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Biomarkers of interest for heart failure

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The measurement of cardiac biomarkers in patients with heart failure has led to significant insights into the diagnosis, prognosis and management of this disease. There are numerous biomarkers for heart failure, each useful for gleaning valuable information at different stages of heart failure development and progression.

In ambulatory or outpatient individuals presenting with dyspnea, the 2013 American College of Cardiology Foundation/American Heart Association Guideline for the Management of Heart Failure recommended measuring B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) to guide the diagnosis of heart failure. These biomarkers are considered particularly useful in clinically ambiguous cases, according to the guideline authors.

In patients diagnosed with chronic heart failure, measurement of BNP or NT-proBNP is recommended for determining prognosis or disease severity. According to the guideline, although lower BNP or NT-proBNP levels can rule out heart failure and elevated levels have fairly a high positive predictive value, physicians should keep in mind that elevated plasma concentrations of both these biomarkers have been linked to a wide range of cardiac and noncardiac conditions.

The ACCF/AHA guideline also offers a class IIa recommendation for the use of BNP or NT-proBNP to determine the best dosage for guideline-directed medical therapy (GDMT) in certain patients with normal blood volumes, as part of a structured heart failure disease management program. The authors noted, however, that the value of serial measurement of these biomarkers to decrease hospitalization or death in heart failure patients is unclear.

Additional risk stratification in patients with chronic heart failure may also be achieved with measurement of other biomarkers, such as those linked with myocardial injury or fibrosis. Emerging biomarkers, including galectin-3, growth differentiation factor-15, highly sensitive troponins, mid-regional pro-adrenomedullin (MR-proADM), mid-regional pro-atrial natriuretic peptide (MR-proANP), and soluble ST2, are also considered promising additive tools for determining heart failure prognosis.

In hospitalized patients, testing for BNP or NT-proBNP is recommended by the ACCF/AHA guideline to corroborate a diagnosis of acutely decompensated heart failure. Prognosis and severity of acutely decompensated heart failure can be determined through the measurement of BNP or NT-proBNP. However, insufficient evidence exists to support the value of BNP or NT-proBNP-guided treatment for acutely decompensated heart failure.

Other types of biomarkers, such as those used to measure myocardial injury or fibrosis, may serve in an additive capacity for further risk stratification in patients with acutely decompensated heart failure. According to the guideline, approaches using multiple biomarkers may eventually be valuable for selecting a treatment strategy for heart failure patients.

Additional information can be found at these websites:

http://circ.ahajournals.org/content/128/16/e240.full

http://www.ncbi.nlm.nih.gov/pubmed/23313577