Disclosures Nothing to disclose Intern J of Cardiol
- Slides: 35
Disclosures Nothing to disclose
Intern J of Cardiol 219 ; 2016 : 111– 114
BNP Accuracy is 90% Optimal cut-off point determined @ 100 pg/m. L 1. 0 BNP=50 pg/m. L 0. 8 Positive predictive value=75% BNP=80 pg/m. L Sensitivity 0. 6 BNP=100 pg/m. L BNP=125 pg/m. L 0. 4 BNP=150 pg/m. L Final Diagnosis Heart Failure Final Diagnosis NOT Heart Failure BNP 100 pg/m. L “Test positive” 673 227 BNP <100 pg/m. L “Test negative” 71 Sensitivity =90% 615 Specificity =73% 0. 2 0. 0 0. 2 0. 4 0. 6 0. 8 Negative predictive value=90% 1. 0 1 -Specificity N Engl J Med. 2002; 347: 161 -167.
The use of NPs for rule-out heart failure in symptomatic patients in primary care Identifying the right patients for echocardiography Patient presenting with symptoms suggestive of heart failure < cut-off value “Rule out” Search for other explanation ? > cut-off value Maisel A. ESC 2018 Referral to specialist
Assesment of Heart Failure Probability Clinical History Physical examination ECG ≥ 1 present Biomarkers not routinely done in clinical practice Natriuretic peptides NT –pro BNP >125 pg/ml BNP>35 pg/ml Echocardiography All absent HF unlikely ESC Guidelines 2016
STOP-HF trial Vs. Routine care (n=677) BNP-directed care (n=697) Routine primary care Annual BNP check Cardiology care PRN If BNP >50 pg/ml at any time: cardiology consult, echo, nurse-coaching 1° Endpoint: LV systolic or diastolic dysfunction, or heart failure 2° Endpoints: Emergency hospitalization for arrhythmia, TIA, stroke, MI, PE/DVT, HF JAMA. 2013; 310(1): 66 -74.
JAMA 2013; 310(1): 66 -74
Biomarkers for prevention
Biomarkers for Diagnosis
GUIDE IT In high-risk patients with HFr. EF, a strategy of NTpro. BNP– guided therapy was not more effective than a usual care strategy in improving outcomes
Biomarkers for Prognosis
Confounders of NP interpretation Higher NP levels than expected Lower NP levels than expected Increasing age* Obesity ACS* Flash pulmonary edema Renal insufficiency Pericarditis/Tamponade RV dysfunction* Genetic polymorphisms Atrial fibrillation “Burned-out” Cardiomyopathy Pulmonary hypertension* Pulmonary embolism* Anemia/high output states* Sepsis * Delineates likely elevation from Ventricular stretch Mitral Regurgiation*
High Sensitivity Troponin in Heart Failure
Mechanism of Cardiac Troponin Release in Heart Failure J Am Coll Cardiol 2010; 56: 1071– 8
Are they really false positives when the elevation gives you greater risk? • Chronic HF • Elevated in 50% • Acute HF • Elevated in >80%
Cardiac Troponin and outcome in Acute HF N Engl J Med. 2008 May 15; 358(20): 2117 -2
Cardiac Troponin and outcome in Acute HF N Engl J Med. 2008 May 15; 358(20): 2117 -2
No CV deaths through day 180 were observed in patients with hs. Tn. T levels<0. 014 mg/l despite high. NT-pro BNP Baseline hs. Tn. T may identify patients with acute HF at very low risk for CV mortality
A combination of Natriuretic Peptide and PCT can be used to better diagnose dyspneic patients Eur Journal of Heart Failure 2012; 14: 278– 286
ESC Heart Fail. 2017; 4(3): 203 -208
IMPACT EU –BIC-18: Procalcitonin-guided antibiotic therapy does not improve mortality in patients with shortness of breath and suspected AHF NCT 02392689 Terminated : At 75% patient completion overall mortality was much lower than expected and without significant difference at day 90. No chance to reach the primary endpoint.
s. ST 2 soluble suppressor of Tumorigenicity 2 Arq Bras Cardiol. 2016; 106(2): 145 -152
s. ST 2 –solid cutpoints >35 ng/ml RISK
ST 2 not effected by l Age l Sex l BMI l Etiology of HF l Atrial Fibrillation l Anemia
The prognostic value of s. ST 2 was not influenced by renal function In a cohort of 879 heart failure patients ST 2 did not show any correlation with renal function whereas NT-pro. BNP concentrations increased significantly with decreasing renal function J Cardiac Fail 2013; 19: 768 e 775
Repeated ST 2 measurements appeared to be a strong predictor of outcome in patients with acute HF independent of repeatedly measured NT-pro BNP J Am Coll Cardiol 2017; 70: 2378– 88
s. ST 2 is a predictor of all-cause CV death JACC Heart Fail 2017; 5: 284
Why ST-2 levels might be better than NP levels to follow patients Natriuretic peptides • Much day to day variability of BNP- diuretic use, salt load from meals, time of blood draw. • “wet BNP” changes rapidly- which may justrepresent volume and not remodeling • Difficult to use with CKD • GUIDE IT negative s. ST 2 • Little variability • Does not seem to be affected by volume as much • Not effected by CKD • ST-2 especially responsive to antifibrotic drugs like MRA and sacubitril–valsartan
s. ST 2 unanswered issues • Timing • Frequency of testing • Earlier evaluation after hospitalization • Treatment escalation • Initiation/uptitration of antifibrotic drugs • Monitoring device ( Cardio-MEMS) Implantation?
Conclusions • Several biomarkers have emerged as adjunct tools to clinical decision making and CV imaging • Natriuretic peptides can be useful for • prevention of LV dysfunction • HF diagnosis in the ED setting • Improved risk stratification of HF patients • Cardiac Troponin may be considered for added risk stratification • s. ST 2 as a marker of myocardial fibrosis may also be considered for added risk stratification and relevant therapeutic decision making
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