Biomarkers for Predicting the Occurrence and Progression of Atrial Fibrillation: Soluble Suppression of Tumorigenicity 2 Protein and Tissue Inhibitor of Matrix Metalloproteinase-1

Predictive value of soluble suppression of tumorigenicity 2 in atrial fibrillation: a systematic review and meta-analysis

Purpose

Atrial fibrosis is the main pathological basis for the pathogenesis and progression of atrial fibrillation (AF). Soluble suppression of tumorigenicity 2 (sST2) is involved in fibrosis. Recent studies have explored its predictive value in AF outcomes. We performed this study to assess whether sST2 is an independent biomarker of AF outcomes and explore the potential mechanism.

Methods

PubMed, Web of Science, EMBASE, and Cochrane Library databases were searched systematically from inception through July 1, 2023, to identify relevant studies. Outcomes of interest included occurrence, recurrence, and major adverse cardiac events (MACEs) of AF. This meta-analysis was reported following the criteria outlined in PRISMA 2020, and the protocol was registered in PROSPERO (number: CRD42023459789). All statistical analyses were performed using the STATA version 16.

Result

Twenty four studies with 14,755 patients were included in the meta-analysis. The meta-analyses found that sST2 was significantly associated with the risk of occurrence [HR:1.04, 95% CI: 1.02-1.07, P < 0.01; I2 = 67.8%], recurrence [HR:1.09, 95% CI: 1.02-1.16, P < 0.01; I2 = 89.5%], and MACEs (HR:1.60, 95% CI: 1.13-2.27, P < 0.01; I2 = 82.0%) of AF. Furthermore, patients with AF showed higher sST2 than controls without AF (SMD: 0.41, 95% CI: 0.27-0.54, P < 0.01; I2 = 0%), and AF patients with recurrence after catheter ablation (CA) showed significantly higher sST2 than those without recurrence (SMD: 0.81, 95% CI: 0.33-1.28, P < 0.01; I2 = 83.9%). Sensitivity analyses showed that the outcomes were stable.

Conclusions

Higher sST2 was association with an increased risk of occurrence, recurrence, and MACEs of AF. Assessing sST2 can be used as a potential screening method to predict AF outcomes.

Systematic Review Registration

PROSPERO (CRD42023459789).

The Role of Biochemical Cardiac Markers in Atrial Fibrillation

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Proteins are a component of cardiac biomarkers containing cell structures that are released into the circulation when a myocardial injury occurs. They are essential in the diagnosis, risk assessment, and treatment of patients who have chest pain, are thought to have acute coronary syndrome, or are experiencing acute heart failure exacerbations. There are numerous biochemical cardiac markers, but this article summarizes the basic role of major biochemical cardiac markers, including cardiac natriuretic peptides, cardiac troponins, C-reactive protein (CRP), creatine kinase-MB, heart-type fatty acid-binding protein, ischemia-modified albumin, lipoprotein (a), osteopontin (OPN), and soluble suppression of tumorigenicity 2 (sST2), in AF. Atrial natriuretic peptide may serve as an indicator of atrial integrity, which may help to select appropriate treatment approaches for AF. Higher levels of N-terminal pro-B-type natriuretic peptide and brain natriuretic peptide are predictive of incidental AF. Increased troponin T release may indicate better clinical results following AF ablation. Similarly, CRP increases the risk of the AF-increasing calcium (Ca) influx in atrial myocytes, but not because of atrial fibrosis. Patients with postoperative AF have lower FABP3 gene expression in the atrium. Lipoprotein (a) (Lp[a]) may play a causative role in the onset of AF and impact various cardiac tissues. Clinical trials for Lp(a)-lowering drugs should assess their impact on preventing AF. Also, OPN was highly expressed in the circulation of AF patients and further increased with the progression of AF. sST2 was a reliable predictor of new-onset AF and can improve the accuracy of the AF risk model. There is a greater chance that these cardiac biomarkers might be employed to enhance clinical risk stratification in AF.

Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion

Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.

Correlation between Serum Myosin Light Chain 4 Levels and Recurrence after Radiofrequency Ablation in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia that is harmful to human health. This study aims to explore the relationship between myosin light chain 4 (MYL4) and AF recurrence after radiofrequency ablation (RFA). Patients with AF (n = 85) were enrolled, and healthy subjects (n = 90) with normal sinus rhythm and no previous history of AF were selected as controls. The serum levels of MYL4, transforming growth factor (TGF) -β1, and procollagen type-I C-terminal propeptide (PICP) were determined. The correlation between MYL4 and atrial fibrosis remodeling indicators (TGF-β1/PICP) and left atrial diameter (LAD) was analyzed. The influence of MYL4 on AF recurrence after RFA was evaluated, and the independent correlation between them was assessed. Patients with AF and the controls showed no significant differences in age, gender, body mass index, systolic blood pressure, diastolic blood pressure, left ventricular ejection fraction, triglycerides, total cholesterol, high-density lipoprotein, low-density lipoprotein, white blood cell count, neutrophil/lymphocyte ratio, brain natriuretic peptide, and history of smoking, drinking, hypertension, and diabetes (P > 0.05), but with increased LAD in patients with AF (P < 0.01). Serum MYL4 level was reduced in patients with AF (0.6 ± 0.2) compared with that of controls (0.1 ± 0.6) (P < 0.01), and it was negatively correlated with TGF-β1, PICP, and LAD (r = -0.2389, P < 0.05; r = -0.5174, P < 0.01; r = -0.3191; P < 0.01). Low levels of MYL4 increased the risk of AF recurrence after RFA (χ² = 16.64; P < 0.0001). A low MYL4 level in patients with AF showed a poorer prognosis. Serum MYL4 level and AF type were independent risk factors affecting AF recurrence after RFA.