Elevation of carbohydrate antigen 125 in chronic heart failure may be caused by mechanical extension of mesothelial cells from serous cavity effusion

Cardiovascular Biomarkers in Cardio-Oncology: Antineoplastic Drug Cardiotoxicity and Beyond

Serum biomarkers represent a reproducible, sensitive, minimally invasive and inexpensive method to explore possible adverse cardiovascular effects of antineoplastic treatments. They are useful tools in risk stratification, the early detection of cardiotoxicity and the follow-up and prognostic assessment of cancer patients. In this literature review, we aim at describing the current state of knowledge on the meaning and the usefulness of cardiovascular biomarkers in patients with cancer; analyzing the intricate relationship between cancer and cardiovascular disease (especially HF) and how this affects cardiovascular and tumor biomarkers; exploring the role of cardiovascular biomarkers in the risk stratification and in the identification of chemotherapy-induced cardiotoxicity; and providing a summary of the novel potential biomarkers in this clinical setting.

Carbohydrate antigen 125 in congestive heart failure: ready for clinical application?

Congestion is the permanent mechanism driving disease progression in patients with acute heart failure (AHF) and also is an important treatment target. However, distinguishing between the two different phenotypes (intravascular congestion and tissue congestion) for personalized treatment remains challenging. Historically, carbohydrate antigen 125 (CA125) has been a frequently used biomarker for the screening, diagnosis, and prognosis of ovarian cancer. Interestingly, CA125 is highly sensitive to tissue congestion and shows potential for clinical monitoring and optimal treatment of congestive heart failure (HF). Furthermore, in terms of right heart function parameters, CA125 levels are more advantageous than other biomarkers of HF. CA125 is expected to become a new biological alternative marker for congestive HF and thereby is expected be widely used in clinical practice.

CA-125 variation in acute heart failure: a single-centre analysis

Aims

A decrease in carbohydrate antigen 125 (CA‐125) predicts survival advantage in chronic heart failure (HF); the impact of its variation in acute HF is unknown. We studied the association of CA‐125 decrease with prognosis in acute HF.

Methods and results

We studied acute hospitalized HF patients. Predictors of admission and discharge CA‐125 were determined by linear regression. Follow‐up was 1 year; endpoint was all‐cause death. The association of admission and discharge CA‐125 with mortality was assessed using a Cox‐regression analysis. A Cox‐regression analysis was also used to assess the prognostic impact of CA‐125 decrease during hospitalization. Analysis was stratified by length of hospital stay (LOS). We studied 363 patients, 51.5% male, mean age 75 ± 12 years, 51.5% ischaemic, 30.0% with preserved ejection fraction, and 57.3% with reduced ejection fraction; patients presented elevated comorbidity burden. Median LOS was 7 (5–11) days. In the subgroup of 262 patients with CA‐125 measured both at admission and at discharge, we reported a significant increase in its levels: 56.0 (26.0–160.7) U/mL to 74.0 (32.3–195.0) U/mL. Independent predictors of admission CA‐125 were higher BNP and lower creatinine. Predictors of discharge CA‐125 were higher discharge BNP, lower discharge albumin, and younger age. Both admission and discharge CA‐125 predicted mortality. During follow‐up, 75 (31.8%) patients died. A decrease in CA‐125 predicted a 68% reduction in the 1 year death risk only in patients with LOS > 10 days.

Conclusions

Our results suggest that an early re‐evaluation (>10 days) with CA‐125 measurement after an acute HF hospitalization may be of interest in patient management.

Cancer antigen-125 is a predictor of mortality in patients with pulmonary arterial hypertension

BACKGROUND

Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase and be associated with severity in heart failure and chronic obstructive pulmonary disease. Patients with pulmonary arterial hypertension may also die due to developing right heart failure. The aim of this study is to evaluate the prognostic role of CA-125 in PAH patients.

METHODS

A total of 40 consecutive patients with PAH were evaluated prospectively. The mean age of patients was 52 ± 11 years (12% males, 88% females) with a median follow-up period of 16 months.

RESULTS

After follow-up period, 12 out of 40 patients (30%) died. CA-125 levels were higher among those who died compared to those who survived [78.5 (11.0-292) vs. 27.5 (2.10-138) U/ml, p = 0.001]. The optimal cut-off value of CA-125 to predict mortality was found as 35.29 U/ml, with 85.7% specificity and 75% sensitivity. In multivariable Cox proportional-hazards model with forward stepwise method; CA-125 > 35.32 U/ml on admission (HR = 7.645, 95% CI: 1.356-43.121, p = 0.021), age (HR = 1.132, 95% CI: 1.040-1.233, p = 0.004), TAPSE (HR = 0.740, 95% CI: 0.549-0.998, p = 0.048) and uric acid (HR = 1.444, 95% CI: 1.022-2.042, p = 0.037) remained associated with an increased risk of death.

CONCLUSION

In this study, we showed for the first time that serum CA-125 values were an independent predictor for the long-term mortality in PAH patients.

Congestion occurrence and evaluation in acute heart failure scenario: time to reconsider different pathways of volume overload

Although congestion is considered to be the main reason for hospital admission in patients with acute heart failure, a simplistic view considering idro saline retention and total body volume accumulation did not provide convincing data. Clinical congestion occurrence is often the tip of the iceberg of several different mechanisms ranging from increased filling pressure to extravascular fluid accumulation and blood flow redistribution. Therefore, the clinical evaluation is often restricted to a simple physical examination including few and inaccurate signs and symptoms. This superficial approach has led to contradictory data and patients have not been evaluated according to a more realistic clinical scenario. The integration with new diagnostic ultrasonographic and laboratory tools would substantially improve these weaknesses. Indeed, congestion could be assessed by following the most recognized HF subtypes including primitive cardiac defect, presence of right ventricular dysfunction, and organ perfusion. Moreover, there is a tremendous gap regarding the interchangeable concept of fluid retention and redistribution used with a univocal meaning. Overall, congestion assessment should be revised, considering it as either central, peripheral, or both. In this review, we aim to provide different evidence regarding the concept of congestion starting from the most recognized pathophysiological mechanisms of AHF decompensation. We highlight the fact that a better knowledge of congestion is a challenge for future investigation and it could lead to significant advances in HF treatment.

Tumour biomarkers: association with heart failure outcomes

BACKGROUND

There is increasing recognition that heart failure (HF) and cancer are conditions with a number of shared characteristics.

OBJECTIVES

To explore the association between tumour biomarkers and HF outcomes.

METHODS

In 2,079 patients of BIOSTAT-CHF cohort, we measured six established tumour biomarkers: CA125, CA15-3, CA19-9, CEA, CYFRA 21-1 and AFP.

RESULTS

During a median follow-up of 21 months, 555 (27%) patients reached the primary end-point of all-cause mortality. CA125, CYFRA 21-1, CEA and CA19-9 levels were positively correlated with NT-proBNP quartiles (all P < 0.001, P for trend < 0.001) and were, respectively, associated with a hazard ratio of 1.17 (95% CI 1.12-1.23; P < 0.0001), 1.45 (95% CI 1.30-1.61; P < 0.0001), 1.19 (95% CI 1.09-1.30; P = 0.006) and 1.10 (95% CI 1.05-1.16; P < 0.001) for all-cause mortality after correction for BIOSTAT risk model (age, BUN, NT-proBNP, haemoglobin and beta blocker). All tumour biomarkers (except AFP) had significant associations with secondary end-points (composite of all-cause mortality and HF hospitalization, HF hospitalization, cardiovascular (CV) mortality and non-CV mortality). ROC curves showed the AUC of CYFRA 21-1 (0.64) had a noninferior AUC compared with NT-proBNP (0.68) for all-cause mortality (P = 0.08). A combination of CYFRA 21-1 and NT-proBNP (AUC = 0.71) improved the predictive value of the model for all-cause mortality (P = 0.0002 compared with NT-proBNP).

CONCLUSIONS

Several established tumour biomarkers showed independent associations with indices of severity of HF and independent prognostic value for HF outcomes. This demonstrates that pathophysiological pathways sensed by these tumour biomarkers are also dysregulated in HF.

Adjustment of serum HE4 to reduced glomerular filtration and its use in biomarker-based prediction of deep myometrial invasion in endometrial cancer

Background

We investigated the efficacy of circulating biomarkers together with histological grade and age to predict deep myometrial invasion (dMI) in endometrial cancer patients.

Methods

HE4ren was developed adjusting HE4 serum levels towards decreased glomerular filtration rate as quantified by the eGFR-EPI formula. Preoperative HE4, HE4ren, CA125, age, and grade were evaluated in the context of perioperative depth of myometrial invasion in endometrial cancer (EC) patients. Continuous and categorized models were developed by binary logistic regression for any-grade and for G1-or-G2 patients based on single-institution data from 120 EC patients and validated against multicentric data from 379 EC patients.

Results

In non-cancer individuals, serum HE4 levels increase log-linearly with reduced glomerular filtration of eGFR ≤ 90 ml/min/1.73 m². HE4ren, adjusting HE4 serum levels to decreased eGFR, was calculated as follows: HE4ren = exp[ln(HE4) + 2.182 × (eGFR-90) × 10^-2]. Serum HE4 but not HE4ren is correlated with age. Model with continuous HE4ren, age, and grade predicted dMI in G1-or-G2 EC patients with AUC = 0.833 and AUC = 0.715, respectively, in two validation sets. In a simplified categorical model for G1-or-G2 patients, risk factors were determined as grade 2, HE4ren ≥ 45 pmol/l, CA125 ≥ 35 U/ml, and age ≥ 60. Cumulation of weighted risk factors enabled classification of EC patients to low-risk or high-risk for dMI.

Conclusions

We have introduced the HE4ren formula, adjusting serum HE4 levels to reduced eGFR that enables quantification of time-dependent changes in HE4 production and elimination irrespective of age and renal function in women. Utilizing HE4ren improves performance of biomarker-based models for prediction of dMI in endometrial cancer patients.

[Prognostic value of measuring the diameter and inspiratory collapse of the inferior vena cava in acute heart failure]

OBJECTIVES

To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion.

PATIENTS AND METHODS

An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or >20mm) and inspiratory collapse (< or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days.

RESULTS

Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and <50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and <50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse.

CONCLUSIONS

Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months.

High serum carbohydrate antigen 125 concentration can predict serous effusion but not gastrointestinal malignancy in male patients

This study aims to evaluate the diagnostic accuracy of carbohydrate antigen 125 (CA125) in male patients for predicting gastrointestinal malignant diseases. One hundred twenty consecutive male patients underwent CA125 test after admission to the Department of Gastroenterology in Changhai Hospital, the Second Military Medical University, from April to June 2013. Data of age, main symptoms, and final diagnosis were summarized. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of CA125 for malignancy were estimated, and the receiver operating characteristic (ROC) analysis and the area under the curve (AUC) were also performed to evaluate the diagnostic value of CA125 in male patients. The PPV, NPV, PLR, and NLR of CA125 in malignancy were 55 %, 69 %, 1.90, and 0.71, respectively. However, we found that an elevated serum CA125 level was more common in male patients with serous effusion than those with malignancy. The PPV, NPV, PLR, and NLR of CA125 in serous effusion were 85 %, 96 %, 12.70, and 0.09, respectively. In the ROC analysis, the AUC values for CA125 was 0.96 (95 % confidence interval, 0.93-0.99) for discriminating patients with serous cavity effusion from those without serous effusion. CA125 has a higher accuracy in detecting serous effusion than malignancy in male patients with gastrointestinal diseases. It is of little significance for male patients to perform CA125 test for malignancy.