Disclosures Nothing to disclose Intern J of Cardiol

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Disclosures Nothing to disclose

Disclosures Nothing to disclose

Intern J of Cardiol 219 ; 2016 : 111– 114

Intern J of Cardiol 219 ; 2016 : 111– 114

BNP Accuracy is 90% Optimal cut-off point determined @ 100 pg/m. L 1. 0

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

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

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

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

JAMA 2013; 310(1): 66 -74

Biomarkers for prevention

Biomarkers for prevention

Biomarkers for Diagnosis

Biomarkers for Diagnosis

GUIDE IT In high-risk patients with HFr. EF, a strategy of NTpro. BNP– guided

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

Biomarkers for Prognosis

Confounders of NP interpretation Higher NP levels than expected Lower NP levels than expected

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

High Sensitivity Troponin in Heart Failure

Mechanism of Cardiac Troponin Release in Heart Failure J Am Coll Cardiol 2010; 56:

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

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;

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;

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

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

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

ESC Heart Fail. 2017; 4(3): 203 -208

IMPACT EU –BIC-18: Procalcitonin-guided antibiotic therapy does not improve mortality in patients with shortness

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

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

s. ST 2 –solid cutpoints >35 ng/ml RISK

ST 2 not effected by l Age l Sex l BMI l Etiology of

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

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

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;

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

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

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

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