Recherche de biomarqueurs pronostiques dans l'insuffisance cardiaque

Risk stratification of patients with systolic chronic heart failure (HF) is critical to better identify those who may benefit the most from invasive therapeutic strategies such as cardiac transplantation. In spite of recent advances, risk stratification of HF patients needs to be further improved. Indeed, there remains variability in the prognosis with some patients who are categorized at low risk but experience early mortality; and conversely, patients categorized as severe but have an unexpectedly prolonged survival. Proteomics has been used to provide prognostic information in various diseases.Aim – Our aim was to investigate the potential value of plasma proteomic profiling for risk stratification in HF and to find new circulating biomarkers that are associated with early cardiovascular mortality of chronic HF patients.Methods and results – For that purpose, we first designed 2 populations: a discovery and a validation population. Both populations issued from the INsuffisance CArdiaque (INCA) cohort, which is constituted of all consecutive patients referred in our institution for extensive prognostic evaluation of systolic chronic HF (LVEF <45%) between November 1998 and May 2010. For the discovery phase (case/control population), we selected 198 patients included between November 1998 and December 2005: 99 patients who died from cardiovascular cause within 3 years after the initial evaluation (cases) were individually matched for age, sex, and HF etiology with 99 patients who were still alive at 3 years (controls). For the validation phase, we evaluated a cohort of 344 consecutive patients included between January 2006 and May 2010. Study populations were carefully phenotyped. Cardiovascular death included cardiovascular-related death, urgent transplantations defined as United Network for Organ Sharing status 1 and urgent assist device implantation. A proteomic profiling using surface enhanced laser desorption ionization - time of flight - mass spectrometry was then performed in the case/control discovery population on plasma samples collected at inclusion. Plasma samples were depleted for major proteins and randomly analyzed in duplicate using CM10 (Weak Cation Exchanger) and H50 (Reverse Phase) proteinchip arrays. Forty two ion m/z peaks were found differentially abundant between cases and controls in the discovery population and were used to develop proteomic scores predicting cardiovascular death using 3 statistical regression methods: support vector machine, sparse partial least square discriminant analysis and lasso logistic regression. The proteomic scores were then tested in the validation population and score levels were significantly higher in patients who subsequently died within 3 years with the 3 methods. Proteomic scores remained significantly associated with cardiovascular mortality after adjustment on confounders. Furthermore, use of the proteomic scores allowed a significant improvement in discrimination of HF patients as determined by integrated discrimination improvement and net reclassification improvement indexes on top of “classic” prognostic evaluation. The next step was the purification and identification of the proteins related to the different m/z peaks (n=13) that were found significantly differentially abundant in both populations. We have currently identified several peaks as apolipoproteins: 14511 CM10-BM (ApoA1), 29024 CM10-BM (ApoA1), 3267 H50-BM (ApoC1), 6416 H50-BM (ApoC1), 6616 H50-BM (ApoC1), 6825 H50-BM (ApoC1), 8764 H50-BM (ApoC3), 9421 H50-BM (ApoC3). This has led to the quantification of these apolipoproteins in the INCA population using mass reaction monitoring technique.Conclusion – Proteomic analysis of plasma proteins may help to improve risk prediction of early mortality in HF patients.Perspectives – Further investigations are ongoing in order to determine the impact of the different apolipoproteins tested in risk stratification of chronic HF patients.La stratification du risque des patients atteints d'insuffisance cardiaque (IC) systolique chronique est essentielle afin d'identifier ceux qui pourront bénéficier de stratégies invasives telle que la transplantation cardiaque. En dépit des avancées récentes, cette stratification nécessite d'être encore améliorée. En effet, certains patients caractérisés à faible risque vont décéder précocement ; et inversement, d'autres identifiés à haut risque auront une survie prolongée.Objectif - Notre objectif était d'investiguer la place d'une analyse protéomique du plasma dans la stratification du risque des patients IC et de découvrir des biomarqueurs circulants associés à la mortalité cardiovasculaire précoce de ces patients.Méthodes et résultats - Pour ce faire, nous avons d'abord désigné 2 populations : une population test et une de validation. Ces 2 populations étaient issues de la population INsuffisance CArdiaque (INCA) constituée de l'ensemble des patients référés à notre centre pour une évaluation pronostique extensive d'une IC systolique chronique (FEVG <45%) entre novembre 1998 et mai 2010. Pour la phase test (population cas/témoins), nous avons sélectionné 198 patients entre novembre 1998 et décembre 2005: 99 patients décédés de cause cardiovasculaire dans les 3 ans suivant l'inclusion (cas) ont été comparés à 99 survivants à 3 ans appariés sur l'âge, le sexe et la cause de l'IC (témoins). Pour la phase de validation, nous avons évalué une cohorte de 344 patients consécutifs inclus entre janvier 2006 et mai 2010. Les populations ont été parfaitement caractérisées. La mortalité cardiovasculaire était définie comme un décès de cause cardiovasculaire, une transplantation en urgence (critère United Network for Organ Sharing status 1) ou une assistance cardiaque en urgence.Une analyse protéomique utilisant la technique SELDI-TOF-MS a ensuite été réalisée dans la population test sur des échantillons de plasma prélevés à l'inclusion. Les échantillons ont été déplétés des protéines majoritaires et analysés après randomisation en duplicate en utilisant des puces CM10 (échangeur de cations) et H50 (hydrophobie). Au total, 42 pics m/z étaient différentiellement abondants entre les cas et les témoins et ont été utilisés pour développer des scores protéomiques prédicteurs de la mortalité cardiovasculaire à l'aide de 3 méthodes statistiques de régression : machine à vecteur de support, régression des moindres carrés partiels et régression logistique de Lasso. Les scores protéomiques ont ensuite été testés dans la population de validation et étaient significativement plus élevés chez les patients qui vont décéder dans les 3 ans avec les 3 méthodes. Ces scores protéomiques persistaient associés à la mortalité cardiovasculaire après ajustement sur les facteurs confondants. De plus, l'utilisation de ces scores permettait une amélioration significative de la discrimination des patients IC par rapport à une évaluation pronostique classique selon les index suivants : "integrated discrimination improvement" et "net reclassification improvement".L'étape suivante a été de procéder à la purification et à l'identification des protéines correspondant aux pics m/z différentiellement abondants dans les 2 populations (n=13). Actuellement, nous avons pu identifier plusieurs apolipoprotéines : 14511 CM10-BM (ApoA1), 29024 CM10-BM (ApoA1), 3267 H50-BM (ApoC1), 6416 H50-BM (ApoC1), 6616 H50-BM (ApoC1), 6825 H50-BM (ApoC1), 8764 H50-BM (ApoC3), 9421 H50-BM (ApoC3). ceci a conduit à la quantification de ces apolipoprotéines dans la population INCA par une technique de "mass reaction monitoring".Conclusion - Une analyse protéomique des protéines du plasma semble améliorer la stratification du risque de mortalité précoce chez les patients atteints d’une IC chronique.Perspectives - Des investigations complémentaires sont en cours afin de déterminer l'impact des apoplipoprotéines dans la stratification du risque de ces patients

Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion

The role of the beta-adrenergic signaling pathway in heart failure (HF) is pivotal. Early blockade of this pathway with beta-blocker (BB) therapy is recommended as the first-line medication for patients with HF and reduced ejection fraction (HFrEF). Conversely, in patients with severe acute HF (AHF), including those with resolved cardiogenic shock (CS), BB initiation can be hazardous. There are very few data on the management of BB in these situations. The present expert consensus aims to review all published data on the use of BB in patients with severe decompensated AHF, with or without hemodynamic compromise, and proposes an expert-recommended practical algorithm for the prescription and monitoring of BB therapy in critical settings

021: Clopidogrel low response and correlation between the different tests: light transmission aggregometry, VerifyNow-P2Y12 and V ASP

BackgroundClopidogrel low response correlates with poor prognosis after percutaneous coronary intervention (PCI). Many biological tests are currently available to test the clopidogrel response. However, the presence of any correlation between the different tests is today poorly reported.MethodsIn this prospective study, clopidogrel response was assessed in 100 consecutive patients. All patients were tested between 18h and 24h after a600mg clopidogrel loading dose using 3 different tests: light transmission aggregometry with 10μmol ADP (LTA, results expressed as platelet inhibition percentage), VerifyNow-P2Y12 (VN, results expressed as PRU) and vasodilatator stimulated phosphoprotein (VASP, results expressed as IRP). Patients under chronic clopidogrel therapy were excluded.ResultsThe mean platelet inhibition percentage, PRU value and IRP value were 38.5±13% by LTA, 178±89 PRU by VN and 52±21% by VASP. When results were analyzed as continuous variables, there was a good correlation between the different tests: LTA/VN (R2=0,642, p<0,001), LTA/VASP (R2=0,409, p<0,001) and VN/VASP (R2=0,616, p<0,001). However, when results were analyzed as pre-specified cut-off points to define patients as “low or good responders” (according to the literature: 50% for LTA, 235 PRU for VN and 50% IRP for VASP), only 47% of the patients were defined as “good” or “low responders” by the 3 tests. Altogether, 33% of the patients were defined as “low responders” by only 1 test, 20% by 2 tests and only 16% by the 3 tests.ConclusionIf the correlation between the different tests is good when results are analyzed as continuous variables, each individual is rarely (less than 50%) defined as “low or good responder” by all the 3 tests when recognized cut-off values are used. In that way, a sole test might not be sufficient to manage antiplatelet therapy in an individual patient

Impact of initial clinical presentation on clopidogrel low response

SummaryBackgroundLarge interindividual variability exists in clopidogrel response. Clopidogrel low response correlates with poor prognosis after percutaneous coronary intervention. Some authors also suggest intraindividual variability over time.AimTo assess the impact of initial clinical presentation on clopidogrel low response.MethodsIn this prospective study, clopidogrel response was assessed in 100 patients. Fifty patients presenting with acute coronary syndromes (ACS group) were compared with 50 patients with stable coronary artery disease matched 1:1 for age, sex, body mass index and diabetes (stable group). All patients were tested 18–24h after a 600mg loading dose of clopidogrel using the VerifyNow-P2Y12 test (results expressed as platelet reaction units [PRUs]). Patients under chronic clopidogrel therapy or treated with glycoprotein IIb/IIIa inhibitors, bivalirudin or thrombolytics were excluded.ResultsMean age was 61±12 years in each group; 28% of patients in each group were diabetic; mean body mass index was 27.6±5.6kg/m2 in the ACS group and 27.9±5.9kg/m2 in the stable group (p=0.80). Mean PRU values were 197±81 in the ACS group and 159±94 in the stable group (p=0.03). By multivariable analysis, the ACS group was significantly associated with a higher PRU value (p=0.02). There were significantly more clopidogrel low responders (PRU value>230) in the ACS group (38% vs. 18%; p=0.04).ConclusionOur study confirms that initial clinical presentation, especially ACS, is a strong predictor of clopidogrel low response; this suggests that the evolution of coronary artery disease for one patient influences the clopidogrel response over time. These results are in accordance with recent trials showing a benefit for more aggressive antiplatelet therapy in ACS patients

Simple risk models to predict cardiovascular death in patients with stable coronary artery disease

Aims: Risk estimation is important to motivate patients to adhere to treatment and to identify those in whom additional treatments may be warranted and expensive treatments might be most cost effective. Our aim was to develop a simple risk model based on readily available risk factors for patients with stable coronary artery disease (CAD). Methods and results: Models were developed in the CLARIFY registry of patients with stable CAD, first incorporating only simple clinical variables and then with the inclusion of assessments of left ventricular function, estimated glomerular filtration rate, and haemoglobin levels. The outcome of cardiovascular death over ∼5 years was analysed using a Cox proportional hazards model. Calibration of the models was assessed in an external study, the CORONOR registry of patients with stable coronary disease. We provide formulae for calculation of the risk score and simple integer points-based versions of the scores with associated look-up risk tables. Only the models based on simple clinical variables provided both good c-statistics (0.74 in CLARIFY and 0.80 or over in CORONOR), with no lack of calibration in the external dataset. Conclusion: Our preferred model based on 10 readily available variables [age, diabetes, smoking, heart failure (HF) symptom status and histories of atrial fibrillation or flutter, myocardial infarction, peripheral arterial disease, stroke, percutaneous coronary intervention, and hospitalization for HF] had good discriminatory power and fitted well in an external dataset. Study registration: The CLARIFY registry is registered in the ISRCTN registry of clinical trials (ISRCTN43070564)

Expression and implication of clusterin in left ventricular remodeling after myocardial infarction

International audienceBACKGROUND: Left ventricular remodeling (LVR) after myocardial infarction is associated with an increased risk of heart failure and death. In spite of a modern therapeutic approach, LVR remains relatively frequent and difficult to predict in clinical practice. Our aim was to identify new biomarkers of LVR and understand their involvement in its development.METHODS AND RESULTS:Proteomic analysis of plasma from the REVE-2 study (Remodelage Ventriculaire)-a study dedicated to the analysis of LVR which included 246 patients after a first anterior myocardial infarction-identified increased plasma levels of CLU (clusterin) in patients with high LVR. We used a rat model of myocardial infarction to analyze CLU expression in the LV and found a significant increase that was correlated with LVR parameters. We found increased CLU expression and secretion in primary cultures of rat neonate cardiomyocytes hypertrophied by isoproterenol. Silencing of CLU in hypertrophied neonate cardiomyocytes induced a significant decrease in cell size, ANP (atrial natriuretic peptide), and BNP (B-type natriuretic peptide) expression, associated with a decreased ERK (extracellular signal-regulated kinase) 1/2 activity, suggesting a prohypertrophic role of CLU. We then confirmed a significant increase of both intracellular p-CLU (precursor form of CLU) and m-CLU (mature form of CLU) in failing human hearts. Finally, the circulating levels of CLU (secreted form) were increased in patients with chronic heart failure who died from cardiovascular cause during a 3-year follow-up (n=99) compared with survivors (n=99).CONCLUSIONS: Our results show for the first time that plasma CLU levels are associated with LVR post-myocardial infarction, have in part a cardiac origin, and are a predictor of early death in heart failure patients

Fatal Enterovirus-related Myocarditis in a Patient with Devic’s Syndrome Treated with Rituximab

Enteroviruses are a frequent source of infection and among the most common central nervous system viral pathogens. Enteroviruses – in particular, the Coxsackie B viruses – are a known cause of myocarditis. Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody. Many reports in the literature suggest a higher risk of infection following repeated rituximab therapy, including viral infection. However, observations of enterovirus-related myocarditis in the context of rituximab treatment are scarce. The authors describe the case of a patient with neuromyelitis optica spectrum disorder who developed severe and fatal enterovirus-related myocarditis after rituximab therapy with a difficult differential diagnosis of autoimmune or giant-cell myocarditis. This case highlights the importance of complete diagnostic workup in difficult cases of myocarditis, including endomyocardial biopsies

Research of prognostic biomarkers in heart failure

La stratification du risque des patients atteints d'insuffisance cardiaque (IC) systolique chronique est essentielle afin d'identifier ceux qui pourront bénéficier de stratégies invasives telle que la transplantation cardiaque. En dépit des avancées récentes, cette stratification nécessite d'être encore améliorée. En effet, certains patients caractérisés à faible risque vont décéder précocement ; et inversement, d'autres identifiés à haut risque auront une survie prolongée.Objectif - Notre objectif était d'investiguer la place d'une analyse protéomique du plasma dans la stratification du risque des patients IC et de découvrir des biomarqueurs circulants associés à la mortalité cardiovasculaire précoce de ces patients.Méthodes et résultats - Pour ce faire, nous avons d'abord désigné 2 populations : une population test et une de validation. Ces 2 populations étaient issues de la population INsuffisance CArdiaque (INCA) constituée de l'ensemble des patients référés à notre centre pour une évaluation pronostique extensive d'une IC systolique chronique (FEVG <45%) entre novembre 1998 et mai 2010. Pour la phase test (population cas/témoins), nous avons sélectionné 198 patients entre novembre 1998 et décembre 2005: 99 patients décédés de cause cardiovasculaire dans les 3 ans suivant l'inclusion (cas) ont été comparés à 99 survivants à 3 ans appariés sur l'âge, le sexe et la cause de l'IC (témoins). Pour la phase de validation, nous avons évalué une cohorte de 344 patients consécutifs inclus entre janvier 2006 et mai 2010. Les populations ont été parfaitement caractérisées. La mortalité cardiovasculaire était définie comme un décès de cause cardiovasculaire, une transplantation en urgence (critère United Network for Organ Sharing status 1) ou une assistance cardiaque en urgence.Une analyse protéomique utilisant la technique SELDI-TOF-MS a ensuite été réalisée dans la population test sur des échantillons de plasma prélevés à l'inclusion. Les échantillons ont été déplétés des protéines majoritaires et analysés après randomisation en duplicate en utilisant des puces CM10 (échangeur de cations) et H50 (hydrophobie). Au total, 42 pics m/z étaient différentiellement abondants entre les cas et les témoins et ont été utilisés pour développer des scores protéomiques prédicteurs de la mortalité cardiovasculaire à l'aide de 3 méthodes statistiques de régression : machine à vecteur de support, régression des moindres carrés partiels et régression logistique de Lasso. Les scores protéomiques ont ensuite été testés dans la population de validation et étaient significativement plus élevés chez les patients qui vont décéder dans les 3 ans avec les 3 méthodes. Ces scores protéomiques persistaient associés à la mortalité cardiovasculaire après ajustement sur les facteurs confondants. De plus, l'utilisation de ces scores permettait une amélioration significative de la discrimination des patients IC par rapport à une évaluation pronostique classique selon les index suivants : "integrated discrimination improvement" et "net reclassification improvement".L'étape suivante a été de procéder à la purification et à l'identification des protéines correspondant aux pics m/z différentiellement abondants dans les 2 populations (n=13). Actuellement, nous avons pu identifier plusieurs apolipoprotéines : 14511 CM10-BM (ApoA1), 29024 CM10-BM (ApoA1), 3267 H50-BM (ApoC1), 6416 H50-BM (ApoC1), 6616 H50-BM (ApoC1), 6825 H50-BM (ApoC1), 8764 H50-BM (ApoC3), 9421 H50-BM (ApoC3). ceci a conduit à la quantification de ces apolipoprotéines dans la population INCA par une technique de "mass reaction monitoring".Conclusion - Une analyse protéomique des protéines du plasma semble améliorer la stratification du risque de mortalité précoce chez les patients atteints d’une IC chronique.Perspectives - Des investigations complémentaires sont en cours afin de déterminer l'impact des apoplipoprotéines dans la stratification du risque de ces patients.Risk stratification of patients with systolic chronic heart failure (HF) is critical to better identify those who may benefit the most from invasive therapeutic strategies such as cardiac transplantation. In spite of recent advances, risk stratification of HF patients needs to be further improved. Indeed, there remains variability in the prognosis with some patients who are categorized at low risk but experience early mortality; and conversely, patients categorized as severe but have an unexpectedly prolonged survival. Proteomics has been used to provide prognostic information in various diseases.Aim – Our aim was to investigate the potential value of plasma proteomic profiling for risk stratification in HF and to find new circulating biomarkers that are associated with early cardiovascular mortality of chronic HF patients.Methods and results – For that purpose, we first designed 2 populations: a discovery and a validation population. Both populations issued from the INsuffisance CArdiaque (INCA) cohort, which is constituted of all consecutive patients referred in our institution for extensive prognostic evaluation of systolic chronic HF (LVEF <45%) between November 1998 and May 2010. For the discovery phase (case/control population), we selected 198 patients included between November 1998 and December 2005: 99 patients who died from cardiovascular cause within 3 years after the initial evaluation (cases) were individually matched for age, sex, and HF etiology with 99 patients who were still alive at 3 years (controls). For the validation phase, we evaluated a cohort of 344 consecutive patients included between January 2006 and May 2010. Study populations were carefully phenotyped. Cardiovascular death included cardiovascular-related death, urgent transplantations defined as United Network for Organ Sharing status 1 and urgent assist device implantation. A proteomic profiling using surface enhanced laser desorption ionization - time of flight - mass spectrometry was then performed in the case/control discovery population on plasma samples collected at inclusion. Plasma samples were depleted for major proteins and randomly analyzed in duplicate using CM10 (Weak Cation Exchanger) and H50 (Reverse Phase) proteinchip arrays. Forty two ion m/z peaks were found differentially abundant between cases and controls in the discovery population and were used to develop proteomic scores predicting cardiovascular death using 3 statistical regression methods: support vector machine, sparse partial least square discriminant analysis and lasso logistic regression. The proteomic scores were then tested in the validation population and score levels were significantly higher in patients who subsequently died within 3 years with the 3 methods. Proteomic scores remained significantly associated with cardiovascular mortality after adjustment on confounders. Furthermore, use of the proteomic scores allowed a significant improvement in discrimination of HF patients as determined by integrated discrimination improvement and net reclassification improvement indexes on top of “classic” prognostic evaluation. The next step was the purification and identification of the proteins related to the different m/z peaks (n=13) that were found significantly differentially abundant in both populations. We have currently identified several peaks as apolipoproteins: 14511 CM10-BM (ApoA1), 29024 CM10-BM (ApoA1), 3267 H50-BM (ApoC1), 6416 H50-BM (ApoC1), 6616 H50-BM (ApoC1), 6825 H50-BM (ApoC1), 8764 H50-BM (ApoC3), 9421 H50-BM (ApoC3). This has led to the quantification of these apolipoproteins in the INCA population using mass reaction monitoring technique.Conclusion – Proteomic analysis of plasma proteins may help to improve risk prediction of early mortality in HF patients.Perspectives – Further investigations are ongoing in order to determine the impact of the different apolipoproteins tested in risk stratification of chronic HF patients