The predictive value of cardiac biomarkers in prognosis and risk stratification of patien…

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Utility of B-natriuretic peptide in the evaluation of left ventricular diastolic function and diastolic heart failure.

Curr Opin Cardiol. 2009 Mar;24(2):155-60

Authors: Parekh N, Maisel AS

PURPOSE OF REVIEW: Heart failure with preserved ejection fraction or diastolic heart failure is an increasingly prevalent disease process today. Natriuretic peptides have been shown to provide diagnostic and prognostic utility in patients with systolic heart failure. Here we review current publications exploring the relationship between B-natriuretic peptide (BNP) and diastolic dysfunction. RECENT FINDINGS: Investigators have found significant correlations between echocardiographic parameters for diastolic dysfunction and serum BNP levels in diagnosing diastolic heart failure. This relationship is linear with respect to severity of left ventricular dysfunction. Newer echocardiographic modalities like tissue Doppler imaging provide measures of elevated left ventricular filling pressures, which are associated with higher plasma BNP levels. Admission and predischarge BNP levels in patients with decompensated diastolic heart failure have been prognostic with respect to in-hospital mortality, short-term mortality, and hospital readmission. SUMMARY: Review of current literature shows that BNP can be useful in providing diagnostic and prognostic data in patients with symptomatic and asymptomatic diastolic dysfunction. These data, combined with other values such as echocardiographic indices and cardiovascular risk factors, can augment the sensitivity and specificity of BNP.

PMID: 19532102 [PubMed - indexed for MEDLINE]

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Implantable cardioverter defibrillator therapy for patients with less severe left ventricular dysfunction.

Curr Opin Cardiol. 2009 Jan;24(1):61-7

Authors: Exner DV

PURPOSE OF REVIEW: The implantable cardioverter defibrillator (ICD) is an effective therapy for sudden cardiac death (SCD). Identifying patients who will benefit from an ICD is key. Most SCD events occur in patients with less severe left ventricular (LV) dysfunction, yet past trials and guidelines focus on those with severe LV dysfunction. Given the large pool of patients with less severe LV dysfunction and a modest risk of SCD, methods to identify those who might benefit from an ICD are required. RECENT FINDINGS: Observational studies indicate that abnormal cardiac repolarization and impaired autonomic function, particularly in combination, appear to identify patients with less severe LV dysfunction at risk of SCD. Extensive scarring also appears to identify patients at risk. Ongoing and planned studies will better define the role of using noninvasive tests to select patients for ICD therapy. SUMMARY: Noninvasive measures of cardiac structure, autonomic function and myocardial substrate appear to be promising in identifying patients with less severe LV dysfunction at risk of SCD. However, it is not clear that ICD therapy will improve survival in these patients. Until definitive data from prospective randomized trials are available it is premature to recommend use of these tools to guide ICD therapy.

PMID: 19077818 [PubMed - indexed for MEDLINE]

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Atrial fibrillation and congestive heart failure.

Curr Opin Cardiol. 2009 Jan;24(1):29-34

Authors: Roy D, Talajic M, Dubuc M, Thibault B, Guerra P, Macle L, Khairy P

PURPOSE OF REVIEW: The present review will examine the prognostic importance of atrial fibrillation and heart failure, explore the different therapeutic options for treating atrial fibrillation and present the results of the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial. RECENT FINDINGS: The Atrial Fibrillation and Congestive Heart Failure trial was a randomized trial involving patients with both atrial fibrillation and heart failure. The trial was designed to compare the maintenance of sinus rhythm with the control of ventricular rate in patients with left ventricular dysfunction, heart failure and a history of atrial fibrillation. There was no significant difference in the rate of death from cardiovascular causes in the rhythm-control group as compared with the rate-control strategy. In addition, there was no significant difference in any of the secondary outcomes including death from any cause, worsening heart failure or stroke. The rate-control strategy eliminated the need for repeated cardioversion and reduced rates of hospitalization. SUMMARY: The results of the Atrial Fibrillation and Congestive Heart Failure trial indicate that a routine strategy of rhythm control does not reduce rate of death and suggest that rate control should be considered a primary approach for patients with atrial fibrillation and heart failure.

PMID: 19102036 [PubMed - indexed for MEDLINE]

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Antiplatelet and anticoagulant agents: key differences in mechanisms of action, clinical application, and therapeutic benefit in patients with non-ST-segment-elevation acute coronary syndromes.

Curr Opin Cardiol. 2008 Jul;23(4):302-8

Authors: Jennings LK, Saucedo JF

PURPOSE OF REVIEW: Platelet activation and aggregation are important pathophysiologic elements of both non-ST-elevation acute coronary syndromes and the ischemic complications of percutaneous coronary intervention, making antiplatelet agents necessary components of the pharmacotherapeutic treatment paradigm for these patients. This review evaluates and interprets the role of oral antiplatelet agents, glycoprotein IIb-IIIa inhibitors, and bivalirudin in the context of current clinical evidence and practice. RECENT FINDINGS: The current standard of care for patients with non-ST-elevation acute coronary syndromes–aspirin, clopidogrel, and glycoprotein IIb-IIIa inhibitors for the majority of patients–is being challenged by recent clinical trials (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment, Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 2, Randomized Evaluation of Percutaneous coronary intervention Linking Angiomax to Reduced Clinical Events-2, Acute Catheterization and Urgent Intervention Triage StrategY), raising important questions regarding the value of glycoprotein IIb-IIIa inhibitors as accompaniments of high-dose clopidogrel pretreatment and increased use of the anticoagulant bivalirudin. SUMMARY: Current data indicate that antiplatelet regimens consisting of aspirin, clopidogrel, and a glycoprotein IIb-IIIa inhibitor provide substantial benefit among patients who undergo percutaneous coronary intervention. Optimized antiplatelet and anticoagulant therapy–including aspirin, clopidogrel, a glycoprotein IIb-IIIa inhibitor, and an anticoagulant–may reduce the incidence of subclinical and clinical events.

PMID: 18520712 [PubMed - indexed for MEDLINE]

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The future of biomarkers in the management of patients with acute coronary syndromes.

Curr Opin Cardiol. 2008 Jul;23(4):309-14

Authors: O’Donoghue M, Morrow DA

PURPOSE OF REVIEW: Biomarkers play an important role in the diagnosis and management of patients with acute coronary syndromes. The rapid growth of candidate novel markers has emphasized the need for a systematic approach to their evaluation. RECENT FINDINGS: Several biomarkers in the past few years have been shown to be useful for risk stratification in patients with acute coronary syndromes. However, in addition to demonstrating reproducibility across large patient populations, novel markers, including high-sensitivity troponin assays, need to convincingly demonstrate their incremental utility beyond that of existing markers and should contribute toward improved patient care. Many existing biomarkers measure facets of the same disease process and are tightly correlated, thereby reducing the probability that a candidate marker will add substantial incremental discrimination for risk stratification. Unbiased approaches to identifying new markers, such as genome-wide association studies, may prove to be useful for helping in identifying genomic sequence variants, as well as protein or metabolite perturbations, which reflect novel disease-associated pathways. SUMMARY: The number of novel biomarkers is expected to continue to grow exponentially over the next few years. Candidate markers should undergo rigorous evaluation before being adopted into clinical practice.

PMID: 18520713 [PubMed - indexed for MEDLINE]

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Long-term anticoagulation in patients with coronary disease, and future developments.

Curr Opin Cardiol. 2008 Jul;23(4):315-9

Authors: Verheugt FW

PURPOSE OF REVIEW: As anticoagulant therapy is a cornerstone in the early management of acute coronary syndrome, the question remains whether long-term anticoagulation after discharge will further improve outcome. RECENT FINDINGS: Major trials demonstrated benefit from routine oral anticoagulation with an attained international normalized ratio over 2.0 in patients after myocardial infarction. However, the benefit seen in these trials was achieved at the expense of increased bleeding and high dropout rate. In addition, a significant number of patients in both these trials had an international normalized ratio below the target range. Furthermore, the trials were performed before the clopidogrel era in which the great majority of patients with both non-ST-elevation and ST-elevation acute coronary syndromes are treated with an early invasive strategy. The benefit with warfarin therapy is in the range of benefit seen with clopidogrel, which is easier to administer, and there are no data assessing a possible benefit of warfarin therapy in patients taking aspirin and clopidogrel in whom the bleeding risk might be excessive. Very recently, direct oral thrombin blockade has been developed and found to be effective in venous thromboembolism and after myocardial infarction. In addition, oral direct factor Xa blockers are also good candidates for replacing warfarin. SUMMARY: Oral anticoagulation after myocardial infarction is beneficial but increases bleeding risk and is notoriously difficult to monitor. Novel oral anticoagulants are currently evaluated for this indication with aspirin and clopidogrel as background therapy.

PMID: 18520714 [PubMed - indexed for MEDLINE]

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Will new higher-precision troponins lead to clarity or confusion?

Curr Opin Cardiol. 2008 Jul;23(4):292-5

Authors: White HD

PURPOSE OF REVIEW: Troponins are a cornerstone for the diagnosis of myocardial infarction, assessment of risk and prognosis, and determination of antithrombotic and a revascularization strategy in patients with acute coronary syndromes. Newer assays with higher precision for detection of troponin levels are about to enter clinical practice. The present review discusses the implications of the new assays for patients. RECENT FINDINGS: Several studies have found that higher-precision troponin assays can determine prognosis at lower cutpoints than currently used in patients with acute coronary syndromes and that about a third of patients 6 months after admission have detectable low levels of troponins.Elevation of troponins can also be detected with the new assays at about 2 h after the onset of ischemic symptoms. This could result in earlier triage to an invasive strategy, and the findings of a repeat normal level at an earlier time point than currently recommended could lead to earlier discharge from the emergency department and cost savings. Elevated high-precision troponin levels have also been found in the community and in patients with heart failure. SUMMARY: The new high-precision assays will enable better determination of risk and new paradigms will be developed about detection of elevated troponin levels in patients with chronic stable angina and the normal population. Patients with acute coronary syndromes will be able to be triaged earlier and patient care will be improved.

PMID: 18520710 [PubMed - indexed for MEDLINE]

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Management of acute coronary syndromes in patients with renal dysfunction.

Curr Opin Cardiol. 2008 Jul;23(4):320-6

Authors: Melloni C, Mahaffey KW

PURPOSE OF REVIEW: Chronic kidney disease is becoming common among patients with acute coronary syndromes and is associated with substantial cardiovascular morbidity and mortality. Often, patients with chronic kidney disease are excluded from clinical trials, so in clinical practice physicians may not have definitive evidence to support treatment decisions. RECENT FINDINGS: Recent studies have shown that chronic kidney disease is an independent risk factor for outcomes in patients with acute coronary syndromes and that there is a stepwise increase in mortality with progressive decline of glomerular filtration rate. It has been demonstrated that the use of aggressive treatment strategies in these patients may be associated with improved outcome that is similar to, if not higher than, in those patients without renal disease. Yet, although critical for the correct dose adjustment of many antithrombotic and antiplatelet therapies, accurate renal function estimation often is not done. SUMMARY: Chronic kidney disease is common, and the stages of chronic kidney disease are strongly related to the risk of adverse in-hospital outcomes and to the use of evidence-based therapies. Many antithrombotic drugs are eliminated mainly by the kidneys, so an accurate assessment of renal function is required in all patients with acute coronary syndromes for a proper dose adjustment. There is a clear need for clinical trials in patients with moderate-to-severe kidney dysfunction to further refine their optimal management in the setting of acute coronary syndromes.

PMID: 18520715 [PubMed - indexed for MEDLINE]

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Nonischemic heart failure in diabetes mellitus.

Curr Opin Cardiol. 2008 May;23(3):241-8

Authors: Guha A, Harmancey R, Taegtmeyer H

PURPOSE OF REVIEW: Diabetic patients with heart failure have a poor prognosis. Although it has been demonstrated in animal models that metabolic maladaptation plays a pivotal role in contractile dysfunction of the heart, the understanding of ‘diabetic cardiomyopathy’ and its treatment in humans remains incomplete. RECENT FINDINGS: Epidemiological studies show that structural changes in the left ventricle can be demonstrated before onset of clinical diabetes. Diastolic dysfunction is the earliest manifestation that is associated with increasing level of serum-free fatty acids and worsening glycemic control. Spectroscopic and histologic evidence in the human myocardium indicates a maladaptive metabolic response in diabetes, characterized by intramyocellular triglyceride accumulation. Studies also suggest a link between myocardial isoform switching, calcium homeostasis and altered metabolism in the development of heart failure. However, treatment directed at deranged metabolic control in diabetes is effective only in animals, and not in humans. SUMMARY: Although clinical studies suggest the existence of ‘diabetic cardiomyopathy’, it is still difficult to prove causality. However, animal models and human studies suggest that systemic metabolic derangements may lead to metabolic, functional and structural maladaptation of the heart. The exact mechanisms of heart failure in diabetes remain elusive.

PMID: 18382213 [PubMed - indexed for MEDLINE]

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