Multimarker approach for heart failure management: perspectives and limitations

Heart failure (HF) is a major public health problem and the approach for an accurate individualization of HF risk and care should include a profile of laboratory data, in addition to clinical and imaging data. The possibility of identifying the most vulnerable patients is clinically important, especially considering that many therapeutic interventions are available today. This goal has not been yet reached although many novel biomarkers have been proposed and tested. The complexity of the biochemical network at the basis of HF pathophysiology clearly suggests that a single marker cannot reflect all the features of this syndrome, whereas the combined use of more indices would better characterize HF patients and create new options for their management, helping identify which patients to follow more closely. The multimarker approach, considering various biochemical pathways simultaneously, bases its robustness on a suitable choice of indices known to be individually associated with HF. The choice of biomarker combination is essential to the performance of the multimarker strategy. A major problem in selecting the biomarker profile is the proportional increase in economic burden; thus a "parsimonious" biomarker combination has to be used in a cost-effective evaluation. Statistical analysis and analytical performance of the different elements of the combination, in turn, may heavily influence results. This review summarizes the results obtained using a multimarker approach for HF risk stratification, for predicting HF incidence in a population, and evaluating the response to therapy. An insight into transcriptomic biomarkers, recently proposed for HF individual risk assessment, is also reported. A reliable selection of biomarkers for the careful management of HF patients is of pivotal importance in reducing healthcare costs without reducing patient care

Novel biodegradable, biomimetic and functionalised polymer scaffolds to prevent expansion of post-infarct left ventricular remodelling.

Abstract Over the past decade, a large number of strategies and technologies have been developed to reduce heart failure progression. Among these, cardiac tissue engineering is one of the most promising. Aim of this study is to develop a 3D scaffold to treat cardiac failure. A new three-block copolymer, obtained from δ-valerolactone and polyoxyethylene, was synthesised under high vacuum without catalyst. Copolymer/gelatine blends were microfabricated to obtain a ECM-like geometry. Structures were studied under morphological, mechanical, degradation and biological aspects. To prevent left ventricular remodelling, constructs were biofunctionalises with molecularly imprinted nanoparticles towards the matrix metalloproteinase MMP-9. Results showed that materials are able to reproduce the ECM structure with high resolution, mechanical properties were in the order of MPa similar to those of the native myocardium and cell viability was verified. Nanoparticles showed the capability to rebind MMP-9 (specific rebinding 18.67) and to be permanently immobilised on the scaffold surface

Evaluation of the expression of transcripts coding for CNP and for its specific receptor, NPR-B, by Real Time PCR in cardiac tissue of normal and heart failure animals

Purpose: Higher plasma levels and a cardiac production of C-type natriuretic peptide (CNP) were recently observed in patients with chronic heart failure (HF), but its cellular source and possible difference between atrium and ventricle expression are so far lacking. Aim of this study was to evaluate the expression of transcripts coding for CNP and for its specific receptor, NPR-B, in cardiac tissue (right and left atrium and ventricle) of normal and CHF animals. CNP tissue levels were also determined in cardiac extracts. Methods: Adult male minipigs (n=5) were chronically instrumented with a unipolar pacemaker connected to the anterior left ventricular (LV) wall. HF was induced by rapid pacing (180 beats/min) for 4 weeks. End-stage HF occurred at 24?2 days of pacing when the LV end-diastolic pressure was !25 mmHg. As control, we studied 5 adult male minipigs. At 4 weeks, myocardial samples were collected. Both CNP mRNA and proteins were extracted from a same sample with the method of phenol/guanidine-thiocyanate/chloroform. Tissue CNP levels were determined by a radioimmunoassay after a preliminary extraction on Sep-Pak C18, while the expression of mRNA coding for CNP and NPR-B in myocardial tissue (n=40) by Real Time reverse transcriptase-polymerase chain reaction (PCR) with DDCt method. As overall control, a parallel Real Time-PCR assay for BNP mRNA expression was carried out in the same samples. Real Time-PCR analysis was performed using an automated sequence instrument (7900HT Fast, Applied Biosystems) for the real-time monitoring of nucleic acid green dye fluorescence (SYBR Green I). Results: As to myocardial extracts, CNP was found in all cardiac chambers of controls and its content was ten fold higher in atria than in ventricles (RA: 13.7?1.9 pg/mg; LA: 8.7?3.8 pg/mg; RV: 1.07?0.33 pg/mg; LV: 0.93?0.17 pg/mg). At 4 weeks of pacing stress, myocardial levels of CNP in LV were higher than in controls (15.8?9.9 pg/mg vs.0.9?0.17 pg/mg, p=0.01). The expression of mRNA coding for CNP was higher at 4 weeks of pacing althought CNP gene expression appears to be noticeable lower than that of BNP. The NPR-B resulted to be expressed in all cardiac regions analyzed, and a down-regulation was observed in ventricles after HF. Althought further investigations are necessary, the high tissue levels of CNP found after pacing stress as well as the myocardial CNP and NPR-B expression suggest an important role of this peptide in a so complex pathology as HF

A2A and A3, Adenosine receptors mRNA are overexpressed in an experimental animal model of myocardial infarction

Background: Adenosine, a purine nucleoside and a "retaliatory metabolite" in ischemia, is ubiquitous in the body, and increases 100-fold during ischemia. Its biological actions are mediated by four adenosine receptors (ARs): A1 and A3, coupled to Gi/o, and the high-affinity A2A and low-affinity A2B, coupled to Gs. Because A1R and A3R are distributed mainly in myocardial cells and A2 are on coronary vascular smooth cells in the heart, adenosine may substantially modulate cardiac function as a whole. Aim: To determine possible myocardial alterations in the expression of ARs, in an experimental animal model of myocardial infarction (MI). Materials and Methods: Left ventricular (LV) tissue was collected from male adult minipigs with MI (n=5), induced by permanent surgical legation of the left anterior descending coronary artery and from 5 healthy pigs. mRNA expression of A1R, A2AR, A2BR,A3R was determined by semi-quantitative RT-PCR in tissue sampled collected from border (BZ) and remote zones (RZ) of infarcted area. Results: Transmural infarction affected about 15% of the LV wall mass. After 4 weeks, mRNA expression was higher in infarct regions than in control for A1R (controls=2.0?1.0, BZ=2.4?0.4, RZ=1.2?0.1), A2AR (controls=0.6?0.3, BZ=1.9?0.2, RZ=1.3?0.04 p=0.002, p=0.04, controls vs. BZ and RZ), A2BR (controls=1.1?0.5, BZ=1.2?0.2, RZ=0.5?0.04) and A3R (controls=0.2?0.07, BZ=2.4?0.7, RZ=0.7?0.07, p=0.006, p=0.002, controls vs. BZ and RZ). Conclusion: All adenosine receptors, and expecially A2A and A3, are overexpressed in the BZ of MI, consistently with an adaptative retaliatory anti-ischemic adenosinergic changes of post-infarcted heart

Real time PCR evaluation for c-type natriuretic peptide and for its specific receptor, NPR-B in cardiac tissue of normal and chronic heart failure animals

Background. C-type natriuretic peptide (CNP) was recently found in the myocardium, but possible differences between atrium and ventricle production are so far lacking. Aim. To evaluate the expression of transcripts coding for CNP and for its specific receptor, NPR-B, in cardiac tissue (right and left atrium and ventricle) of normal and HF animals. Methods. Cardiac tissue was collected from male adult minipigs without (control, n=5) and with pacing-induced HF (n=5). HF was induced by rapid pacing (180 beats/ min) for 3 weeks. mRNA was extracted with the method of phenol/guanidine-thiocyanate/chloroform. The expression of mRNA coding for CNP and NPR-B was determined in myocardial tissue (n=40) by Real Time-PCR with DDCt method. As overall control, a parallel Real Time-PCR assay for BNP mRNA expression was carried out in the same samples. Results. CNP gene expression was observed in controls and at 3 weeks of pacing resulting lower than that of BNP (left ventricle: p=0.05 controls vs. HF). As expected, BNP gene expression in all the cardiac chambers resulted higher after 3 weeks of pacing compared to normal heart (right atrium and left ventricle: p=0.003 controls vs. HF). Moreover, BNP mRNA expression was higher in atrium than in ventricle. We also observed higher, but not significantly, levels of CNP mRNA expression between normal and HF animals in all chambers. The NPR-B resulted to be expressed in all cardiac regions analyzed, and a down- regulation was observed in ventricles after HF (right ventricle p=0.001 controls vs. HF). Conclusions. In the present study, we provided the first evidence of CNP and NPR-B expression in tissue from normal and HF. The increased myocardial CNP synthesis was associated to the NPR-B down regulation in HF. The co-localization of the CNP system and its specific receptor suggests a possible role of this peptide in a complex pathology such as HF and the present results may prompt novel therapeutical strategies targeting NPR-B

Mismatch between mRNA cardiac expression of BNP and CNP in pacing-induced heart failure

Purpose: It has been recently demonstrated in an animal model of heart failure (HF) that the high-frequency pacing of the left ventricle (LV) free wall causes a dyssynchronous pattern of contraction that leads to progressive cardiac failure with pronounced differences in regional contractility. Aim of this study was to evaluate the possible variation of brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP) mRNA expression in the anterior/anterior lateral region (pacing site, PS) compared with the infero-septal region (opposite site, OS) to individualize the possible association between the contraction patterns and the expression of these biomarkers. Methods: Cardiac tissue was collected from male adult minipigs without (controls, n=6) and with pacing-induced HF (n=8) from PS, and from the tissue remote from the pacing-site. mRNA expression of BNP and CNP was evaluated by semiquantitative polymerase chain reaction (PCR) by using GAPDH as housing gene. Results: A significant difference in mRNA expression of BNP in PS was observed between HF animals and controls (BNP/GAPDH: 0.65?0.11 vs. 0.35?0.04, p=0.02) whereas in OS BNP levels resulted similar to those of controls (BNP/GAPDH: 0.36?0.05). mRNA expression of CNP was higher in HF with respect to controls both in PS and in OS, although not significantly (CNP/GAPDH: controls 0.089?0.036, PS 0.29?0.23, OS 0.54?0.16). These findings are in tune with the increase of CNP tissue concentrations (controls=0.69?0.13; PS=1.56?0.19; OS=1.70?0.42 pg/mg protein; p=0.039 controls vs.OS). The higher levels of BNP mRNA expression in PS are in agreement with a reduction of contractile function in this region while the higher CNP mRNA expression in OS could suggest the presence of a major endothelial dysfunction in the remote region. Conclusions: In clinical conditions the endothelial dysfunction precedes the overt HF, so, although further investigations are necessary, these results suggest that CNP could be a early marker of HF. In this context, CNP could be a marker more relevant than BNP in early recognizing patients with HF

Myocardial infarction activates the expression of cardiometabolic biomarkers in the heart: study in a swine model.

Purpose. Inflammation, extra-cellular matrix (ECM) remodeling and adipokine system activation represent essential processes of molecular response to cardiac injury. The aim of this study was to evaluate the cardiac expression of biomarkers involved in the inflammation, ECM remodeling and adiponectin system in an experimental animal model of myocardial infarction (AMI). Methods. Left ventricular (LV) tissue was collected from male adult pigs with AMI (n=6), induced by permanent surgical ligation of the left anterior descending coronary artery and from 6 healthy pigs. mRNA expression was determined by RT-PCR in tissue samples collected from border (BZ) and remote zones (RZ) of infarcted area. Proinflammatory cytokines (IL-6, TNF-&#945;), matrix metalloproteinases (MMP)-2, -9, their tissue inhibitors (TIMP)-1, -2 and collagen (COL3&#945;) were evaluated. In addition, adiponectin and its receptors, adipo-R1 and adipo-R2, were evaluated, owing its anti-inflammatory actions. Results. This surgical approach resulted in a permanent transmural infarction affecting 10-15% of the LV wall mass and after 4 weeks the mRNA expression of biomarkers, normalized on the respective GAPDH, was significantly higher in infarcted regions than in controls (MMP-9: 7.09?4.31; 1.18?0.28; 0.72?0.11, respectively for BZ, RZ and controls, p<0.05 BZ vs. RZ and controls; TIMP-1: 2.41?1.20; 0.28?0.04; 0.33?0.05, p=0.01; TIMP-2: 2.75?1.51; 0.53?0.04; 0.38?0.03, p<0.05; COL3&#945;: 4.28?1.11; 0.87?0.13; 0.61?0.18, p<0.0004). Inflammatory indices were increased in AMI, both BZ and RZ. Adiponectin was significantly increased with respect to controls (BZ: 2.95?1.69; RZ: 0.93?0.33; controls: 0.52?0.12, p<0.05 BZ vs controls) as well as the Adipo-R1 (BZ: 1.40?0.31, RZ: 1.26?0.20, controls: 0.63?0.07; p<0.05 BZ and RZ vs controls). Conclusions. The inflammatory and ECM remodelling processes are activated after myocardial injury together with the system of adiponectin, confirming its involvement in the process of cardiac remodelling/repair. The knowledge of the interaction between the various mediators of the complex response to cardiac damage could represent an important target for new therapies. Reference. Shibata R et al, Cardiovasc Res. 2007 Jun 1;74(3):471-9

Adrenomedullin plasma levels as predictors of left ventricular reverse remodelling in patients treated with cardiac resynchronization therapy

Purpose: Adrenomedullin (ADM), a potent natriuretic and vasorelaxing peptide, has been isolated from human pheochromocytoma cells and from cardiovascular tissue. Increase in ADM plasma levels in congestive heart failure (CHF) patients (pts) is due to many cardiac and systemic factors and in particular to the greater plasma volume and to the activation of sympathetic nervous system. Aim of this study was to assess the role of plasma ADM levels in CHF pts treated by cardiac resynchronization therapy (CRT). Methods: 42 pts, mean age 70 years, 27 males, NYHA Class III-IV CHF underwent CRT. Cause of CHF were idiopathic dilated cardiomyopathy in 27 pts, post ischemic in 15; all pts were in sinus rhythm and with complete left bundle branch block (QRS duration 138?8 msec). A complete echoDoppler exam, blood samples for brain natriuretic peptide (BNP) and ADM were obtained within 2 days before implantation. Results: At 18?6 months follow-up, >1 NYHA Class improvement was observed in 31/42 pts. However, a >10% reduction in end-systolic dimensions (ESD): -18.2?2.3% was reported in 16 pts (Group I); in the remaining 26 pts ESD change was almost negligible: -1.5?3.2% (Group II). The two groups were comparable for age, sex, cause of LV dysfunction, ongoing therapy, QRS duration at baseline, pre implantation ESD (60.6?1.8 vs 59.9?1.9 mm - Group I vs II), LVEF% (24.3?1.2 vs 25.4?1.3%) and BNP (545?80 vs 494?89 pg/ml). Significantly higher pre implantation ADM levels were present in Group I than in Group II (25.8?2.4 pmol/l vs. 17.1?1.6, p = 0.005). Conclusions: Significantly higher ADM levels indicate a subgroup of pts in whom significant reverse remodelling can be observed after CRT. Since AM is also produced in cardiac myocytes, lower ADM values before CRT could suggest the presence of more severe myocardial damage which may impair LV reverse remodelling even in the setting of clinically successful resynchronization

Plasma adiponectin is a marker of severity in heart failure

Purpose. Adiponectin, a 247 aminoacid protein produced mainly by adipose tissue, beside its effects on glucose metabolism, plays important protective function against cardiovascular disease. Adiponectin is inversely correlated with an increased cardiovascular risk and hypo-adiponectinemia is considered an independent cardiovascular risk factor. On the contrary, the role of adiponectin in heart failure (HF) is not fully known. In order to evaluate the prognostic value of circulating adiponectin, we measured total adiponectin plasma levels in patients with HF of different severity. Methods. Total adiponectin, leptin and interleukin(IL)-6 levels were measured in plasma samples of 159 no diabetic patients with different etiology HF (17 in NYHA class I, 82 in NYHA class II, 46 in NYHA class III and 14 in NYHA class IV, age 62?14 yrs, LEVF% 32.5?0.79, mean?sem) and in 31 healthy subjects as control, by dedicated ELISA (Linco Res-US, DRG Diagnostics-Germany, Diaclone Research-France, respectively). In the same group brain natriuretic peptide (BNP) levels were determined by IRMA (Shionogi, Osaka, Japan). Results. Our findings indicated that total adiponectin levels increased significantly as a function of disease severity (7.1?0.61 mg/ml vs 10.9?1.4 in NYHA class I vs 12.8?0.95 in NYHA class II vs 15.7?1.3 in NYHA III vs 16.7?1.8 in NYHA class IV; p<0.001 NYHA II, III and IV vs controls) and they correlated negatively with LVEF% (p=0.0009), positively with cardiac function (BNP levels) (p<0.0001) and inflammation (IL-6 levels) (p<0.0001). We did not observe any correlation with metabolism (BMI) in patients with HF, while a significant correlation was found between leptin and BMI (p<0.0001). Conclusion. Circulating adiponectin is associated with cardiovascular function and inflammation in HF patients. The increased adiponectin plasma levels in HF is a marker of disease severity, indipendent of metabolism

Circulating adrenomedullin levels and Doppler-derived dP/dt in idopathic cardiomyopathy

Chronic heart failure (CHF) is characterized both by ventricular and vascular remodeling. Osteopontin (OP) is an extracellular matrix protein,that might have a role as a marker of ventricular remodelling, its expression being increased in myocardial tissue of CHF patients from biopsies. Adrenomedullin (AM), a potent vasodilator peptide secreted by endothelial cells, and endothelin (ET), a substance with long-acting vasocostrictor action, might express the paracrine vasomotor response to CHF progression