Using Biomarkers to Guide Heart Failure Therapy.

Abstract

Being able to target specific therapies to specific disease entities is the goal of all precision medical initiatives. Such approaches have been implemented in malignancies with individual examples of great responses. Such successes have fueled enthusiasm to apply this approach to other forms of chronic disease. Ideal implementation would include a companion diagnostic (a blood test), which would specifically signal when initiation, reduction, or intensification of a therapy is indicated. Testing could then be used serially to titrate therapy. This ideal state has not yet fully developed for cardiovascular diseases but has been pursued in some areas of heart disease management such as using cardiac troponin to determine therapy with antiplatelet drugs, inflammatory biomarkers to define the need for lipid lowering agents, and cardiovascular stress biomarkers to guide heart failure (HF)3 management (1). Most data in chronic HF have focused on patients with reduced ejection fraction (HFrEF). Such patients are treated with a variety of defined treatment strategies predicated on guideline-supported therapies that reduce mortality (2). Although these therapies have been proven in randomized controlled trials, inadequacies in their application exist in nontrial settings. This may be because it is difficult for physicians to evaluate changes in functional status during patient visits and thus decide when to increase or decrease therapies. Furthermore, the polypharmacy in HFrEF is titrated to target doses, rather than physiological goals. Accordingly, understanding the timing and appropriateness of titration may be challenging for less experienced clinicians especially if patients insist they feel fine. For these reasons, multiple biomarkers have been suggested to assist objectively in the titration of therapy. The ones most utilized have been the natriuretic peptides (NPs). Increases in NP concentrations provide an objective signal concerning the compensation of HF patients. Application or intensification of these therapies has been shown to reduce …