Evolving Use of Biomarkers in the Management of Heart Failure

New Biomarkers in the Prognostic Assessment of Acute Heart Failure with Reduced Ejection Fraction: Beyond Natriuretic Peptides

Natriuretic peptides are established biomarkers related to the prognosis of heart failure. New biomarkers have emerged in the field of cardiovascular disease. The prognostic value of these biomarkers in heart failure with reduced left ventricular ejection fraction is not well-established. We conducted a prospective, single-centre study, including (July 2019 to March 2023) 104 patients being consecutively admitted with a diagnosis of acute heart failure with reduced ejection fraction decompensation. The median follow-up was 23.5 months, during which 20 deaths (19.4%) and 21 readmissions for heart failure (20.2%) were recorded. Plasma biomarkers, such as NT-proBNP, GDF-15, sST2, suPAR, and FGF-23, were associated with an increased risk of all-cause mortality. However, a Cox regression analysis showed that the strongest predictors of mortality were an estimated glomerular filtration rate (HR 0.96 [0.93-0.98]), GDF-15 (HR 1.3 [1.16-1.45]), and sST2 (HR 1.2 [1.11-1.35]). The strongest predictive model was formed by the combination of the glomerular filtration rate and sST2 (C-index 0.758). In conclusion, in patients with acute decompensated heart failure with reduced ejection fraction, GDF-15 and sST2 showed the highest predictive power for all-cause mortality, which was superior to other established biomarkers such as natriuretic peptides. GDF-15 and sST2 may provide additional prognostic information to improve the prognostic assessment.

Identification of hub genes in heart failure by integrated bioinformatics analysis and machine learning

Objective

To screen feature genes of heart failure patients through machine learning methods, in order to identify characteristic genes driving heart failure and investigate the progression of heart failure.

Methods

Heart failure patient samples were downloaded from the public database GEO (Gene Expression Omnibus), including the datasets GSE116250, GSE120895, and GSE59867. GSE116250 and GSE120895 were used as the testing set, while GSE59867 was used as the validation set. LASSO regression analysis and SVM-RFE were utilized to identify feature genes.

Results

Analysis showed that among the differentially expressed genes between normal and heart failure patients, 9 genes were upregulated and 10 genes were downregulated. ROC curve analysis in the training set showed that TAGLN and SGPP2 had AUC values greater than 0.7. Moreover, SDSL and SMTNL2 had even higher AUC values of greater than 0.9. However, further analysis in the validation set showed that only SDSL had an AUC value greater than 0.7. Western blot experiments, RT-PCR, and ISO-induced experiments confirmed that SDSL was highly expressed in heart failure patients and promoted heart failure progression. In addition, SDSL promoted PARP1 expression and knockdown of SDSL expression led to decreased Cleaved-PARP1 expression and reduced cardiomyocyte apoptosis. Conversely, overexpression of SDSL resulted in increased PARP1 expression and myocardial cell apoptosis. These results suggest that elevated expression of SDSL in cardiomyocytes from heart failure patients may be an important factor promoting the occurrence and development of heart failure.

Conclusions

Using machine learning methods and experimental validation, it has been demonstrated that SDSL is a driving gene in patients with heart failure, providing a new treatment direction for clinical treatment.

Growth Differentiation Factor 15 (GDF-15), a New Biomarker in Heart Failure Management

The emergence of biomarkers across medicine's subspecialties continues to evolve. In essence, a biomarker is a biological observation that clearly substitutes a clinical endpoint or intermediate outcome not only are more difficult to observe but also, biomarkers are easier, less expensive and could be measured over shorter periods. In general, biomarkers are versatile and not only used for disease screening and diagnosis but, most importantly, for disease characterization, monitoring, and determination of prognosis as well as individualized therapeutic responses. Obviously, heart failure (HF) is no exception to the use of biomarkers. Currently, natriuretic peptides are the most used biomarkers for both diagnosis and prognostication, while their role in the monitoring of treatment is still debatable. Although several other new biomarkers are currently under investigation regarding diagnosis and determination of prognosis, none of them are specific for HF, and none are recommended for routine clinical use at present. However, among these emerging biomarkers, we would like to highlight the potential for growth differentiation factor (GDF)-15 as a plausible new biomarker that could be helpful in providing prognostic information regarding HF morbidity and mortality.

Oncostatin M: a Potential Biomarker to Predict Infection in Patients with Left Ventricular Assist Devices

Infection is a serious adverse event limiting left ventricular assist device (LVAD) therapy in advanced heart failure patients, but a reliable means to identify patients at increased risk of infection is still lacking. We hypothesized that preoperative elevated levels of plasma Oncostatin M (OSM), a cytokine marker of leukocyte activation and inflammation, would be predictive of subsequent infection. We measured plasma OSM in 41 LVAD patients one day before LVAD implantation and postoperatively over two months. Preoperative plasma OSM levels were normal in 27 patients (group A, 4.9 ± 3.2 pg/ml) but elevated in 14 patients (group B, 1649.0 ± 458.9 pg/ml) ( p = 0.003). Early postoperative levels rose in both groups and declined rapidly in group A, with group B declining slowly over two months. Significantly more infections developed in group B than group A patients over two months postimplantation ( p = 0.004). No other routine clinical assessment or laboratory testing afforded this differentiation. These findings suggest that preoperative plasma OSM levels may assist in identifying patients at increased risk of infections after LVAD implantation.

Targeting mitochondrial dysfunction with elamipretide

Although currently employed therapies for heart failure decrease overall mortality and improve patient quality of life temporarily, the disease is known to progress even for patients who receive all guideline-recommended therapies. This indicates that our concise understanding of heart failure and of disease progression is incomplete, and there is a need for new interventions that may augment, or even supplant, currently available options. A literature review reveals that an exciting, novel area of current research is focused on mitochondria, which are uniquely juxtaposed at the sites of both generation of high-energy molecules and initiation of programmed cell death. Elamipretide is being studied both to maintain cellular biogenetics and prevent reactive oxygen species-induced cell damage by targeting and stabilizing the cardiolipin-cytochrome c supercomplex. Thus far, elamipretide has been shown to increase left ventricular ejection fraction in dog models of heart failure with reduced ejection fraction and to prevent left ventricular remodeling in rats. In early-phase clinical trials, elamipretide administration has not resulted in any severe adverse events, and it has shown promising improvements in cardiac hemodynamics at highest doses. Nonetheless, additional studies are necessary to describe the long-term safety and efficacy of elamipretide.

Exploration of Potential Genetic Biomarkers for Heart Failure: A Systematic Review

Patients with heart failure (HF) often present with signs and symptoms that are often nonspecific and with a wide differential diagnosis, making diagnosis and prognosis of HF by clinical presentation alone challenging. Our knowledge on genetic diversity is rapidly evolving with high-throughput DNA sequencing technology, which makes a great potential for genetic biomarker development. The present review attempts to provide a comprehensive review on the modification of major genetic components in HF patients and to explore the potential application of these components as clinical biomarkers in the diagnosis and in monitoring the progress of HF. The literature search was conducted using six databases, resulting in the inclusion of eighteen studies in the review. The findings of these studies were summarized narratively. An appraisal of the reporting quality of the included studies was conducted using a twelve-item checklist adapted from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. The findings showed that changes in genetic components in patients with HF compared to healthy controls could be noninvasive diagnostic or prognostic tools for HF with higher specificity and sensitivity in comparison with the traditional biomarkers. This review provided evidence for the potential of developing genetic biomarkers of HF.

Suppression tumorigenicity 2 (ST2) turbidimetric immunoassay compared to enzyme-linked immunosorbent assay in predicting survival in heart failure patients with reduced ejection fraction

BACKGROUND

Suppressor of tumorigenicity 2 (ST2) is a powerful marker of prognosis and treatment response in heart failure (HF), however, it is an enzyme-linked immunosorbent assay (ELISA) which may be cumbersome and costly. A turbidimetric immunoassay (TIA) that can run on common chemistry analyzers could overcome this. We studied a novel TIA for ST2, comparing it to commercial ST2 (ELISA).

METHODS

Patients age ≥ 18 years meeting Framingham definition for HF were enrolled in a prospective registry (Oct 2007 - March 2015) at Henry Ford Hospital and donated blood samples. Participants with reduced ejection fraction (<50%) and available plasma samples were included and valid ST2 measurements were obtained on the same sample using both TIA and ELISA (N = 721). The primary endpoint was all cause death. Correlation between the methods was quantified. The association with survival was tested using unadjusted and adjusted (for MAGGIC score and NTproBNP) Cox models and comparing the Area Under the Curve (AUC).

RESULTS

The inter-assay Spearman correlation coefficient was 0.77. Nonparametric regression showed no significant proportional difference (slope = 0.97) and a very small systematic difference (3.2 ng/mL). In univariate analyses, both TIA and ELISA ST2 were significant associates of survival with similar effect sizes (HR 4.46 and 3.50, respectively, both p < 0.001). In models adjusted for MAGGIC score, both ST2 remained significant in Cox models and incrementally improved AUC vs. MAGGIC alone (MAGGIC AUC = 0.757; TIA + MAGGIC AUC = 0.786, p = 0.025; ELISA + MAGGIC AUC = 0.793, p = 0.033). In models with both MAGGIC and NTproBNP included, both ST2 still remained significant but did not improve AUC.

CONCLUSIONS

A novel TIA method for ST2 quantification correlates highly with ELISA and offers similarly powerful risk-stratification.

Multivalent Lactose-Ferrocene Conjugates Based on Poly (Amido Amine) Dendrimers and Gold Nanoparticles as Electrochemical Probes for Sensing Galectin-3

Galectin-3 is considered a cancer biomarker and bioindicator of fibrosis and cardiac remodeling and, therefore, it is desirable to develop convenient methods for its detection. Herein, an approach based on the development of multivalent electrochemical probes with high galectin-3 sensing abilities is reported. The probes consist of multivalent presentations of lactose–ferrocene conjugates scaffolded on poly (amido amine) (PAMAM) dendrimers and gold nanoparticles. Such multivalent lactose–ferrocene conjugates are synthesized by coupling of azidomethyl ferrocene–lactose building blocks on alkyne-functionalized PAMAM, for the case of the glycodendrimers, and to disulfide-functionalized linkers that are then used for the surface modification of citrate-stabilized gold nanoparticles. The binding and sensing abilities toward galectin-3 of both ferrocene-containing lactose dendrimers and gold nanoparticles have been evaluated by means of isothermal titration calorimetry, UV–vis spectroscopy, and differential pulse voltammetry. The highest sensitivity by electrochemical methods to galectin-3 was shown by lactosylferrocenylated gold nanoparticles, which are able to detect the lectin in nanomolar concentrations.

Heart failure biomarker levels correlate with invasive haemodynamics in pulmonary valve replacement

BACKGROUND

Although widely used in cardiology, relation of heart failure biomarkers to cardiac haemodynamics in patients with CHD (and in particular with pulmonary insufficiency undergoing pulmonary valve replacement) remains unclear. We hypothesised that the cardiac function biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP), soluble suppressor of tumorigenicity 2, and galectin-3 would have significant associations to right ventricular haemodynamic derangements.

METHODS

Consecutive patients ( n = 16) undergoing cardiac catheterisation for transcatheter pulmonary valve replacement were studied. NT-proBNP, soluble suppressor of tumorigenicity 2, and galectin-3 levels were measured using a multiplex enzyme-linked immunosorbent assay from a pre-intervention blood sample obtained after sheath placement. Spearman correlation was used to identify significant correlations (p ≤ 0.05) of biomarkers with baseline cardiac haemodynamics. Cardiac MRI data (indexed right ventricular and left ventricular end-diastolic volumes and ejection fraction) prior to device placement were also compared to biomarker levels.

RESULTS

NT-proBNP and soluble suppressor of tumorigenicity 2 were significantly correlated (p < 0.01) with baseline mean right atrial pressure and right ventricular end-diastolic pressure. Only NT-proBNP was significantly correlated with age. Galectin-3 did not have significant associations in this cohort. Cardiac MRI measures of right ventricular function and volume were not correlated to biomarker levels or right heart haemodynamics.

CONCLUSIONS

NT-proBNP and soluble suppressor of tumorigenicity 2, biomarkers of myocardial strain, significantly correlated to invasive pressure haemodynamics in transcatheter pulmonary valve replacement patients. Serial determination of soluble suppressor of tumorigenicity 2, as it was not associated with age, may be superior to serial measurement of NT-proBNP as an indicator for timing of pulmonary valve replacement.

Monitoring of biomarkers in heart failure

The role of biomarkers is increasingly recognized in heart failure (HF) management, for diagnosis, prognostication, and screening of high-risk patients. Beyond natriuretic peptides and troponins, the utility of novel, emerging biomarkers is less established. This document reflects the key points of a Heart Failure Association of the European Society of Cardiology (ESC) consensus meeting on biomarker monitoring in HF.