Use of biomarkers in acute cardiac care is an area in continuous development that addresses the clinical and research interest of cardiologists worldwide and leads to an endless flux of new information. New biomarkers are developed and new applications for “old” biomarkers are proposed at a rate unparalleled before.
In session 170 “New biomarker of acute cardiac care” four of the most respectful experts in the field reported on the new developments in the area of Inflammatory markers, markers of necrosis, acute renal failure and acute heart failure.
Dr. Kaski, from London, discussed the pro and contra of inflammatory markers; first described in acute coronary syndromes in 1994, these markers have gained substantial approval for risk stratification in patients with acute coronary syndrome. Although their prognostic implications, in particular for C-reactive protein (CRP), are strong, Dr. Kaski has shown that, once corrected to other risk factors, or added to established risk scores as Grace, the additional information they provide is small. Dr Kaski has, therefore, proposed as an alternative a multimarker approach, with the use of BNP and fibrinogen, which in the multicentre Siesta study published this year, was able to increase to some extent the prediction based on conventional assessment of risk.
The observations of Dr Kaski are completely reasonable. However, the possible role of inflammatory markers as a guide to therapy, in particular statins, was not discussed. In Prove-it TIMI22 , Ridker and coll. have shown that statin therapy tailored to LDL cholesterol levels <70 mg/ml and CRP <2mg/l is associated with the best survival. Although such use of inflammatory markers has not reached a consensus yet, its application seems promising.
Dr. Peacock, from Cleveland, discussed the implication of the new high sensitive troponins (HsTn). This is a very hot topic, as hsTn may considerably change the way chest pain patients are treated in the emergency room (ER). Dr Peacock said the over 8 million admissions to ER in US are due to chest pain, raising the problem of the correct diagnosis in the ER to avoid the risk of discharging a patient with MI or hospitalising a healthy subject. The hsTn have an excellent sensitivity, reducing almost to zero the risk of missing an MI, but at the cost of a lower specificity compared with the previous troponin. To overcome this limitation, Dr Peacock proposed to use a second marker of necrosis or a double cut-off level (lower=risk, higher=MI )
Dr Peacock’s presentation is in line with expectations and fears of many cardiologists and has precisely described the pros and contras of hs-Tn. However, the proposal of a dual cut-off or the use of a second biomarker would lead to more complex work-up and increased costs. Education of doctors to the correct use of the hsTn together with the assessment of the clinical data may represent a more reliable solution.
Dr.Parissis, from Athens, addressed the novel topic of acute renal failure. Although not novel per se, the problem has come to the interest of cardiologists because of the elevated cardiovascular risk associated with acute and chronic renal failure (RF). Dr Parissis overviewed the available data demonstrating the straight association between acute renal failure and CV mortality, stressing the importance of this problem in areas such as heart failure and coronary interventions. Novel biomarkers, such as cystatin-C and N-GAL, which are more prompt that creatinine to detect initial RF, may help to make an early diagnosis and, in Dr Parissis’ opinion, prevent potentially fatal complications.
Dr Parissis’ presentation has the merit of stressing a clinical problem still not well acknowledged by many cardiologists: the association of renal failure with cardiovascular risk. However, more data are necessary to better evaluate the real impact of early detection of acute RF, at least in patients undergoing coronary interventions.
Finally, Dr Maisel, from Solana Beach, discussed the role of novel biomarkers of heart failure. Although BNP and NT-proBNP are excellent markers, Dr. Maisel said they also have limitations, such as obesity, renal insufficiency and the grey-area of the low levels where both of them have little discriminatory power. Dr Maisel presented promising data in particular on mid-regional proANP (atrial natriuretic peptide) and mid-regional pro-adrenomedullin, these markers represent an evolution of the natriuretic peptides now available for testing, overcoming previous limitations and improving diagnostic accuracy.
The data presented by Dr Maisel are of interest. However, as he agreed in the discussion of his presentation, the question remains, for these as for all other new biomarkers, whether and to what extent their introduction in the clinical arena may actually improve our ability to treat the patients and if this is worth the increase in economical burden.
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