Dr. M. Weber
Circulating biomarkers have gained great interest for diagnosis and prognostication in patients presenting with acute coronary syndromes. With an advanced understanding of the pathophysiology of plaque initiation and progression, numerous new biomarkers providing incremental prognostic information have been evaluated in recent years. However, for many of those biomarkers the clinical implications for patients care are undetermined. Therefore, this session’s objective was to demonstrate the linkage between biomarker concentrations and the therapeutical implications.
In the first presentation Alan Jaffe presented data on new trends with respect to the assessment of myocardial necrosis by troponins. He pointed out that the 99th percentile of the respective assay is the best threshold for prognostication. However, even values below this threshold measured with ultra sensitive troponin assays provide prognostic information. Furthermore, the development of more sensitive troponin assays allows earlier detection of acute myocardial infarction as compared to standard assays. With the introduction of the new generation of ultra sensitive troponin assays, more conditions with chronically elevated tropnin concentrations will be detected and most probably dynamic biomarker patterns with a change and rise will be of interest.
In the second presentation Keith Fox indicated that in routine clinical practice, the estimated GFR is sufficient for the assessment of renal function, even though cystatin C is more accurate and a stronger predictor of adverse clinical course. He convincingly demonstrated that renal dysfunction is a clinically relevant issue in ACS patients, with one third of patients having a creatinine clearance below 60 ml/min. Renal dysfunction has a major impact on outcome as demonstrated in several large randomized trials with an increased mortality and major bleeding events. Bleeding events especially can be avoided by an adoption of appropriate anticoagulant treatment regimen.
In the third presentation, Stefan James pointed out that both BNP and NT-proBNP provide good prognostic information and that there is good evidence that both markers are useful to identify patients who benefit from an invasive treatment. In contrast there is no evidence that BNP or NT-proBNP are helpful to decide on a treatment with an ACE inhibitor. He furthermore showed that growth diffentiation factor 15 (GDF-15) is a strong predictor of clinical outcome with good data available from the FRIS II trial suggesting that it can be used to decide which patients should undergo an invasive strategy.
In the last presentation of the session, David Morrow introduced several new biomarkers that are linked to plaque instability, namely MCP-1, IL-18, MPO, sCD40L, MRP 8/14, MMPs, PAPP-A, Neopterin and hsCRP. For all of these biomarkers there is good evidence that they provide incremental prognostic information. However, the clinical implications on treatment are yet undetermined with the exception of hsCRP and Neopterin. For these markers there is evidence that they could be applied to decide on a treatment with statins.
The usefulness for risk stratification of various biomarkers in patients with acute coronary syndromes has been demonstrated. Implications for therapeutic interventions can only be derived from retrospective analysis of randomized trials or no specific data are available. Therefore, further prospective studies are mandatory before new biomarkers should be introduced for routine clinical use.
Biomarkers for tailoring of treatment in acute coronary syndromes - the new opportunities Symposium
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