The use of biomarkers to diagnose heart failure, estimate prognosis, and guide therapy has increased over the last several years. In many instances, the biomarkers have helped improve diagnosis, but often, they are used to make prognostic determinations. However, in many studies, most individuals are already suspected to be at high risk. Typically, these studies have relied on the use of B-Type natriuretic peptides (BNP) and cardiac troponin (cTn).
Over time, some researchers have championed the idea that clinicians really need serial values to accurately assess patients’ risk. Patient characteristics change over time and with treatment, patients may improve or worsen. By monitoring serial measurements within patients, clinicians may be better able to identify patients at risk. In addition, such data may point out the best window of opportunity to reduce that risk therapeutically.
In a study published in the Journal of Cardiac Failure, Mayo Clinic researchers assessed the value of serial measurements of soluble suppression of tumorigenicity 2 (ST2) and galectin-3 (Gal3) when added to natriuretic peptides and cTnT to identify the risk for adverse events over time.
In our model, cTnT is highly predictive for cardiovascular events,” said Allan Jaffe, M.D., a consultant in the Cardiovascular Diseases Department and Laboratory Medicine and Pathology at Mayo Clinic and author on the paper. “By assessing novel markers ST2 and Gal3, we wanted to determine how they respond in comparison to cTnT and natriuretic peptides and if they provided additional information.”
The study evaluated patients with biomarkers collected every three months over a two-year period in patients with class 2 and class 3 heart failure. ST2 performed very well and added markedly to identification of heart failure risk. These findings are in line with previous data collected that indicates the biologic variation of ST2 is relatively small, signifying it might be a good one to follow. In addition, it is known that changes occur in response to therapy.
Alternatively, Gal3 did not respond as well and did not provide any incremental information. Once Gal3 is elevated, although the marker identifies risk, it does not change in response to therapy.
These results suggest that ST2 has the potential to be an important biomarker with cTnT to monitor patients with heart failure over time. This data also begins to put into place a way of anticipating events so that clinicians can test interventions.
“If a clinician can use variations to determine when to change treatments, they may be able to modulate risk over time,” said Dr. Jaffe. “At this time, the best time window for intervention is unknown because researchers are just beginning to focus on these types of studies. Once we are able to define the best biomarkers to identify risk, and the timing, then—and only then—will we be able to test interventions to mitigate that risk.”
Moving forward, serial monitoring of ST2 along with cTnT can assist in identifying high-risk outpatients and perhaps may be valuable in guiding patient-tailored therapy.
“Now that we know the risk and have a better idea of when in time this may occur, we need to progress to therapy trials to define the most optimal way to help patients,” added Dr. Jaffe.