Added value of H-FABP as plasma biomarker for the early evaluation of suspected acute coronary syndrome

Advances in congestive heart failure biomarkers

Congestive heart failure (CHF) is the leading cause of morbidity and mortality in the elderly worldwide. Although many biomarkers associated with in heart failure, these are generally prognostic and identify patients with moderate and severe disease. Unfortunately, the role of biomarkers in decision making for early and advanced heart failure remains largely unexplored. Previous studies suggest the natriuretic peptides have the potential to improve the diagnosis of heart failure, but they still have significant limitations related to cut-off values. Although some promising cardiac biomarkers have emerged, comprehensive data from large cohort studies is lacking. The utility of multiple biomarkers that reflect various pathophysiologic pathways are increasingly being explored in heart failure risk stratification and to diagnose disease conditions promptly and accurately. MicroRNAs serve as mediators and/or regulators of renin-angiotensin-induced cardiac remodeling by directly targeting enzymes, receptors and signaling molecules. The role of miRNA in HF diagnosis is a promising area of research and further exploration may offer both diagnostic and prognostic applications and phenotype-specific targets. In this review, we provide insight into the classification of different biochemical and molecular markers associated with CHF, examine clinical usefulness in CHF and highlight the most clinically relevant.

Fatty Acid-Binding Proteins: Their Roles in Ischemic Stroke and Potential as Drug Targets

Stroke is among the leading causes of death and disability worldwide. However, despite long-term research yielding numerous candidate neuroprotective drugs, there remains a lack of effective neuroprotective therapies for ischemic stroke patients. Among the factors contributing to this deficiency could be that single-target therapy is insufficient in addressing the complex and extensive mechanistic basis of ischemic brain injury. In this context, lipids serve as an essential component of multiple biological processes and play important roles in the pathogenesis of numerous common neurological diseases. Moreover, in recent years, fatty acid-binding proteins (FABPs), a family of lipid chaperone proteins, have been discovered to be involved in the onset or development of several neurodegenerative diseases, including Alzheimer’s and Parkinson’s disease. However, comparatively little attention has focused on the roles played by FABPs in ischemic stroke. We have recently demonstrated that neural tissue-associated FABPs are involved in the pathological mechanism of ischemic brain injury in mice. Here, we review the literature published in the past decade that has reported on the associations between FABPs and ischemia and summarize the relevant regulatory mechanisms of FABPs implicated in ischemic injury. We also propose candidate FABPs that could serve as potential therapeutic targets for ischemic stroke.

Are fatty acids and fatty acid binding proteins novel biomarkers for cryoablation efficiency?

PURPOSE

Cryoablation is a recommended, modern and well-tolerated method of treating atrial fibrillation (AF). The study evaluates plasma biomarkers related to AF and the effectiveness of its treatment - cryoablation. Heart- and adipocyte-type fatty acid binding proteins (H-FABP and A-FABP, respectively) as well as fatty acids (FAs) were assessed in patients that underwent cryoballoon ablation (CBA) for AF.

PATIENTS AND METHODS

Concentrations of plasma FABPs and FAs were measured in 33 AF patients on admission and 24 ​h after CBA (enzyme-linked immunoassay and gas liquid chromatography, respectively). The control group consisted of 20 volunteers.

RESULTS

We showed that plasma H-FABP and A-FABP concentrations were significantly higher in the patients with AF than in the control group (1135 ​pg/mL vs 836 ​pg/mL, and 34.29 ​ng/mL vs 15.14 ​ng/mL, respectively; p ​< ​0.05). After CBA, H-FABP plasma concentration increased even further (1574 ​pg/mL vs 1135 ​pg/mL; p ​< ​0.05) and FAs levels decreased concomitantly. AF recurred in 8 patients (24.25%) after 3 months and in 13 patients (39.4%) after 6 months. Initially higher concentration of oleic acid (680.24 ​± ​189.768 vs 567.04 ​± ​70.002; p ​< ​0.05) correlated substantially with lower AF relapse rate in 6 months follow-up.

CONCLUSIONS

The patients with AF showed increased concentration of H-FABP, whereas CBA triggered further elevation of H-FABP with a simultaneous decline in the total plasma FAs concentration. H-FABP and A-FABP could not be confirmed as new biomarkers of cryoablation efficiency, but this requires further investigation due to the limitations of the study.

Diagnostic Value of Heart-type Fatty Acid Binding Protein in Group of Patients with NSTEMI at the Time of Application for Medical Care

The relevance of the early detection of myocardial necrosis is due to the difficulties of differential diagnosis in the first hours of the development of acute coronary syndrome. Therefore, the doctors of the first contact, as before, are interested in an early cardiac marker and the presence of tests based on it. Heart fatty acid binding protein (h-FABP) is a cardiac marker that increases in the blood to diagnostic values after just one hour from the beginning of clinical manifestations. The objective: to determine the diagnostic value of heart fatty acid binding protein in group of patients with NSTEMI. Materials and methods. We examined 280 patients with STEMI, 91 patients with NSTEMI, 76 with stable angina pectoris. Blood samples were taken from all patients at the first contact to determine troponin I, a heart fatty acid binding protein and CPK-MB. Patients with NSTEMI were divided into three subgroups: the first – up to 3 hours from the onset of symptoms, the second – from 3 to 6, the third from 6 to 12. The level of heart fatty acid binding protein in plasma was determined by enzyme immunoassay. Results. The early detection of AMI in people visiting primary care doctors with chest pain continues to be a challenge. Undoubtedly, cardiac troponins are the “gold standard” for the diagnosis of AMI, but early detection of these can give a negative result. The results of the studies show a high diagnostic efficacy of h-FABP in the early diagnosis of AMI, and it is superior in sensitivity (in the first hours from the onset of the disease) to cardiac troponins. So, for example, in the subgroup of patients with the onset of symptom manifestation up to 3 hours for h-FABP with a cut-off >0,48 ng/ml, the sensitivity was 92.7 % and specificity was 97,3 % (AUC=0,99; 95 % CI AUC 0,942–0,998). In the same subgroup, troponin I had a specificity of  22,0 %, with cut off >0,84 ng/ml (AUC=0,71; 95 % CI AUC 0,615–0,787). Conclusions. The level of cardiac protein that binds fatty acids is significantly increased in patients with acute myocardial infarction compared with stable coronary heart disease.

Heart-type fatty acid-binding protein: an overlooked cardiac biomarker

Cardiac troponins (cTn) are currently the standard of care for the diagnosis of acute coronary syndromes (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). However, their plasma kinetics necessitate a prolonged ED stay or overnight hospital admission, especially in those presenting early after CP onset. Moreover, ruling out ACS in low-risk patients requires prolonged ED observation or overnight hospital admission to allow serial measurements of c-Tn, adding cost. Heart-type fatty acid-binding protein (H-FABP) is a novel marker of myocardial injury with putative advantages over cTn. Being present in abundance in the myocellular cytoplasm, it is released rapidly (<1 h) after the onset of myocardial injury and could potentially play an important role in both earlier diagnosis of high-risk patients presenting early after CP onset, as well as in risk-stratifying low-risk patients rapidly. Like cTn, H-FABP also has a potential role as a prognostic marker in other conditions where the myocardial injury occurs, such as acute congestive heart failure (CHF) and acute pulmonary embolism (PE). This review provides an overview of the evidence examining the role of H-FABP in early diagnosis and risk stratification of patients with CP and in non-ACS conditions associated with myocardial injury. Key messages Heart-type fatty acid-binding protein is a biomarker that is elevated early in myocardial injury The routine use in the emergency department complements the use of troponins in ruling out acute coronary syndromes in patients presenting early with chest pain It also is useful in risk stratifying patients with other conditions such as heart failure and acute pulmonary embolism.

Heart-Type Fatty Acid-Binding Protein (H-FABP) and its Role as a Biomarker in Heart Failure: What Do We Know So Far?

BACKGROUND

Heart failure (HF) remains one of the leading causes of death to date despite extensive research funding. Various studies are conducted every year in an attempt to improve diagnostic accuracy and therapy monitoring. The small cytoplasmic heart-type fatty acid-binding protein (H-FABP) has been studied in a variety of disease entities. Here, we provide a review of the available literature on H-FABP and its possible applications in HF. Methods: Literature research using PubMed Central was conducted. To select possible studies for inclusion, the authors screened all available studies by title and, if suitable, by abstract. Relevant manuscripts were read in full text.

RESULTS

In total, 23 studies regarding H-FABP in HF were included in this review.

CONCLUSION

While, algorithms already exist in the area of risk stratification for acute pulmonary embolism, there is still no consensus for the routine use of H-FABP in daily clinical practice in HF. At present, the strongest evidence exists for risk evaluation of adverse cardiac events. Other future applications of H-FABP may include early detection of ischemia, worsening of renal failure, and long-term treatment planning.

Clinical effects of tanshinone IIA sodium sulfonate combined with trimetazidine and levocarnitine in the treatment of AVMC and its effects on serum TNF-α, IL-18 and IL-35

Clinical effects of tanshinone IIA sodium sulfonate combined with trimetazidine and levocarnitine in the treatment of acute viral myocarditis (AVMC) were investigated. Eighty-six patients with AVMC treated in Dongying City People's Hospital from August 2016 to July 2017 were selected and randomly divided into control group (n=43) and observation group (n=43). Patients in control group were treated with tanshinone IIA sodium sulfonate, while those in observation group were treated with trimetazidine and levocarnitine. The curative effect and improvement in clinical symptoms were compared between the two groups of patients, and enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of heart-type fatty acid-binding protein (H-FABP), creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) in patients after treatment. Besides, the changes in levels of serum tumor necrosis factor-α (TNF-α), interleukin (IL)-18 and IL-35 were detected via ELISA. The total effective rate of treatment in observation group was significantly higher than that in control group (p<0.05). The improvement in clinical symptoms in observation group was significantly superior to that in control group (p<0.05). After treatment, levels of H-FABP, CK-MB and cTnI in observation group were obviously lower than those in control group (p<0.05). At 3, 5 and 7 days after treatment, the levels of TNF-α and IL-18 in both groups of patients were decreased compared with those before treatment, but the level of IL-35 was increased compared with that before treatment, and changes in observation group were more significant than those in control group (p<0.05). Tanshinone IIA sodium sulfonate combined with trimetazidine and levocarnitine has definite curative effects in the treatment of patients with AVMC, which can alleviate myocardial injury with higher safety, and effectively mitigate the inflammatory response in patients, so it is of great clinical significance.

Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on 'international data', at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice.

Effects of dexmedetomidine on H-FABP, CK-MB, cTnI levels, neurological function and near-term prognosis in patients undergoing heart valve replacement

This study investigated the effects of dexmedetomidine on heart-type fatty acid binding protein (H-FABP), creatine kinase isoenzymes (CK-MB), and troponin I (cTnI) levels, neurological function and near-term prognosis in patients undergoing heart valve replacement. Patients undergoing heart valve replacement were randomly allocated to remifentanil anesthesia (control group, n=48) or dexmedetomidine anesthesia (observation group, n=48). Hemodynamic parameters were measured before anesthesia induction (T1), 1 min after intubation (T2), 10 min after start of surgery (T3), and on completion of surgery (T4). Levels of plasma H-FABP, CK-MB and cTnI were measured 10 min before anesthesia induction (C1), 10 min after start of surgery (C2), on completion of surgery (C3), 6 h after surgery (C4), and 24 h after surgery (C5). S100β protein and serum neuron-specific enolase (NSE) were detected 10 min before anesthesia induction (C1), and 24 h after surgery (C5). Neurological and cardiac function was evaluated 24 h after surgery. Incidence of cardiovascular adverse events was recorded for 1 year of follow-up. There were no significant differences in the average heart rate between the two groups during the perioperative period. The mean arterial pressure in the observation group was significantly lower than control group (P<0.05). Levels of H-FABP, CK-MB and cTnI at C2, C3, C4 and C5, were significantly higher than C1, but significantly lower in the observation versus control group (P<0.05). Twenty-four hours after surgery, levels of S100β and NSE in both groups were higher than those before induction (P<0.05), but significantly lower in the observation versus control group (P<0.05). Twenty-four hours after surgery, neurological function scores were better, and myocardial contractility and arrhythmia scores significantly lower in the observation versus control group (P<0.05 for all). After follow-up for 1 year, incidence of cardiovascular adverse events was significantly lower in the observation versus control group (P<0.05). Dexmedetomidine anesthesia can effectively maintain hemodynamic stability, reduce myocardial injury and the occurrence of cognitive dysfunction, and improve prognosis in patients undergoing heart valve replacement.

The interobserver reliability of a novel qualitative point of care assay for heart-type fatty acid binding protein

BACKGROUND

Heart-type fatty acid-binding protein (h-FABP) may help to improve the early diagnosis of acute coronary syndromes in patients presenting to the Emergency Department (ED) with chest pain. A novel qualitative point of care h-FABP lateral flow immunoassay (True Rapid, FABPulous BV) could provide results to clinicians within just 5min. Given the qualitative nature of this test and prior to evaluation in a large diagnostic study, we aimed to determine inter-observer reliability when interpreted contemporaneously by staff in the ED.

METHODS

In a nested prospective cohort study including adult patients with suspected cardiac chest pain, venous blood samples were tested for h-FABP (FABPulous BV) on arrival and 3h later. Each test result was independently interpreted by two different investigators after 5min. The investigators were blinded to each other's interpretation and recorded their findings on separate case report forms. We determined interobserver reliability by calculating the Cohen's kappa score and 95% confidence intervals.

RESULTS

A total of 43 test results (from 31 patients) were each interpreted by two independent investigators. Absolute agreement between investigators was 93.0%, with a Cohen's kappa of 0.81 (95% CI 0.6-1.0), indicating near perfect agreement. In total there were three (7.0%) disagreements. In each case one investigator reported a 'weak positive' result while the other interpreted the result as 'negative'.

CONCLUSIONS

These findings demonstrate the interobserver reliability of a qualitative point of care h-FABP assay. Further work must evaluate diagnostic accuracy and determine the clinical implications of the small rate of disagreement.

Prognostic value of plasma biomarkers in patients with acute coronary syndrome: a review of advances in the past decade

Acute coronary syndrome (ACS), especially myocardial infarction, commonly known as a heart attack, is a serious life-threatening cardiovascular disease. Despite dramatic therapeutic advances, there have still been more than 20% patients with ACS suffering recurrent adverse cardiovascular events 3 years after disease onset. Therefore, the aim to prevent cardiac death caused by the heart attack remains challenging. Plasma biomarkers, originally developed to complement clinical assessment and electrocardiographic examination for the diagnosis of ACS, have been reported to play important prognostic roles in predicting adverse outcomes. These biomarkers mirror different pathophysiological mechanisms in association with ACS. In this review, we focus on advances of prognostic biomarkers in the past decade for short- and long-term risk assessment and management of patients with ACS.

Sensitive Detection of Cardiac Biomarkers Using a Magnetic Microbead Immunoassay

To achieve improved sensitivity in cardiac biomarker detection, a batch incubation magnetic microbead immunoassay was developed and tested on three separate human protein targets: myoglobin, heart-type fatty acid binding protein, and cardiac troponin I. A sandwich immunoassay was performed in a simple micro-centrifuge tube allowing full dispersal of the solid capture surface during incubations. Following magnetic bead capture and wash steps, samples were analyzed in the presence of a manipulated magnetic field utilizing a modified microscope slide and fluorescent inverted microscope to collect video data files. Analysis of the video data allowed for the quantitation of myoglobin, heart-type fatty acid binding protein and cardiac troponin I to levels of 360 aM, 67 fM, and 42 fM, respectively. Compared to the previous detection limit of 50 pM for myoglobin, this offers a five-fold improvement in sensitivity. This improvement in sensitivity and incorporation of additional markers, along with the small sample volumes required, suggest the potential of this platform for incorporation as a detection method in a total sample analysis device enabling multiplexed detection for the analysis of clinical samples.

Suspected acute coronary syndrome in the emergency room: Limited added value of heart type fatty acid binding protein point of care or ELISA tests: The FAME-ER (Fatty Acid binding protein in Myocardial infarction Evaluation in the Emergency Room) study

BACKGROUND

Timely recognition of acute coronary syndrome remains a challenge as many biomarkers, including troponin, remain negative in the first hours following the onset of chest pain. We assessed the diagnostic accuracy of heart-type fatty acid binding protein (H-FABP), a cardiac biomarker with potential value immediately post symptom onset.

METHODS AND RESULTS

Prospective monocentre diagnostic accuracy study of H-FABP bedside point of care (CardioDetect®) and ELISA tests in acute coronary syndrome suspected patients presenting within 24 hours of symptom onset to the emergency department, in addition to clinical findings, electrocardiography and the currently recommended biomarker high sensitivity troponin-T (hs-cTnT). The final diagnosis of acute coronary syndrome was adjudicated by two independent cardiologists, blinded to H-FABP results. Acute coronary syndrome was diagnosed in 149 (32.9%) of 453 unselected patients with suspected acute coronary syndrome (56% men, mean age 62.6 years). Negative predictive values were similar for H-FABP point of care and ELISA tests (79% vs. 78% respectively), but inferior to initial hs-cTnT (negative predictive value 86%). The addition of H-FABP point of care results to hs-cTnT increased the negative predictive value to 89%. In a multivariable logistic regression model, H-FABP point of care and ELISA tests yielded relevant diagnostic information in addition to clinical findings and ECG (likelihood ratio test p<0.001) and increased area under the receiver operating characteristics curve (AUC; 0.82 vs. 0.84 and 0.84). This added value attenuated, however, after inclusion of hs-cTnT in the diagnostic model (AUC 0.88).

CONCLUSIONS

In patients suspected of acute coronary syndrome presenting to the emergency department, H-FABP testing improves diagnostic accuracy in addition to clinical findings and electrocardiography. H-FABP, however, has no additional diagnostic value when hs-cTnT measurements are also available.