Biomarkers May Help Stratify Patient Heart Failure Risk, Guide Treatment.

Abstract

HomeCirculationVol. 141, No. 5Biomarkers May Help Stratify Patient Heart Failure Risk, Guide Treatment Free AccessNewsPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessNewsPDF/EPUBBiomarkers May Help Stratify Patient Heart Failure Risk, Guide Treatment Bridget M. Kuehn Bridget M. KuehnBridget M. Kuehn Search for more papers by this author Originally published3 Feb 2020https://doi.org/10.1161/CIRCULATIONAHA.119.045477Circulation. 2020;141:399–400The cardiovascular risk biomarkers high-sensitivity cardiac troponin T (hsTnT) and NT-proBNP (N-terminal pro-B-type natriuretic peptide) may help clinicians stratify which patients may benefit the most from therapies for hypertension or diabetes mellitus, according to a pair of studies presented at the American Heart Association 2019 Annual Scientific Sessions.There has been growing evidence in recent years that elevated hsTnT levels can indicate heart wear and tear, that elevated NT-proBNP may indicate cardiac stress, and that both are associated with an elevated risk of heart failure in patients with and without kidney disease. Now, studies are demonstrating potential clinical applications of these biomarkers. One study shows that this pair of biomarkers may help identify patients with moderately elevated blood pressure who are not currently recommended for antihypertensive therapy but who have elevated heart failure risk. The second abstract shows that this pair of biomarker identifies patients with diabetes mellitus at elevated heart failure and cardiac event risk and which patients may benefit most from dapagliflozin.“We are getting to the stage where we are able to take the next step of determining where we can implement these biomarkers in day-to-day clinical practice and where we can get the most benefit in terms of the risk stratification,” said Ambarish Pandey, MD, MSCS, lead author of study hypertension risk stratification study and assistant professor of medicine at the University of Texas Southwestern Medical Center in Dallas.Flying Under the RadarThe number of US patients diagnosed with hypertension greatly increased on the basis of the recommendations of the 2017 “American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.” But many of these newly diagnosed patients had fewer traditional risk factors for cardiovascular events and were not recommended for hypertension treatment. This left clinicians with questions about how to best care for them.Pandey and his colleagues pooled data on >12 000 participants from 3 large cohort studies to see whether hsTnT and NT-proBNP levels could help stratify patients in this category who may have elevated heart failure risk. They found that participants with elevated blood pressure not currently recommended for hypertension therapy with elevated hsTnT and NT-proBNP had a 10-year cardiovascular event rate of 11% compared with 4.6% among those who did not have elevated biomarkers. From these data, they concluded that treating 36 patients in the elevated biomarker group would prevent 1 event, compared with treating 85 in the group without elevated biomarkers. Pandey noted that up to one-third of the patients not currently recommended for antihypertensives had elevated biomarkers and that their risks of a cardiovascular event were comparable to those of patients with a blood pressure >160/100 mm Hg.“We found that those patients who fall out of [the recommended range for antihypertensive therapy] but have elevated biomarkers face comparable risks to many of the patients who are currently recommended for blood pressure control in clinical practice guidelines,” said study coauthor Muthiah Vaduganathan, MD, MPH, a cardiologist and instructor in medicine at Brigham and Women’s Hospital and Harvard Medical School. “Biomarkers may serve as an important risk marker that can identify people who may be flying under the radar who are in fact at high risk.”Thomas Zelniker, MD, MSc, a consultant at Vienna General Hospital and the Medical University of Vienna in Austria, called the study very elegant. “It showed a nice way biomarkers may be used in risk stratification.”Zelniker presented results from the DECLARE-TIMI 58 trial (Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction 58), which randomized patients with diabetes mellitus to dapagliflozin or control to determine the effects of the treatment on cardiovascular outcomes. Zelniker, who conducted the study as a postdoctoral research fellow at the TIMI Study Group, analyzed the outcomes of >14 000 patients using NT-proBNP and hsTnT levels. They showed that dapagliflozin reduced the risk of cardiovascular death and hospitalization for heart failure in all patients. However, those patients with the highest biomarker levels had the greatest risks and saw the greatest absolute benefit from dapaglioflozin. Those patients with the highest quartile of NT-proBNP levels had a 2.9% absolute risk reduction and a number needed to treat to avoid a cardiac event of 35, according to the abstract. Those in the highest quartile for hsTnT had a 2.4% absolute risk reduction and a number needed to treat of 42.“If you have systems where you can’t give this drug to every patient, then this could be a helpful tool to stratify patients,” Zelniker said.Another interesting finding was that patients without heart failure who had high biomarker levels had risks of hospitalization similar to those of patients with heart failure. He noted that more research is needed to see whether dapagliflozin might help prevent heart failure in patients at high risk.Vaduganathan said the DECLARE-TIMI 58 trial results were remarkable because of the large number of patients with biomarker samples in the study and the fact that patients included were representative of the types of patients who would be seen in practice.“These findings are an important advance forward,” he said. “They have important clinical implications as we face a growing burden of diabetes mellitus in the United States and worldwide. Targeting interventions is going to be our next step in matching interventions with our highest risk patients.”Personalized PreventionTogether, the 2 studies mark a turning point toward applying these biomarkers in day-to-day practice. Pandey noted that the tests are already widely available and can be used in an office setting to assess cardiovascular risk.“These studies put into a clinical context to the biomarker biology that we have long known, and it shows that they can be implemented in a day-to-day clinical setting to actually stratify risk and guide treatment decisions for that population,” Pandey said.Vaduganathan predicted that these biomarkers will increasing play a role across the spectrum of cardiovascular care from prevention to diagnosis and treatment. These 2 studies in particular may help guide more personalized approaches to prevention. He noted that applying preventive strategies at the population scale can be too costly, so having cheap, widely available tests that could help target preventive interventions is essential. They may also facilitate shared decision making with patients, he said.“We are moving toward a personalized prevention approach,” he said.Footnoteshttps://www.ahajournals.org/journal/circ Previous Back to top Next FiguresReferencesRelatedDetails February 4, 2020Vol 141, Issue 5 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.045477PMID: 32011922 Originally publishedFebruary 3, 2020 PDF download Advertisement SubjectsDiabetes, Type 2Hypertension