Arrash Fard

Biomarkers in acute myocardial injury

Acute coronary syndrome (ACS) is a significant cause of morbidity and mortality worldwide. The proper diagnosis of ACS requires reliable and accurate biomarker assays to detect evidence of myocardial necrosis. Currently, troponin is the gold standard biomarker for myocardial injury and is used commonly in conjunction with creatine kinase-MB (CK-MB) and myoglobin to enable a more rapid diagnosis of ACS. A new generation of highly sensitive troponin assays with improved accuracy in the early detection of ACS is now available, but the correct interpretation of assay results will require a careful consideration of assay characteristics and the clinical setting prior to incorporation into routine practice. B-type natriuretic peptides, copeptin, ischemia-modified albumin, heart-type fatty-acid-binding protein, myeloperoxidase, C-reactive protein, choline, placental growth factor, and growth-differentiation factor-15 make up a promising group of other biomarkers that have shown the ability to improve prognosis and diagnosis of ACS compared with traditional markers.

Cardiac biomarkers: new tools for heart failure management

The last decade has seen exciting advances in the field of biomarkers used in managing patients with heart failure (HF). Biomarker research has broadened our knowledge base, shedding more light on the underlying pathophysiological mechanisms occurring in patients with both acute and chronic HF. The criterion required by an ideal cardiovascular biomarker has been progressively changing to an era of sensitive assays that can be used to guide treatment. Recent technological advances have made it possible to rapidly measure even minute amounts of these proteins by means of higher sensitivity assays. With a high prevalence of comorbidities associated with HF, an integrated approach utilizing multiple biomarkers have shown promise in predicting mortality, better risk stratification and reducing re-hospitalizations, thus lowering health-care costs. This review provides a brief insight into recent advances in the field of biomarkers currently used in the diagnosis and prognosis of patients with acute and chronic HF.

Role of Biomarkers in the Diagnosis and Management of Cardio-Renal Syndromes

The complex interaction between heart and kidney disease has been increasingly recognized over the recent years. Pathologies within these two organs frequently coexist and, due to organ cross-talk, dysfunction in one often leads to problems in the other. The classification of the various forms of cardio-renal syndrome has made these interactions clearer. To aid in the diagnosis, management and prognosis of these conditions, many novel cardiac and renal biomarkers have emerged to supplement traditional markers which have limited specificity and sensitivity. In this review we will summarize the literature on novel renal behind these and other biomarkers and discuss their potential relevance to the clinical scenarios of cardio-renal syndrome.

Cardiac biomarkers, mortality, and post-traumatic stress disorder in military veterans.

Post-traumatic stress disorder (PTSD) is gaining increasing recognition as a risk factor for morbidity and mortality. The aim of this study was to examine the impact of PTSD and abnormal cardiovascular biomarkers on mortality in military veterans. Eight hundred ninety-one patients presenting for routine echocardiography were enrolled. Baseline clinical data and serum samples for biomarker measurement were obtained and echocardiography was performed at the time of enrollment. Patients were followed for up to 7.5 years for the end point of all-cause mortality. Ninety-one patients had PTSD at the time of enrollment. There were 33 deaths in patients with PTSD and 221 deaths in those without PTSD. Patients with PTSD had a trend toward worse survival on Kaplan-Meier analysis (p = 0.057). Among patients with elevated B-type natriuretic peptide (>60 pg/ml), those with PTSD had significantly increased mortality (p = 0.024). Among patients with PTSD, midregional proadrenomedullin (MR-proADM), creatinine, and C-terminal proendothelin-1 were significant univariate predictors of mortality (p = 0.006, p = 0.024, and p = 0.003, respectively). In a multivariate model, PTSD, B-type natriuretic peptide, and MR-proADM were independent predictors of mortality. In patients with PTSD, MR-proADM was a significant independent predictor of mortality after adjusting for B-type natriuretic peptide, cardiovascular risk factors, cancer, and sleep apnea. Adding MR-proADM to clinical predictors of mortality increased the C-statistic from 0.572 to 0.697 (p = 0.007). In conclusion, this study demonstrates an association among PTSD, abnormal cardiac biomarker levels, and increased mortality.

Mid‐region pro‐adrenomedullin adds predictive value to clinical predictors and Framingham risk score for long‐term mortality in stable outpatients with heart failure

The aim of this study was to evaluate the long‐term prognostic utility of mid‐region prohormone adrenomedullin (MR‐proADM) in stable outpatients with heart failure (HF).

Role of biomarkers in the diagnosis and prognosis of acute kidney injury in patients with cardiorenal syndrome

Cardiac and renal disease frequently coexist but have long been difficult to diagnose in a timely manner and treat effectively. Noninvasive and cost-effective biomarkers are needed to help identify cardiac patients who are at risk of acute kidney injury early in the course of disease. Biomarkers can provide insights into underlying mechanisms and lead to a better understanding of complex disease states such as the cardiorenal syndrome, which can lead to better therapies and, ultimately, to improved patient outcomes. The natriuretic peptides are established biomarkers in heart failure and have set the standard for how a well-validated biomarker can be useful for diagnosis/prognosis, monitoring response to therapy and chronic disease management. For patients with acute kidney injury in the setting of cardiac disease, new biomarkers such as neutrophil gelatinase-associated lipocalin, cystatin C, kidney injury molecule-1 and IL-18 are emerging as early signals of renal dysfunction prior to any elevations in serum creatinine. Other promising candidate biomarkers for the early diagnosis of acute kidney injury include osteopontin, N-acetyl-b-d-glucosaminidase, stromal cell-derived factor-1 and exosomes. More research with all of these novel biomarkers is needed; however, the early results are very promising.

Evolving use of biomarkers for kidney injury in acute care settings.

Purpose of reviewAcute kidney injury is increasingly recognized in acute care settings in more recent years. Proper diagnosis and risk stratification for acute kidney injury is necessary for carrying out appropriate and cost-effective treatments in patients with acute kidney injury. Kidney markers serve as diagnostic and prognostic tools to give physicians a more complete perspective of renal insult. The aim of this review is to highlight some of the evidence from recent studies, involving kidney markers and provide current opinion on the accuracy of these markers. Recent findingsRecent studies demonstrate that novel kidney markers such as cystatin C, interleukin-18, kidney injury molecule 1, and neutrophil gelatinase-associated lipocalin serve as more accurate markers for acute kidney injury as compared with the more traditional marker, creatinine. Additionally, there seems to be a correlation between the concentrations of each marker and the level of deterioration of kidneys, patient recovery time, length of hospital stay, and hospital costs. SummaryEach individual kidney marker possesses its own strengths and weaknesses in determining the onset and severity of acute kidney injury. However, in combination, a panel of kidney markers may serve as powerful tools in diagnosing kidney injury with high accuracy.

Hypervolemic and optivolemic natriuretic peptides in acute heart failure.

Acute heart failure has emerged as the leading diagnosis among hospitalized patients, and challenges in accurate diagnosis, risk stratification and optimized management still remain. Here, biomarkers--with their low cost, objectivity and widespread availability--can play an indispensible role. Among the biomarkers available, natriuretic peptides (NPs) are the most validated and accepted for risk stratification and treatment guidance. The physiological basis for this lies in the strong correlation between NP levels and pulmonary capillary wedge pressure. The ability to classify individuals on the basis of risk could allow clinicians to tailor therapies to fit individual patient needs, thus reducing morbidity, mortality and costs.

Diagnostic and Prognostic Biomarkers in Emergency Department Heart Failure

Heart failure is a growing public health issue worldwide. Significant challenges still remain in the diagnosis and risk stratification of acute heart failure in the emergency department. Biomarkers, with their objectivity, reproducibility, and widespread availability, have an indispensable role in improving heart failure diagnostic accuracy and risk stratification. Natriuretic peptides are perhaps the most well-known and validated biomarkers for the diagnosis of acute heart failure. They have become a routine part of the diagnostic workup of acute heart failure in many clinical settings. Natriuretic peptides along with traditional biomarkers such as troponin, creatinine, blood urea nitrogen, and serum sodium can help to identify high-risk patients who may need closer monitoring and more intensive therapy. In addition, many novel biomarkers have emerged from basic science laboratories worldwide to provide insight into different pathophysiological processes involved in heart failure. These exciting new biomarkers include mid-region proadrenomedullin (MR-proADM), C-terminal pre-pro-vasopressin (copeptin), ST2, high-sensitivity troponin, and neutrophil gelatinase-associated lipocalin (NGAL). With more experience, these new biomarkers can provide an ever clearer picture into the pathophysiology of heart failure, leading to more accurate diagnosis and better risk stratification of heart failure patients.