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Ulrika Birgersdotter-Green, MD, FHRSProfessor of MedicineDivision of Cardiology
University of California, San Diego
BiomarkersandArrhythmias/Devices
Disclosures
Honoraria, Research Grants, Medtronic
Honoraria, Research Grants, St. Jude Medical
Honoraria, Research Grants, Biotronik
Outline
• BiomarkersinAtrialFibrillation
• BiomarkersinCardiacResynchronizationTherapy
• BiomarkersinDiagnosisofDeviceInfections
BiomarkersinAtrialFibrillation
• AFisthemostcommonclinicalarrhythmiaandtheprevalenceisprojectedtoincreasemarkedlyinthecomingdecades
• AFisindependentlyassociatedwithuptotwo-foldhigherriskofdeath
• AFhasbeenestimatedtocontributeto130000deathseachyear
• Establishedriskscoreforischemicstroke;CHA2DS2-VASc
• Overall,useofbiomarkershasnotbeenintegratedintoclinicalmanagementofAF
BiomarkersinAtrial FibrillationGuidelineRecommendations
Recommendationforpredictionofstrokeandbleedingrisk
• Troponinisprognosticinpatientswithatrialfibrillation,correlatingwithincreasedcardiovasculareventssuchasischemicstroke,TIA,acutecoronarysyndrome,acuteheartfailure,majorbleedinganddeath
BiomarkersinAtrial FibrillationTroponin
• Howdoyouimplementthisfindingclinically?
• CantroponinhelpdetectincreasedriskofAF?
BiomarkersinAtrial FibrillationTroponin
Notenoughdata
Noclearbenefit
• CantroponinhelppredictpostopAF?
• Cantroponin aidinAFpatientswhopresentwithchestpain,r/o MI?
BiomarkersinAtrial FibrillationTroponin
Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
• CantroponinhelpdetectincreasedriskofAF?
BiomarkersinAtrial FibrillationTroponin
Notenoughdata
Noclearbenefit• CantroponinhelppredictpostopAF?
• Cantroponin aidinAFpatientswhopresentwithchestpain,r/o MI?
• RiskstratificationinnewinsetAF?
BiomarkersinAtrial FibrillationTroponin
Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
• Similartotroponin,BNPandNT-proBNP haveshowntobeassociatedwithAFincidence,postoperativeAFandprognosisinAF
• IthasalsobeenassociatedwithdiagnosisofheartfailureinAFandpredictingsuccessofDCcardioversionforAFCirclethisbulletonasecondclick
• Howtoimplementclinically?
BiomarkersinAtrial FibrillationTroponin
BiomarkersinAtrial FibrillationB-TypeNatriuretic Peptide
Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
BiomarkersinAtrial FibrillationST2
Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
BiomarkersinAtrial FibrillationABCDeathRiskScore
Hijazi Z, et al., European Heart Journal (2018) 39, 477–485
BiomarkersinCardiacResynchronizationTherapy
• Cardiacresynchronizationtherapy(CRT)isan effectivetherapyforselectedpatientswithheartfailure
• CRTreducesmortalityandimprovesmorbidity
• CRTishasaClassIindicationinpatientswithLVEF≤35%,QRSduration ≥150 mswithLeftBundleBranchBlock(LBBB)morphologyandonoptimalmedicaltherapy(OMT)
• However,anon-responserateof20%–40%existsandhasremainedunchangedoverthelastdecade,despiteextensiveresearch
• Couldbiomarkershelppredictreversalofadversecardiacremodeling?
BiomarkersinCardiacResynchronizationTherapy
BiomarkersinCardiacResynchronizationTherapy
Moher D, Liberati J, Altman DG, The PRISMA Group (2009).
Results:• ConsistentobservationinallECMbiomarkerbehaviorbeforeandafterCRTimplantationwasnot observedbetweenstudies.LowertypeIandtypeIIIcollagensynthesisbiomarkers(N-terminalpropeptides oftypeIandIIIprocollagens)expressiondemonstratedreplicatedabilitytopredictreverseleftventricularremodeling
BiomarkersinCardiacResynchronizationTherapy
BiomarkersinCardiacResynchronizationTherapy
Nauffal V, et al., PLoS One. 2017 Apr 7;12(4):e0175205
BiomarkersinCardiacResynchronizationTherapy
ChangesinCT-apelin andNT-proBNP levelsaccordingtoresponsetoCRT
Kosztin A, et al., Journal Biomarkers Vol 22, 2017 Issue 3-4.
BiomarkersinDiagnosisofDeviceInfections
• WorldwideimplantationratesofCardiacImplantableElectronicDevices(CIED)areestimatedat1,250000pacemakersand410000ICDsperyearwithanannualincreaseofabout5%
• Increaseimplantationrateshaveresultedinincreasedcomplicationratesandspecificallyadisproportionateincreaseindeviceinfections
• CIEDinfectionsareassociatedwithsignificantmorbidity,highermortalityandincreasedcosts
BiomarkersinDiagnosisofDeviceInfections
• Insuspecteddevicepocketinfectionsanearlydiagnosisandsubsequentcompletedeviceandleadremovalisimportanttoavoidprogressiontosepsisorendocarditis
• Diagnosingapocketinfectioncanbechallengingaspatientsmaypresentwithmild/fewsymptomsorlackofclearcutsignsoflocalinfection
• ConventionalinflammationrelatedbiomarkerssuchasWBCorESRhavelowsensitivitytopocketinfections.Aretherebetterbiomarkers?
BiomarkersinDiagnosisofDeviceInfections
Comparisonofsensitivityandspecificityforrelevantbiomarkersapplyingestablishedoroptimizedcut-offvalues.
Lennerz C, et al., PLoS One. 2017 Mar 6;12(3):e0172384
Conclusions
• BiomarkersinAtrialFibrillation– showingsomepromise,willbeinterestingtoseeiftheABCriskscoregetsclinicaltraction
• BiomarkersinCardiacResynchronizationTherapy– wearealongwayfromidentifyinganybiomarkersthatcanhelppredictnonresponse
• BiomarkersinDiagnosisofDeviceInfections– seemsreasonable tocheckaPCTlevelinthemorechallengingdiagnosticcases
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