train and Test groups were 0.996 and 0.863, respectively.

CONCLUSIONS

Our research revealed the potential functions and pathways implicated in the progression of HF, and designed an RNA diagnostic model for HF tissues using machine learning and artificial neural networks. Sensitivity, specificity, and stability were confirmed by ROC curves in the two different cohorts.

Research progress of non-coding RNA in atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia in clinic, and its incidence is increasing year by year. In today's increasingly prevalent society, ageing poses a huge challenge to global healthcare systems. AF not only affects patients' quality of life, but also causes thrombosis, heart failure and other complications in severe cases. Although there are some measures for the diagnosis and treatment of AF, specific serum markers and targeted therapy are still lacking. In recent years, ncRNAs have become a hot topic in cardiovascular disease research. These ncRNAs are not only involved in the occurrence and development of AF, but also in pathophysiological processes such as myocardial infarction and atherosclerosis, and are potential biomarkers of cardiovascular diseases. We believe that the understanding of the pathophysiological mechanism of AF and the study of diagnosis and treatment targets can form a more systematic diagnosis and treatment framework of AF and provide convenience for individuals with AF and the society.

Diagnostic accuracy of brain natriuretic peptide and N-terminal-pro brain natriuretic peptide to detect complications of cardiac transplantation in adults: A systematic review and meta-analysis

BACKGROUND

We aimed to evaluate the utility of BNP and NT-proBNP in identifying adverse recipient outcomes following cardiac transplantation.

METHODS

We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception to February 2023. We included studies reporting associations between BNP or NT-proBNP and adverse outcomes following cardiac transplantation in adults. We calculated standardised mean differences (SMD) with 95% confidence intervals (CI); or confusion matrices with sensitivities and specificities. Where meta-analysis was inappropriate, studies were analysed descriptively.

RESULTS

Thirty-two studies involving 2,297 cardiac transplantation recipients were included. We report no significant association between BNP or NT-proBNP and significant acute cellular rejection of grade 3A or higher (SMD 0.40, 95% CI -0.06-0.86) as defined by the latest 2004 International Society for Heart and Lung Transplantation Guidelines. We also report no strong associations between BNP or NT-proBNP and cardiac allograft vasculopathy or antibody mediated rejection.

CONCLUSION

In isolation, serum BNP and NT-proBNP lack sufficient sensitivity and specificity to reliably predict adverse outcomes following cardiac transplantation.

Biomarkers for the Diagnosis of Heart Failure in People with Diabetes: A Consensus Report from Diabetes Technology Society

Diabetes Technology Society assembled a panel of clinician experts in diabetology, cardiology, clinical chemistry, nephrology, and primary care to review the current evidence on biomarker screening of people with diabetes (PWD) for heart failure (HF), who are, by definition, at risk for HF (Stage A HF). This consensus report reviews features of HF in PWD from the perspectives of 1) epidemiology, 2) classification of stages, 3) pathophysiology, 4) biomarkers for diagnosing, 5) biomarker assays, 6) diagnostic accuracy of biomarkers, 7) benefits of biomarker screening, 8) consensus recommendations for biomarker screening, 9) stratification of Stage B HF, 10) echocardiographic screening, 11) management of Stage A and Stage B HF, and 12) future directions. The Diabetes Technology Society panel recommends 1) biomarker screening with one of two circulating natriuretic peptides (B-type natriuretic peptide or N-terminal prohormone of B-type natriuretic peptide), 2) beginning screening five years following diagnosis of type 1 diabetes (T1D) and at the diagnosis of type 2 diabetes (T2D), 3) beginning routine screening no earlier than at age 30 years for T1D (irrespective of age of diagnosis) and at any age for T2D, 4) screening annually, and 5) testing any time of day. The panel also recommends that an abnormal biomarker test defines asymptomatic preclinical HF (Stage B HF). This diagnosis requires follow-up using transthoracic echocardiography for classification into one of four subcategories of Stage B HF, corresponding to risk of progression to symptomatic clinical HF (Stage C HF). These recommendations will allow identification and management of Stage A and Stage B HF in PWD to prevent progression to Stage C HF or advanced HF (Stage D HF).

Diagnostic accuracy of natriuretic peptide screening for left ventricular systolic dysfunction in the community: systematic review and meta-analysis

AIMS

Heart failure (HF) is a global health burden and new strategies to achieve timely diagnosis and early intervention are urgently needed. Natriuretic peptide (NP) testing can be used to screen for left ventricular systolic dysfunction (LVSD), but evidence on test performance is mixed, and international HF guidelines differ in their recommendations. Our aim was to summarize the evidence on diagnostic accuracy of NP screening for LVSD in general and high-risk community populations and estimate optimal screening thresholds.

METHODS

We searched relevant databases up to August 2020 for studies with a screened community population of over 100 adults reporting NP performance to diagnose LVSD. Study inclusion, quality assessment, and data extraction were conducted independently and in duplicate. Diagnostic test meta-analysis used hierarchical summary receiver operating characteristic curves to obtain estimates of pooled accuracy to detect LVSD, with optimal thresholds obtained to maximize the sum of sensitivity and specificity.

RESULTS

Twenty-four studies were identified, involving 26 565 participants: eight studies in high-risk populations (at least one cardiovascular risk factor), 12 studies in general populations, and four in both high-risk and general populations combined. For detecting LVSD in screened high-risk populations with N-terminal prohormone brain natriuretic peptide (NT-proBNP), the pooled sensitivity was 0.87 [95% confidence interval (CI) 0.73-0.94] and specificity 0.84 (95% CI 0.55-0.96); for BNP, sensitivity was 0.75 (95% CI 0.65-0.83) and specificity 0.78 (95% CI 0.72-0.84). Heterogeneity between studies was high with variations in positivity threshold. Due to a paucity of high-risk studies that assessed NP performance at multiple thresholds, it was not possible to calculate optimal thresholds for LVSD screening in high-risk populations alone. To provide an indication of where the positivity threshold might lie, the pooled accuracy for LVSD screening in high-risk and general community populations were combined and gave an optimal cut-off of 311 pg/mL [sensitivity 0.74 (95% CI 0.53-0.88), specificity 0.85 (95% CI 0.68-0.93)] for NT-proBNP and 49 pg/mL [sensitivity 0.68 (95% CI 0.45-0.85), specificity 0.81 (0.67-0.90)] for BNP.

CONCLUSIONS

Our findings suggest that in high-risk community populations NP screening may accurately detect LVSD, potentially providing an important opportunity for diagnosis and early intervention. Our study highlights an urgent need for further prospective studies, as well as an individual participant data meta-analysis, to more precisely evaluate diagnostic accuracy and identify optimal screening thresholds in specifically defined community-based populations to inform future guideline recommendations.

Clinical Influence of Handheld Ultrasound, Supported by Automatic Quantification and Telemedicine, in Suspected Heart Failure

Early and correct heart failure (HF) diagnosis is essential to improvement of patient care. We aimed to evaluate the clinical influence of handheld ultrasound device (HUD) examinations by general practitioners (GPs) in patients with suspected HF with or without the use of automatic measurement of left ventricular (LV) ejection fraction (autoEF), mitral annular plane systolic excursion (autoMAPSE) and telemedical support. Five GPs with limited ultrasound experience examined 166 patients with suspected HF (median interquartile range = 70 (63-78) y; mean ± SD EF = 53 ± 10%). They first performed a clinical examination. Second, they added an examination with HUD, automatic quantification tools and, finally, telemedical support by an external cardiologist. At all stages, the GPs considered whether the patients had HF. The final diagnosis was made by one of five cardiologists using medical history and clinical evaluation including a standard echocardiography. Compared with the cardiologists' decision, the GPs correctly classified 54% by clinical evaluation. The proportion increased to 71% after adding HUDs, and to 74 % after telemedical evaluation. Net reclassification improvement was highest for HUD with telemedicine. There was no significant benefit of the automatic tools (p ≥ 0.58). Addition of HUD and telemedicine improved the GPs' diagnostic precision in suspected HF. Automatic LV quantification added no benefit. Refined algorithms and more training may be needed before inexperienced users benefit from automatic quantification of cardiac function by HUDs.

The Use of Brain Natriuretic Peptide in the Evaluation of Heart Failure in Geriatric Patients

Heart failure is one of the main morbidity and mortality factors in the general population and especially in elderly patients. Thus, at the European level, the prevalence of heart failure is 1% in people under 55 years of age but increases to over 10% in people over 70 years of age. The particularities of the elderly patient, which make the management of heart failure difficult, are the presence of comorbidities, frailty, cognitive impairment and polypharmacy. However, elderly patients are under-represented in clinical trials on the diagnosis and treatment of heart failure. The need for complementary methods (biomarkers) for differential and early diagnosis of heart failure is becoming more and more evident, even in its subclinical stages. These methods need to have increased specificity and sensitivity and be widely available. Natriuretic peptides, in particular B-type natriuretic peptide (BNP) and its fraction NTproBNP, have gained an increasingly important role in the screening, diagnosis and treatment of heart failure in recent years.

Serum Dynamin-Related Protein 1 Concentrations Discriminate Phenotypes and Predict Prognosis of Heart Failure

Background

Dynamin-related protein 1 (Drp1) has been demonstrated as a crucial role in mediating the programed cell death and cardiac metabolism through its regulatory of mitophagy in animal studies. However, the clinical values of Drp1 for human cardiac disease remain unknown. This study is aimed to evaluate the diagnostic and prognostic values of serum Drp1 in these patients with heart failure (HF).

Methods

The enzyme linked immunosorbent assay (ELISA) was used for measuring serum Drp1 concentrations in 85 cases of HF with preserved ejection fraction (HFpEF) and 86 cases of HF with reduced ejection fraction (HFrEF). The diagnostic value of Drp1 was evaluated using the receiver operating characteristic (ROC) analysis. The composite endpoint was consisted of cardiac death and rehospitalization for HF, and the association between Drp1 and clinical outcomes were further determined.

Results

Serum Drp1 concentrations were much higher in HFpEF than that in HFrEF (4.2 ± 3.7 ng/mL vs. 2.6 ± 2.2 ng/mL, p = 0.001) and the ROC analysis demonstrated it as a potential diagnostic biomarker for distinction of the HF phenotypes, with an optimal cutoff point of 3.5 ng/mL (area under the curve (AUC) = 0.659, sensitivity: 45.9%, specificity: 83.7%). Kaplan-Meier survival analysis indicated that a low serum concentration of Drp1 (cut-off value = 2.5 ng/mL, AUC = 0.738) was in relation to poor prognosis of HF. Moreover, binary logistic regression analysis identified the low serum concentration of Drp1 as an independent risk predictor for rehospitalization (odds ratio (OR) = 6.574, p = 0.001) and a composite endpoint (OR = 5.927, p = 0.001).

Conclusions

Our findings suggested that low serum concentrations of Drp1 might serve as a predicting biomarker for distinction of HF phenotypes and overall prognosis of HF.

Anaemia and Congestion in Heart Failure: Correlations and Prognostic Role

The aim of this study was to evaluate the relationship between anaemia and biomarkers of central/peripheral congestion in heart failure (HF) and the impact on mortality. We retrospectively evaluated 434 acute/chronic HF (AHF/CHF) patients. Anaemia was defined as haemoglobin levels <12 g/dL (women) or <13 g/dL (men). The brain natriuretic peptide (BNP) and hydration index (HI) were measured. The endpoint of the study was all-cause mortality. Anaemia occurred in 59% of patients with AHF and in 35% with CHF (p < 0.001) and showed a significant correlation with the NYHA functional class and renal function. BNP and HI were significantly higher in patients with anaemia than in those without anaemia. Independent predictors of anaemia included BNP, estimated creatinine clearance (eCrCL), and HI. The all-cause mortality rate was 21%, which was significantly higher in patients with anaemia than in those without anaemia (30% vs. 14%, p < 0.001; hazard ratio: 2.6). At multivariate Cox regression analysis, BNP, eCrCL, and HI were independent predictors for mortality (Hazard ratios: 1.0002, 0.97, and 1.05, respectively), while anaemia was not. Anaemia correlates with HF status, functional class, renal function, BNP, and HI. Anaemia was not an independent predictor for mortality, acting as a disease severity marker in congestive patients rather than as a predictor of death.

The association of circulating fibroblast growth factor 21 levels with incident heart failure: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Fibroblast growth factor 21 (FGF21) levels are often elevated in heart failure (HF), although this has not been assessed using a longitudinal study design. Therefore, we investigated the association between baseline plasma FGF21 levels and incident HF in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

A total of 5408 participants, free of clinically apparent cardiovascular disease, were included in the analysis, of which 342 developed HF over a median follow-up period of 16.7 years. Multivariable Cox regression analysis was performed and the additive value of FGF21 in the performance of risk prediction over other well-established cardiovascular biomarkers was assessed.

RESULTS

The mean age of the participants was 62.6 years with 47.6 % male. Regression spline analysis demonstrated a significant association of FGF21 levels with incident HF among participants with FGF21 levels ≥239.0 pg/mL (hazard ratio = 1.84 [95 % confidence interval 1.21, 2.80] per SD increase in ln-transformed levels) after adjustment for traditional cardiovascular risk factors and biomarkers, but not in participants with FGF21 levels <239.0 pg/mL (p for heterogeneity = 0.004). Among participants with FGF21 levels ≥239.0 pg/mL, FGF21 levels were associated with HF with preserved ejection fraction (HR [95 % CI] = 2.57 [1.51, 4.37]), but not HF with reduced ejection fraction.

CONCLUSIONS

The present study suggests baseline FGF21 levels could predict the development of incident HF with preserved ejection fraction, among participants with elevated FGF21 levels at baseline. This study may suggest a pathophysiological role of FGF21 resistance in HF with preserved ejection fraction.

Blood pressure per the 2017 ACC/AHA and 2018 ESC/ESH guidelines and heart failure risk: the Suita Study

Hypertension is a significant risk factor for heart failure (HF). Since hypertension definition varies across guidelines, identifying blood pressure (BP) categories that should be targeted to prevent HF is required. We, therefore, investigated the association between hypertension per the 2017 American College of Cardiology/American Heart Association (ACC/AHA) and 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines and HF risk. This prospective cohort study included randomly selected 2809 urban Japanese people from the Suita Study. Cox regression was used to assess HF risk, in the form of hazard ratios (HRs) and 95% confidence intervals (95% CIs), for different BP categories in both guidelines, compared to a reference category defined as systolic BP (SBP) <120 mmHg and diastolic BP (DBP) <80 mmHg. Within 8 years of median follow-up, 339 HF cases were detected. Per the 2017 ACC/AHA guidelines, hypertension I and II and isolated systolic hypertension were associated with increased HF risk: HRs (95% CIs) = 1.81 (1.33-2.47), 1.68 (1.24-2.27), and 1.64 (1.13-2.39), respectively. Per the 2018 ESC/ESH guidelines, high-normal BP, hypertension I, II, and III, and isolated systolic hypertension were associated with increased HF risk: HRs (95% CIs) = 1.88 (1.35-2.62), 1.57 (1.13-2.16), 2.10 (1.34-3.29), 2.57 (1.15-5.77), and 1.51 (1.04-2.19), respectively. In conclusion, hypertension and isolated systolic hypertension per the 2017 ACC/AHA and 2018 ESC/ESH guidelines and high-normal BP per the 2018 ESC/ESH guidelines are risk factors for HF.

Role of N-terminal pro-B type natriuretic peptide as a predictor of poor outcomes in patients with HFrEF receiving primary prevention implantable cardioverter-defibrillator therapy: a systematic review and dose-response meta-analysis

INTRODUCTION

Several studies have demonstrated that combining left ventricular ejection fraction and New York Heart Association functional class is insufficient for predicting risk of appropriate implantable cardioverter-defibrillator (ICD) shock in primary prevention candidates. Hence, our aim was to assess the relationship between N-terminal pro-B type natriuretic peptide (NT-pro BNP) along with appropriate ICD shock and all-cause mortality in order to improve the stratification process of patients with heart failure with reduced ejection fraction (HFrEF) being considered for primary preventive ICD therapy.

METHODS

A systematic literature search from several databases was conducted up until 9 June 2022. Studies were eligible if they investigated the relationship of NT-pro BNP with all-cause mortality and appropriate ICD shock.

RESULTS

This meta-analysis comprised nine studies with a total of 5117 participants. Our study revealed that high levels of NT-pro BNP were associated with all-cause mortality (HR=2.12 (95% CI=1.53 to 2.93); p<0.001, I²=78.1%, p<0.001 for heterogeneity) and appropriate ICD shock (HR=1.71 (95% CI=1.18 to 2.49); p<0.001, I²=43.4%, p=0.102 for heterogeneity). The adjusted HR for all-cause mortality and appropriate ICD shock increased by approximately 3% and 5%, respectively per 100 pg/mL increment pursuant to concentration-response model (P_{non-linearity} <0.001). The curves became steeper after NT-pro BNP reached its inflection point (3000 pg/mL).

CONCLUSION

A positive concentration-dependent association between elevated NT-pro BNP levels along with the risk of all-cause mortality and appropriate ICD shock was found in patients with HFrEF with ICD.

PROSPERO REGISTRATION NUMBER

CRD42022339285.

Prognostic Value of Soluble AXL in Serum from Heart Failure Patients with Preserved and Reduced Left Ventricular Ejection Fraction

Heart failure (HF) is classified according to the degree of reduction in left ventricular ejection fraction (EF) in HF with reduced, mildly reduced, and preserved EF. Biomarkers could behave differently depending on EF type. Here, we analyze the soluble form of the AXL receptor tyrosine kinase (sAXL) in HF patients with reduced and preserved EF. Two groups of HF patients with reduced (HFrEF; n = 134) and preserved ejection fraction (HFpEF; n = 134) were included in this prospective observational study, with measurements of candidate biomarkers and functional, clinical, and echocardiographic variables. A Cox regression model was used to determine predictors for clinical events: cardiovascular mortality and all-cause mortality. sAXL circulating values predicted outcome in HF: for a 1.0 ng/mL increase in serum sAXL, the mortality hazard ratio (HR) was 1.019 for HFrEF (95% CI 1.000 to 1.038) and 1.032 for HFpEF (95% CI 1.013 to 1.052). In a multivariable Cox regression analysis, sAXL and NT-proBNP were independent markers for all-cause and cardiovascular mortality in HFpEF. In contrast, only NT-proBNP remained significant in the HFrEF group. When analyzing the event-free survival at a mean follow-up of 3.6 years, HFrEF and HFpEF patients in the higher quartile of sAXL had a reduced survival time. Interestingly, sAXL is a reliable predictor for all-cause and cardiovascular mortality only in the HFpEF cohort. The results suggest an important role for AXL in HFpEF, supporting sAXL evaluation in larger clinical studies and pointing to AXL as a potential target for HF therapy.

Left atrial reservoir strain measurements derived from intracardiac echocardiography in patients with atrial fibrillation: comparison with transthoracic echocardiography

BACKGROUND

Intracardiac echocardiography (ICE) provides accurate left atrial (LA) anatomical information in the procedure of atrial fibrillation (AF) ablation but lacks LA functional assessment. LA reservoir strain (LASr) is an excellent marker of LA reservoir function. This study aimed to assess the agreement between LASr derived from ICE and transthoracic echocardiography (TTE) in AF patients and analyze the reproducibility of LASr assessed by ICE combined with speckle tracking imaging.

METHODS

This study prospectively enrolled 110 patients with a clinical diagnosis of AF who were ready for AF ablation, including 71 patients with paroxysmal AF and 39 with persistent AF. TTE and ICE examinations were performed on each individual before AF ablation. LASr measurements derived from ICE and TTE images were using dedicated LA-tracking software. Pearson correlation coefficients (r) and Bland-Altman plots were used to evaluate the agreement of LASr between the two modalities. Intraclass correlation coefficients (ICCs) were used to assess intra- and inter-observer reproducibility.

RESULTS

The agreement between LASr obtained from ICE and TTE, especially between LASr_LPV (LASr derived from LA left pulmonary vein view of ICE) and LASr_TTE (LASr derived from TTE) were good in both paroxysmal and persistent AF patients [r = 0.890 (P < 0.001) for overall population; r = 0.815 (P < 0.001) and Bias ± LOA: -0.3 ± 9.9% for paroxysmal AF; r = 0.775 (P < 0.001) and Bias ± LOA: -2.6 ± 3.9% for persistent AF, respectively]. But the values of LASr derived from ICE were slightly lower than those of TTE, especially in patients with persistent AF. The ICCs for LASr derived from ICE were excellent (all ICCs > 0.90).

CONCLUSIONS

In patients with AF, LASr derived from ICE demonstrated excellent reproducibility and showed good agreement with LASr obtained from TTE. Obtaining LASr from ICE images may be a supplementary method to evaluate LA reservoir function in AF patients and expands the potential of ICE in the field of cardiac function assessment.

From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis

Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.

Fibroblast growth factor 21 in heart failure

Fibroblast growth factor 21 (FGF21) is a peptide hormone involved in energy homeostasis that protects against the development of obesity and diabetes in animal models. Its level is elevated in atherosclerotic cardiovascular diseases (CVD) in humans. However, little is known about the role of FGF21 in heart failure (HF). HF is a major global health problem with a prevalence that is predicted to rise, especially in ageing populations. Despite improved therapies, mortality due to HF remains high, and given its insidious onset, prediction of its development is challenging for physicians. The emergence of cardiac biomarkers to improve prediction, diagnosis, and prognosis of HF has received much attention over the past decade. Recent studies have suggested FGF21 is a promising biomarker candidate for HF. Preclinical research has shown that FGF21 is involved in the pathophysiology of HF through the prevention of oxidative stress, cardiac hypertrophy, and inflammation in cardiomyocytes. However, in the available clinical literature, FGF21 levels appear to be paradoxically raised in HF, potentially implying a FGF21 resistant state as occurs in obesity. Several potential confounding variables complicate the verdict on whether FGF21 is of clinical value as a biomarker. Further research is thus needed to evaluate whether FGF21 has a causal role in HF, and whether circulating FGF21 can be used as a biomarker to improve the prediction, diagnosis, and prognosis of HF. This review draws from preclinical and clinical studies to explore the role of FGF21 in HF.

Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy study

BACKGROUND

Natriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.

AIM

To report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.

DESIGN AND SETTING

Diagnostic accuracy study using linked primary and secondary care data (2004 to 2018).

METHOD

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.

RESULTS

In total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).

CONCLUSION

At the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable 'rule-out' test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

NT-proBNP, cerebral small vessel disease and cardiac function in patients with a recent lacunar infarct

NT-proBNP is produced from both atria and ventricles and it is increased in patients with cardiac disease. NT-proBNP is also associated with cerebral small vessel disease(cSVD) but there are no studies that had carried out a systematic evaluation of cardiac function in this specific setting. We conducted a prospective observational study in 100 patients within 30 days after a recent lacunar infarct by means of brain MRI, 24 h ambulatory blood pressure monitoring, transthoracic echocardiography, and plasmatic NT-proBNP. Global cSVD burden was quantified using a validated visual score (0 to 4) and dichotomized into 2 groups (0-2 or 3-4). Age (73.8 vs 63.5 years) and NT-proBNP (156 vs 76 pg/ml) were increased in patients with SVD 3-4, while daytime augmentation index normalized for the heart rate of 75 bpm (AIx75) (22.5 vs 25.6%) was decreased. The proportion of patients with left atrial enlargement, left ventricular hypertrophy, or septal e' velocity <7 cm/s was not different between both groups. NT-proBNP was increased in patients with left atrial enlargement (126 vs 88 pg/ml). In multivariate analysis, age (OR 1.129 CI 95% 1.054-1.209), daytime AIx75 (OR 0.91 CI 95% 0.84-0.987,) and NT-proBNP (OR 1.007 CI 95% 1.001-1.012,) were independently associated with cSVD score 3-4. In conclusion, as well as in other patients with cSVD we found an association between NT-proBNP and cSVD. This association was independent of cardiac function.

Alcohol consumption and the risk of heart failure: the Suita Study and meta-analysis of prospective cohort studies

BACKGROUND

Alcohol consumption is a modifiable lifestyle, but its role in heart failure (HF) development is controversial. Herein, we investigated the prospective association between alcohol consumption and HF risk.

METHODS

A total of 2,712 participants (1,149 men and 1,563 women) from the Suita Study were followed up every two years. Cox regression was applied to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of HF risk for heavy drinking (≥46 g/day in men or ≥23 g/day in women) and never drinking compared to light drinking (<23 g/day in men or <11.5 g/day in women). Then, we combined the results of the Suita Study with those from other eligible prospective cohort studies in a meta-analysis using the random-effects model.

RESULTS

In the Suita Study, within a median follow-up period of 8 years, 319 HF cases (162 in men and 157 in women) were detected. In men, but not women, never and heavy drinking carried a higher risk of HF than light drinking: HRs (95% CIs) = 1.65 (1.00, 2.73) and 2.14 (1.26, 3.66), respectively. Alike, the meta-analysis showed a higher risk of HF among heavy drinkers: HR (95% CI) = 1.37 (1.15, 1.62) and abstainers: HR (95% CI) = 1.18 (1.02, 1.37).

CONCLUSION

We indicated a J-shaped association between alcohol consumption and HF risk among Japanese men. The results of the meta-analysis came in line with the Suita Study. Heavy-drinking men should be targeted for lifestyle modification interventions.

Cost-effectiveness of NT-proBNP-supported screening of chronic heart failure in patients with or without type 2 diabetes in Austria and Switzerland

BACKGROUND

Heart failure (HF) is a clinical syndrome with a global burden. Signs and symptoms of HF are nonspecific and often shared with other conditions. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) serves as a useful biomarker for the diagnosis of HF not only in patients with acute symptoms but also in outpatients with an ambiguous clinical presentation. The aim of the analysis is to evaluate the cost-effectiveness of implementing NT-proBNP in the diagnostic algorithm in patients with/without type 2 diabetes mellitus (T2DM), compared with a diagnosis based primarily on clinical signs or symptoms from the perspective of the Austrian and Swiss healthcare system.

METHODS

A time-discrete Markov model was developed to simulate the effect/improvement (lifetime-costs, quality-adjusted life-years [QALYs], and life-years [LYs]) due to an NT-proBNP screening in undetected HF patients. Undetected HF patients are included in the model according to a distribution of New York Heart Association (NYHA) classes. The model considers disease progression by transition of NYHA classes. Undetected patients may remain undetected or be detected with the help of NT-proBNP or symptoms. Patients with known HF exhibit a slower disease progression. The probability of dying is influenced by the respective NYHA class. Direct costs (2021 € or CHF) were derived from published sources. QALYs, LYs, and costs were discounted (3% p.a.).

RESULTS

In the per-patient analysis (at age 60 over lifetime), the incremental cost-utility ratio (ICUR)/QALY of NT-proBNP vs. no screening was €3,042 for HF patients in Austria. Considering the total cohort of undetected HF patients (n = 9,377) with the corresponding age structure over a lifetime, the ICUR increases to €4,356. In Switzerland, the per-patient results show an ICUR of CHF 897. Considering the total cohort of undetected HF patients (n = 6,826) the ICUR amounts to CHF 4,513. If indirect costs are considered, NT-proBNP screening becomes the dominant strategy in both countries.

CONCLUSION

Overall, the analysis concludes that screening with NT-proBNP is a highly cost-effective or cost-saving diagnostic option for patients with HF, and a sensitivity analysis confirmed these findings.