Pitfalls in the use of biomarkers
|
|
- June Knight
- 5 years ago
- Views:
Transcription
1 Pitfalls in the use of biomarkers Alan Maisel MD Professor of Medicine, University of California, San Diego Director Coronary Care Unit And Heart Failure Program San Diego Veterans Hospital
2 Disclosure information Alan Maisel MD Research support: Alere,Abbott,Brahms- ThermoFisher,Nanosphere Consultant: Alere
3
4
5 The Ideal Biomarker Sensitive and specific Reflects disease severity Correlates with prognosis Should aid in clinical decision making Either highly sensitive (diagnosis) OR highly specific (treatment effect) Reflects abnormal physiology/biochemistry Prognosis is most meaningful if level is clinically actionable Should be used as a basis for specific biomarker guided-therapy Level should decrease following effective therapy Bio-monitoring during treatment is an effective surrogate of improvement Maisel, JACC 2011
6 What is the major limitation of using biomarkers in clinical practice?
7
8
9 Excessive Shortness of Breath We Need Rapid and Accurate Diagnosis and treatment THIS COULD BE YOUR MOTHER
10 Number of Cases How sure are we about the diagnosis of AHF?? Significant Indecision Exists 43 % Pretest Probability of CHF McCullough, Maisel et al. Circulation. 2002;106:
11 Well, Bob, it looks like a paper cut, but just to be sure. Let s get an echo.
12 mortality (%) What happens if we misdiagnose the acute breathless patient? Dyspnea of respiratory origin P<0, Wuerz. Ann Emerg Med 1992;21: bronchodilators No therapy CHF Therapy
13 Getting it right is important Accuracy counts
14 Pre-Pro-BNP Pro-BNP N-terminal Pro-BNP 1-76 BNP t 1/2 = 18 min WALL STRESS Pro-BNP 1-108
15 BNP NT-pro bnp
16 Breathing Not Properly and Pride STUDY The N-terminal Pro-BNP Investigation of Dyspnea in the Emergency department (PRIDE) study James L. Januzzi Jr, MD, Carlos A. Camargo, MD, PhD, Saif Anwaruddin, MD, Aaron L. Baggish, MD, Annabel A. Chen, MD, Daniel G. Krauser, MD, Roderick Tung, MD, Renee Cameron, MS, J. Tobias Nagurney, MD, Claudia U. Chae, MD, MPH, Donald M. Lloyd-Jones, MD, ScM, David F. Brown, MD, Stacy Foran- Melanson, MD, PhD, Patrick M. Sluss, MD, PhD, Elizabeth Lee- Lewandrowski, PhD, MPH, Kent B. Lewandrowski, MD
17 Sensitivity Accuracy is 90% Optimal cut-off point 100 pg/ml BNP=50 pg/ml BNP=80 pg/ml BNP=100 pg/ml BNP=125 pg/ml BNP=150 pg/ml Positive predictive value=75% BNP 100 pg/ml Test positive BNP <100 pg/ml Test negative Final Diagnosis Heart Failure Final Diagnosis NOT Heart Failure Sensitivity =90% 615 Specificity =73% Negative predictive value=90 % Specificity Maisel AS et al. N Engl J Med. 2002;347:
18 BNP levels adds to the physician s ability McCullough, Maisel et al., Circulation :
19 Cost-Effectiveness of BNP at ED: The BASEL Study P=0.001 $8000 $6000 $4000 1,545 Savings/Patient Biosite Triage BNP (in pg/ml) $2000 Mueller C, et al. N Engl J Med. 2004;350:
20 You can t win them all (ask R.Federer) : Caveats to NP testing Dry versus wet BNP Gray Zone Renal dysfunction Obesity Heart Failure with normal levels Gender differences
21 BNP level (pg/ml) NP level = baseline NP(dry) plus change due to increased volume(wet) Wet (Change due to volume overload) Dry ( NYHA Euvolemic state) NYHA Class - Euvolemic (Dry) BNP
22 Rule out Rule in Probability (RRT) Grey Zone 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 BM <xx High NPV PROGNOSTIC UNCERTAINTY Grey area Biomarker X BM >XX High PPV
23 Grey Zone BNP 26.4% of all cases 16.5% CHF 7.9% No CHF McCullough PA, Steg PG, Aumont MC, Duc P, Omland T, Knudsen CW, Nowak RM, McCord J, Hollander JE, Westheim A, Storrow AB, Abraham WT, Lamba S, Wu AHB, Maisel AS, BNP Multinational Study Investigators. What Causes Elevated B-Type Natriuretic Peptide in Patients Without Heart Failure? J Am Coll Cardiol 2003;41:278A.
24 Maisel, Valle, Aspromente et Al EJHF 2009 Obesity There appears to be a linear inverse relationship between BMI and NP levels Patients who are obese (BMI >35kg/m 2 ) should have their NP doubled to use the standard cutpoints.
25 McCullough PA,Maisel AS et al. For the BNP Multinational Study Investigators. American Journal of Kidney Disease2008 Mean BNP by egfr- you can still diagnose heart failure cgfr, ml/min/1.73 m 2
26 The Differential Diagnosis of an Elevated Natriuretic Peptide Unrecognized HF Prior HF LVH Valvular heart disease Atrial fibrillation Advancing age Myocarditis ACS Pulmonary hypertension Congenital heart disease Anemia Pulmonary embolism Cardiac surgery Sleep apnea Critical illness Sepsis Burns Renal failure Toxic-metabolic insults
27 Normal levels of BNP Heart failure Mistaken for HF Flash pulmonary edema Acute atrial fibrillation Acute papillary muscle rupture Cardiac Tamponade Constrictive pericarditis
28 Women are more complex than men!
29 The Female Heart Women have higher basal heart rate than men Women have smaller cardiac vasculature Female hormones effect some cardiac functions Women are more likely than men to have some arrhythmias (Long QT Syndrome, AVNRT, polymorphic VT, et al.)
30 Age and Sex-Specific Reference Values for BNP 95 th %ile Framingham Study Increase with age Higher in women Olmsted County Median (Shinogi assay) Miller et al. Curr Vasc Pharm 07.
31 HRT and BNP Levels Increase with age Higher in women on HRT Redfield et al. JACC 2002.
32 Daniels et al. Eur J Heart Fail BACH trial: MR-proANP
33 PRIDE: NT-proBNP Patients WITH Heart Failure: Krauser et al. J Card Fail 2006.
34
35 Serial NP for Guiding Treatment During Hospitalization? Courtesy of Damien Logeart.
36 PAW (mm Hg) Changes in BNP Mirror changes in PAW* During Treatment of Acute Heart Failure N = 15 (responders) PAW BNP BNP (pg/ml) baseline *Pulmonary artery wedge. Hours Kazenegra, Maisel, A. et al. J Cardiac Failure, Vol. 7, No. 1, 2001
37 BNP trends during hospitalization and subsequent prognosis upon hospital discharge Highest baseline, greatest change; highest discharge level= worse prognosis Lowest Predischarge BNP= best prognosis Lowest Baseline BNP Level=second best prognosis
38 Death or Readmission (%) BNP on Discharge Predictive of Events Predischarge BNP >700 ng/l n=41, events=38 p< Predischarge BNP ng/l n=50, events=30 Predischarge BNP <350 ng/l n=111, events= Follow-Up (Days) p< Hazard Ratios of 2 nd and 3 rd Versus 1 st BNP Range Logeart D et al. J Am Coll Cardiol 2004;43(4):
39 The discharge NP level may be the most important level of all!!!
40 If your BNP is high at discharge >400 pg what can you do? Are they really euvolemic? Dry BNP Impedance Do they need more diuretics? Consider Aldosterone blockade Home monitoring Return visit within one week
41 Biomarkers: From Hospital to Home
42 Bringing NP levels Into the Clinic or Bringing the Clinic to BNP Needs to be interpreted in context Does not take the place of history, physical exam To interpret value must have understanding of NPs and heart failure syndrome Must have previous NP values to which to refer Confidential
43 Sensitivity Weight Change ROC AUC: 0.65/0.63 Source of the Curve Reference Line Percent Absolute Specificity Confidential Lewin J. Eur J Heart Fail Oct;7(6):953-7.
44 BNP Change Correlation Between in BNP and Weight R=0.002 P=0.983 (NS) Weight Change Confidential Lewin J. Eur J Heart Fail Oct;7(6):953-7.
45 Algorithms for BNP Outpatient Management TELEMEDICINE Maisel, Mueller, Yancy, Adams, Nieminen, Zannad, Fonarow, Liu, Peacock, Anker, Cleland, Filippatos, Braunwald, et al BNP consensus. Eur J Heart Fail Sep;10(9): Confidential
46
47 The Ideal Biomarker Sensitive and specific Reflects disease severity Correlates with prognosis Should aid in clinical decision making Either highly sensitive (diagnosis) OR highly specific (treatment effect) Reflects abnormal physiology/biochemistry Prognosis is most meaningful if level is clinically actionable Should be used as a basis for specific biomarker guided-therapy Level should decrease following effective therapy Bio-monitoring during treatment is an effective surrogate of improvement Maisel, JACC 2011
48 What good is a prognostic marker if you can t act on it?
49 Typical JACC meeting We have another great prognostic Biomarker paper this week You re fired
50 Risk Stratification is of Limited Value to Individual Patients Great news! I can predict you will live 4.5 months with a p value of 0.04!
51 Can BNP levels be used to titrate outpatient therapy? The Holy Grail
52 So everyone is supposed to be on the same dose of heart failure medications. That cannot be personalized medicine
53 Comparison of Trials BNP-Guided Therapy Trought on STARS- BNP TIME- CHF BATTLE - SCARR ED PRIMA Adapted from Felker et al. Am Heart J 2009; 158: 422 SIGNAL -HF Berger et al. PROTE CT n Blinding No No Single Double Single Single? No Marker NT-BNP BNP NT-BNP NT-BNP NT-BNP NT-BNP NT-BNP NT-BNP Aim (ng/l) / discharg e Control HF score Usual care 1 EP Death, CV hosp., HF HF death, HF hosp. class II 2 groups Usual care Death, all-cause hosp. Allcause mortality d alive out hosp. 50% red HF spec. 2 groups Usual care d alive out CV hosp. HF hosp., death CV events Age NT-BNP * ~2500 ~
54 NT-proBNP Concentrations By treatment allocation Treatment Baseline Follow-up P SOC 1946 [ ] 1844 [ ].61 NT-proBNP 2344 [ ] 1125 [ ].01
55 *Adjusted for Primary Endpoint Number of events P = events 58 events SOC NT-proBNP 20 0 *Logistic Odds NT-proBNP = 0.44 (95% CI= ; P =.019) Total CV Events
56
57 NEW KIDS ON THE BLOCKbiomarkers in acute heart failure Adrenomedulin procalcitonin ST-2 troponin Galactin-3 NGAL Co-peptin-
58 New biomarkers may give BNP a helping hand! Gal -3 b n p N g a l S T - 2 P C T
59 MR-ANP adds value where natriuretic peptides are not as strong
60 Heart Failure + infection Heart failure plus pneumonia is present about 10-15% of time Heart failure plus any infection may occur in up to 20% of hospitalized heart failure patients. Hospital Mortality may be up to 20% (versus 5%) in heart failure patients with untreated infections
61 BNP [ng/ml] AHF, no Pneumonia (n=539) AHF and Pneumonia (n=29) no AHF, no Pneumonia (n=947) Pneumonia, no AHF (n=126) 0 0 0,05 0,1 0,15 0,2 0,25 PCT [ng/ml] Maisel et al EJHF 2011
62 Trauma Heart Failure Cardiac surgery Radiocontras t ICU Kidney transpla nt NGAL IgA nephropa thy CKD
63
64 NGAL < 100, BNP < 330 NGAL < 100, BNP > 330 NGAL > 100, BNP < 330 NGAL > 100, BNP > Days
65 AKINESIS: Acute Kidney Injury N-gal Evaluation of Symptomatic heart failure Study
66 Find the sweet spot of euvolemia before discharge BNP level Bnp low but is there still wet bnp around? Could you have overdiuresed the patient? Begin diuretics Creatinine Now you ve done- it! 4 more Days in the hospital
67
68 Galectin-3 Mediated HF is Inherently Progressive Illustration of two clinically very similar patients with different galectin-3 levels and dramatically different clinical paths 8.5 ng/ml Patient A SEVERITY OF DISEASE CARDIAC FUNCTION 36.4 ng/ml Patient B DEATH TIME 68
69 Mechanism Galectin-3 and Natriuretic Peptides Who is affected? What happens in decompensation? Response to treatment BNP/NT-proBNP Released by myocytes in response to stretch Maybe elevated in any form of heart failure (100% of HF) Rapid marked rise and fall when cardiac function improves Reduced if treatment is effective Galectin-3 Release by macrophages in response to stimulation by aldosterone and inflammation Only in patients affected by this form of HF (30-50%) Levels unaffected remain constant Most effective treatments work down-stream no effect on galectin-3 levels Role Bystander Mediator or culprit 6 9
70 1-year Mortality 1-Year Mortality Overview Galectin-3 and Natriuretic Peptides Galectin-3 is Complementary to NT-proBNP Natriuretic peptides (BNP and NT-proBNP) Reflect two important dimensions: Degree of stretch/cardiac overload, and presence/absence of this fibrotic form of heart failure Galectin-3 prognostic information is independent of and complementary to information provided by natriuretic peptides Clinical Use Is it HF? - NP What form? Galectin-3 What to do next? NP & Galectin % 50% 40% 30% 20% 10% 0% 40% 35% 30% 25% 20% 15% 10% 5% 0% 13.0% 40.9% 36.9% 51.1% Low NT-proBNP ( 4299 ng/ml) High NT-proBNP (>4299 ng/ml) 6.9% 15.6% 19.3% 36.5% Low BNP ( 447 pg/ml) High BNP (>447 pg/ml) High galectin-3 (>17.8 ng/ml) Low galectin-3 ( 17.8 ng/ml) Galectin-3 is Complementary to BNP High galectin-3 (>17.8 ng/ml) Low galectin-3 ( 17.8 ng/ml) COACH PRIDE-HF
71 Cumulative hazard Additive value of ST2 to NTproBNP in long term prognosis Both sst2 and NT-proBNP elevated (n=276) Only sst2 elevated (n=95) Only NT-proBNP elevated (n=54) Neither elevated (n=168) 0.4 P < Days from enrollment
72 ST2 and BNP Survival Daniels LB, et al. Am Heart J 2010.
73 BNP on Every Street Corner?
74
75
76
77 Present and future uptake of NPs Now 5 Years Diagnosis of Acute HF Following Patient in Hospital Utilizing Discharge BNP Monitoring BNP Post-discharge Guiding Outpatient Rx Use as Part of Dx Criteria for HFPEF Screen for LV Dyfx Outpatient Risk Profiling Maisel and Daniels JACC Confidence uptake (%)
78 Biomarkers will Make bad doctors worse and good doctors better!
79
80
81 Thank You
The Dyspneic Patient in the ED Which Biomarkers should we use and how THIS COULD BE YOUR MOTHER
The Dyspneic Patient in the ED Which Biomarkers should we use and how THIS COULD BE YOUR MOTHER Diagnostic Biomarkers BNP Mid-region proanp Procalcitonin NGAL BIVA Prognostic Biomarkers Troponin Adrenomedulin
More informationThe clinical value of natriuretic peptide testing in heart failure
The clinical value of natriuretic peptide testing in heart failure James L. Januzzi, Jr, MD, FACC, FESC Associate Professor of Medicine Harvard Medical School Roman W. DeSanctis Endowed Clinical Scholar
More informationNatriuretic Peptides The Cardiologists View. Christopher defilippi, MD University of Maryland Baltimore, MD, USA
Natriuretic Peptides The Cardiologists View Christopher defilippi, MD University of Maryland Baltimore, MD, USA Disclosures Research support: Alere, BG Medicine, Critical Diagnostics, Roche Diagnostics,
More informationST2 in Heart Failure. ST2 as a Cardiovascular Biomarker. Competitive Model of ST2/IL-33 Signaling. ST2 and IL-33: Cardioprotective
ST2 as a Cardiovascular Biomarker Lori B. Daniels, MD, MAS, FACC Professor of Medicine Director, Coronary Care Unit University of California, San Diego ST2 and IL-33: Cardioprotective ST2: member of the
More informationBiomarker-guided HF: What have we learned (so far)?
Biomarker-guided HF: What have we learned (so far)? James L. Januzzi, Jr, MD, FACC, FESC Associate Professor of Medicine Harvard Medical School Director, Cardiac ICU Massachusetts General Hospital DECLARATION
More informationBiomarkers in the Assessment of Congestive Heart Failure
Biomarkers in the Assessment of Congestive Heart Failure Mid-Regional pro-adrenomedullin (MR-proADM) vs BNP & NT-proBNP as Prognosticator in Heart Failure Patients: Results of the BACH Multinational Trial
More informationRuolo dei Marcatori Bioumorali nello scompenso cardiaco
Ruolo dei Marcatori Bioumorali nello scompenso cardiaco Head Emergency Medicine Sant Andrea Hospital Director Postgraduate School of Emergency Medicine Faculty od Medicine and Psycology Sapienza University
More informationBiomarkers beyond BNP and Troponin
Biomarkers beyond BNP and Troponin Alan Maisel, MD Professor of Medicine, University of California, San Diego Director, Coronary Care Unit and Heart Failure Program San Diego Veterans Hospital Disclosures
More informationBiomarkers Now and in the Future of Emergency Medicine- TIME TO USE sst2 Alan S. Maisel MD FACC Professor of Medicine, Emeritus University of
Biomarkers Now and in the Future of Emergency Medicine- TIME TO USE sst2 Alan S. Maisel MD FACC Professor of Medicine, Emeritus University of California, San Diego, Chest Pain, Shortness of breath: We
More information6/6/17. Heart Failure and Natriuretic Peptides. Learning objectives
Heart Failure and Natriuretic Peptides Maria-Magdalena Patru, MD, PhD Director, Medical and Scientific Affairs This promotional educational activity is brought to you by Ortho-Clinical Diagnostics, Inc.
More informationΒΙΟΔΕΙΚΤΕΣ ΣΤΗΝ ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ. ΔΗΜΗΤΡΙΟΣ ΤΟΥΣΟΥΛΗΣ Καθηγητής Καρδιολογίας
ΕΘΝΙΚΟ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ ΙΑΤΡΙΚΗ ΣΧΟΛΗ Ά ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ Διευθυντής: Καθηγητής Δημήτριος Τούσουλης ΒΙΟΔΕΙΚΤΕΣ ΣΤΗΝ ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΔΗΜΗΤΡΙΟΣ ΤΟΥΣΟΥΛΗΣ Καθηγητής Καρδιολογίας
More informationHEART FAILURE PATIENT MANAGEMENT. To The Power of 2!
HEART FAILURE PATIENT MANAGEMENT To The Power of 2! Put The Power of 2 To Work For You! THE PRESAGE ST2 ASSAY is a simple blood test that aids physicians in risk assessment of heart failure patients. Elevated
More informationUpdate on Biomarkers in Heart Failure. Professor T A McDonagh, King s College Hospital. London
Update on Biomarkers in Heart Failure Professor T A McDonagh, King s College Hospital. London Known Knowns,,,, for Biomarkers in HF Natriuretic Peptides Troponins BNP... ANP/BNP/ in CHF First to be discovered
More informationBiomarkers in the Age of Sacubitril/Valsa rten: Has the PARADIGM Changed
Biomarkers in the Age of Sacubitril/Valsa rten: Has the PARADIGM Changed Alan S. Maisel MD FACC Professor of Medicine, University of California, San Diego, Director, CCU and Heart Failure Program San Diego
More informationOverview & Update on the Utilization of the Natriuretic Peptides in Heart Failure
June 28, 2016 Overview & Update on the Utilization of the Natriuretic Peptides in Heart Failure Linda C. Rogers, PhD, DABCC, FACB. Agenda Overview of the Natriuretic Peptides and Efficacy studies Similarities
More informationRole of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association
Role of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association We combed through both guidelines and summarized 3 recommendations
More informationΟξεία καρδιακή ανεπάρκεια: Ποιες παράμετροι συμβάλλουν στη διαστρωμάτωση κινδύνου των ασθενών;
Οξεία καρδιακή ανεπάρκεια: Ποιες παράμετροι συμβάλλουν στη διαστρωμάτωση κινδύνου των ασθενών; Γ. Φιλιππάτος, MD, FACC, FESC, FCCP Επ. Καθηγητής Καρδιολογίας Πανεπ. Αθηνών Clinical Outcomes in Patients
More informationNatriuretic Peptide Guided Therapy for Heart Failure
Natriuretic Peptide Guided Therapy for Heart Failure Michael Felker, MD, MHS Associate Professor of Medicine Director of Heart Failure Research Duke Clinical Research Institute Disclosures Research Grants
More informationPearls in Acute Heart Failure Management
Pearls in Acute Heart Failure Management Best Practices Juan M. Aranda Jr., M.D. Professor of Medicine Medical Director of Heart Failure/ Transplant Program University of Florida College of Medicine Disclosures:
More informationTreating HF Patients with ARNI s Why, When and How?
Treating HF Patients with ARNI s Why, When and How? 19 th Annual San Diego Heart Failure Symposium for Primary Care Physicians January 11-12, 2019 La Jolla, CA Barry Greenberg M.D. Distinguished Professor
More informationA Guide to Proper Utilization of Biomarkers
A Guide to Proper Utilization of Biomarkers DR. ABEER BAKHSH CONSULTANT CARDIOLOGIST, ADVANCE HEART FAILURE KING FAHD ARMED FORCES HOSPITAL JEDDAH, SAUDI ARABIA Objective: Mechanism of myocardial injury
More informationBiomarkers in Heart Failure
Biomarkers in Heart Failure James L. Januzzi, Jr, MD Associate Professor of Medicine Harvard Medical School Director, Cardiac ICU Massachusetts General Hospital Disclosures Research grants for clinical
More informationUpdates in Congestive Heart Failure
Updates in Congestive Heart Failure GREGORY YOST, DO JOHNSTOWN CARDIOVASCULAR ASSOCIATES 1/28/2018 Disclosures Edwards speaker on Sapien3 valves (TAVR) Stages A-D and NYHA Classes I-IV Stage A: High risk
More informationDiagnostic value of N-terminal ProB-Type Natriuretic Peptide in Emergency Department: Analysis by subgroups
emergency care journal Diagnostic value of N-terminal ProB-Type Natriuretic Peptide in Emergency Department: Analysis by subgroups P. Villa, A. Dolci*, R. Dominici*, M. Panteghini**, C. Fundarò, S. Guzzetti
More informationHeart Failure Biomarkers: Advances in Diagnostics and Therapeutics
Heart Failure Biomarkers: Advances in Diagnostics and Therapeutics Michael Felker, MD, MHS, FACC, FAHA Associate Professor of Medicine Director, Heart Failure Section Disclosures Consulting and/or Grant
More informationHeart Failure: Guiding-therapy
Heart Failure: Guiding-therapy Justin A. Ezekowitz, MBBCh MSc FRCPC FACC FESC FAHA Associate Professor, University of Alberta Co-Director, Canadian VIGOUR Centre Cardiologist, Mazankowski Alberta Heart
More information*Christian M. Carlsen, 1 Mette Mouridsen, 1 Ahmad Sajadieh, 1 Lars Køber, 2 Olav W. Nielsen 1 ABSTRACT BACKGROUND
USE OF N-TERMINAL NATRIURETIC PEPTIDE IN A REAL- WORLD SETTING OF PATIENTS ADMITTED WITH ACUTE DYSPNOEA AND THE IMPLICATION FOR TRIAGING PATIENTS IN THE EMERGENCY DEPARTMENT *Christian M. Carlsen, 1 Mette
More informationΒιοδείκτες στην καρδιακή ανεπάρκεια διαγνωστικά και θεραπευτικά δεδομένα. Χριστίνα Χρυσοχόου Επιμ Α Α Παν. Καρδιολογικής Κλινικής, ΙΓΝΑ
Βιοδείκτες στην καρδιακή ανεπάρκεια διαγνωστικά και θεραπευτικά δεδομένα Χριστίνα Χρυσοχόου Επιμ Α Α Παν. Καρδιολογικής Κλινικής, ΙΓΝΑ Παθοφυσιολογία καρδιακής ανεπάρκειας Kaye and Krum Nature Reviews
More informationUPDATES IN MANAGEMENT OF HF
UPDATES IN MANAGEMENT OF HF Jennifer R Brown MD, MS Heart Failure Specialist Medstar Cardiology Associates DC ACP Meeting Fall 2017 Disclosures: speaker bureau for novartis speaker bureau for actelion
More informationMeasuring Natriuretic Peptides in Acute Coronary Syndromes
Measuring Natriuretic Peptides in Acute Coronary Syndromes Peter A. McCullough, MD, MPH, FACC, FACP, FAHA, FCCP Consultant Cardiologist Chief Academic and Scientific Officer St. John Providence Health
More informationΟΙ ΒΙΟΔΕΙΚΤΕΣ ΚΑΡΔΙΟΛΟΓΙΑ ΣΗΜΕΡΑ ΔΗΜΗΤΡΙΟΣ ΤΟΥΣΟΥΛΗΣ. Καθηγητής Καρδιολογίας
ΕΘΝΙΚΟ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ ΙΑΤΡΙΚΗ ΣΧΟΛΗ Ά ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ Διευθυντής: Καθηγητής Δημήτριος ΤΟΥΣΟΥΛΗΣ ΟΙ ΒΙΟΔΕΙΚΤΕΣ ΣΤΗΝ ΚΑΡΔΙΟΛΟΓΙΑ ΣΗΜΕΡΑ ΔΗΜΗΤΡΙΟΣ ΤΟΥΣΟΥΛΗΣ Καθηγητής Καρδιολογίας
More informationKeynote Address II Managing Acute Heart Failure: What Can We Do to Improve Outcomes?
Keynote Address II Managing Acute Heart Failure: What Can We Do to Improve Outcomes? 24 th Annual San Diego Heart Failure Symposium June 1-2, 2018 La Jolla, CA Barry Greenberg, MD Distinguished Professor
More informationHeart Failure and Cardio-Renal Syndrome 1: Pathophysiology. Biomarkers of Renal Injury and Dysfunction
CRRT 2011 San Diego, CA 22-25 February 2011 Heart Failure and Cardio-Renal Syndrome 1: Pathophysiology Biomarkers of Renal Injury and Dysfunction Dinna Cruz, M.D., M.P.H. Department of Nephrology San Bortolo
More informationWhat s new in the 2017 heart failure guidelines. Prof.Dr.Mehmet Birhan YILMAZ, FESC, FACC, FHFA
What s new in the 2017 heart failure guidelines Prof.Dr.Mehmet Birhan YILMAZ, FESC, FACC, FHFA Key points to remember 2017 guidelines recommend using natriuretic peptides as biomarkers to screen for heart
More informationTherapeutic Targets and Interventions
Therapeutic Targets and Interventions Ali Valika, MD, FACC Advanced Heart Failure and Pulmonary Hypertension Advocate Medical Group Midwest Heart Foundation Disclosures: 1. Novartis: Speaker Honorarium
More informationImpact of Renal Disease on Natriuretic Peptide Testing for Diagnosing Decompensated Heart Failure and Predicting Mortality
Clinical Chemistry 53:8 1511 1519 (2007) General Clinical Chemistry Impact of Renal Disease on Natriuretic Peptide Testing for Diagnosing Decompensated Heart Failure and Predicting Mortality Christopher
More informationHow might biomarkers and other strategies help establish adequacy of care?
How might biomarkers and other strategies help establish adequacy of care? James L. Januzzi, Jr, MD, FACC, FESC Hutter Family Professor of Medicine, Harvard Medical School Cardiology Division, Massachusetts
More informationFrom PARADIGM-HF to Clinical Practice. Waleed AlHabeeb, MD, MHA Associate Professor of Medicine President of the Saudi Heart Failure Group
From PARADIGM-HF to Clinical Practice Waleed AlHabeeb, MD, MHA Associate Professor of Medicine President of the Saudi Heart Failure Group PARADIGM-HF: Inclusion Criteria Chronic HF NYHA FC II IV with LVEF
More informationRisk Stratification in Heart Failure: The Role of Emerging Biomarkers
Risk Stratification in Heart Failure: The Role of Emerging Biomarkers David G. Grenache, PhD Associate Professor of Pathology, University of Utah Medical Director, ARUP Laboratories Salt Lake City, UT
More informationTHE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION
THE PROPER APPROACH TO DIAGNOSING HEART FAILURE WITH PRESERVED EJECTION FRACTION James C. Fang, MD, FACC Professor and Chief Cardiovascular Division University of Utah School of Medicine Disclosures Data
More informationORIGINAL INVESTIGATION. Clinical Uncertainty, Diagnostic Accuracy, and Outcomes in Emergency Department Patients Presenting With Dyspnea
ORIGINAL INVESTIGATION Clinical Uncertainty, Diagnostic Accuracy, and Outcomes in Emergency Department Patients Presenting With Dyspnea Sandy M. Green, MD; Abelardo Martinez-Rumayor, MD; Shawn A. Gregory,
More informationTODAYSPRING Heart Failure. What s Inside:
Heart Failure TODAYSPRING 2013 What s Inside: Going beyond natriuretic peptides to treat HF The frightening statistics behind heart failure Roger s remarkable survival in the face of terrible odds DON
More informationThe role of remote monitoring in preventing readmissions after acute heart failure
The role of remote monitoring in preventing readmissions after acute heart failure October 20, 2017 Randall C Starling MD MPH FACC FAHA FESA FHFSA Professor of Medicine Kaufman Center for Heart Failure
More informationBiomarkers I: Defining the value of measuring
Biomarkers I: Defining the value of measuring Alan S. Maisel MD FACC Professor of Medicine, University of California, San Diego, Director, CCU and Heart Failure Program San Diego VA Medical Center The
More informationNT-proBNP: Evidence-based application in primary care
NT-proBNP: Evidence-based application in primary care Associate Professor Rob Doughty The University of Auckland, Auckland City Hospital, Auckland Heart Group NT-proBNP: Evidence in Primary Care The problem
More informationHFpEF, Mito or Realidad?
HFpEF, Mito or Realidad? Ileana L. Piña, MD, MPH Professor of Medicine and Epidemiology/Population Health Associate Chief for Academic Affairs -- Cardiology Montefiore-Einstein Medical Center Bronx, NY
More informationHigh-Sensitivity Cardiac Troponin in Suspected ACS
15 th Annual Biomarkers in Heart Failure and Acute Coronary Syndromes STATE-OF-THE-ART High-Sensitivity Cardiac Troponin in Suspected ACS David A. Morrow, MD, MPH Director, Levine Cardiac Intensive Care
More information6/29/2017. Role of Biomarkers in the Management of Heart Failure Patients. What s New in Biomarkers for HF Patients?
What s New in Biomarkers for HF Patients? Role of Biomarkers in the Management of Heart Failure Patients Lori B. Daniels, MD, MAS, FACC Professor of Medicine Director, Cardiovascular Intensive Care Unit
More informationEffective Health Care Program
Comparative Effectiveness Review Number 126 Effective Health Care Program Use of Natriuretic Peptide Measurement in the Management of Heart Failure Executive Summary Background Heart failure (HF) is a
More informationThe ACC Heart Failure Guidelines
The ACC Heart Failure Guidelines Fakhr Alayoubi, Msc,R Ph President of SCCP Cardiology Clinical Pharmacist Assistant Professor At King Saud University King Khalid University Hospital Riyadh-KSA 2017 ACC/AHA/HFSA
More informationBiomarkers & Treatment Guidance
Biomarkers & Treatment Guidance Alan S. Maisel MD FACC Professor of Medicine, University of California, San Diego, Director, CCU and Heart Failure Program San Diego VA Medical Center Easy to measure
More informationIntroduction. Summary. Karim Gariani a, Alain Delabays b, Thomas V. Perneger c, Thomas Agoritsas a,c
Published 9 November 2011, doi:10.4414/smw.2011.13298 Cite this as: Use of brain natriuretic peptide to detect previously unknown left ventricular dysfunction in patients with acute exacerbation of chronic
More informationUsing Lung Ultrasound to Diagnose and Manage Acute Heart Failure
Using Lung Ultrasound to Diagnose and Manage Acute Heart Failure Jennifer Martindale, MD Assistant Professor Department of Emergency Medicine SUNY Downstate/Kings County Hospital Brooklyn, NY What is acute
More informationPost Hoc Analysis of the PARADIGM Heart Failure Trial:
Post Hoc Analysis of the PARADIGM Heart Failure Trial: Pulse Pressure and Outcomes in Heart Failure with Reduced Ejection Fraction Chen-Huan Chen, M.D. Professor, Department of Medicine, National Yang-Ming
More informationCOPD as a comorbidity of heart failure in elderly patients
COPD as a comorbidity of heart failure in elderly patients Professor Mitja Lainscak, MD, PhD, FESC, FHFA Departments of Cardiology and Research&Education, General Hospital Celje Faculty of Medicine, University
More informationESCBM meeting 2018, Prague Utility of Cardiac Biomarkers in Clinical Heart Failure Care. Md. Shahidul Islam, M.D., Ph.D
ESCBM meeting 2018, Prague Utility of Cardiac Biomarkers in Clinical Heart Failure Care Md. Shahidul Islam, M.D., Ph.D shaisl@me.com 2 3 Circulating Biomarkers in Heart Failure. Berezin AE. Adv. Exp. Med.
More informationAcute heart failure syndromes: clinical challenges. Pathophysiology. ESC Congress August. Paris, France. Marco Metra
ESC Congress 2011 27-31 August. Paris, France. Acute heart failure syndromes: clinical challenges. Pathophysiology Marco Metra Cardiology, Dept. Of experimental and applied medicine. University of Brescia.
More information2016 ESC Heart Failure Guidelines: what is new? Piotr Ponikowski Wroclaw, Poland
2016 ESC Heart Failure Guidelines: what is new? Piotr Ponikowski Wroclaw, Poland Disclosures Consultancy fees and speaker s honoraria from: Amgen, Servier, Novartis, Johnson & Johnson, Merck, Berlin Chemie,
More informationLCZ696 A First-in-Class Angiotensin Receptor Neprilysin Inhibitor
The Angiotensin Receptor Neprilysin Inhibitor LCZ696 in Heart Failure with Preserved Ejection Fraction The Prospective comparison of ARNI with ARB on Management Of heart failure with preserved ejection
More informationBNP as a Predictor of Cardiovascular Disease and All Cause Mortality. Dr. Thierry Le Jemtel
BNP as a Predictor of Cardiovascular Disease and All Cause Mortality Dr. Thierry Le Jemtel Outline Role of BNP and probnp as relevant biomarkers in cardiac conditions Role of BNP and probnp as relevant
More informationB-type Natriuretic Peptide for Diagnosis of Heart Failure in Emergency Department Patients: A Critical Appraisal
686 Schwam d BNP FOR DIAGNOSIS OF HF B-type Natriuretic Peptide for Diagnosis of Heart Failure in Emergency Department Patients: A Critical Appraisal Abstract The diagnosis of heart failure in the outpatient
More informationState of the art: Using natriuretic peptide levels in clinical practice
European Journal of Heart Failure 10 (2008) 824 839 www.elsevier.com/locate/ejheart Review State of the art: Using natriuretic peptide levels in clinical practice Alan Maisel a,i,, Christian Mueller b,
More informationManagement of Acute Heart Failure
Management of Acute Heart Failure Uri Elkayam, MD Professor of Medicine University of Southern California School of Medicine Los Angeles, California elkayam@usc.edu ADHF Treatments Goals.2 Improve symptoms.
More informationCurrent Utilities of Cardiac Biomarker Testing at POC. June 24, 2010 Joe Pezzuto, MT (ASCP) Carolyn Kite, RN
Current Utilities of Cardiac Biomarker Testing at POC June 24, 2010 Joe Pezzuto, MT (ASCP) Carolyn Kite, RN 1. Discuss challenges associated with diagnosing Acute Coronary Syndromes (ACS) and Heart Failure
More informationA study of Brain Natriuretic Peptide levels in acute cardiac failure
Original Research Article A study of Brain Natriuretic Peptide levels in acute cardiac failure Bhavik Prajapati 1*, Anirudh Kulkarni 2 1 Assistant Professor, Department of Medicine, SMS Multispecialty
More informationOxford Medicine Online
Oxford Medicine Online The ESC Textbook of Intensive and Acute Cardiovascular Care (2 ed.) Edited by Marco Tubaro, Pascal Vranckx, Susanna Price, and Christiaan Vrints Latest update This online textbook
More informationTo estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome
Original Research Article To estimate the serum level of N-terminal pro-brain natriuretic peptide levels in acute coronary syndrome Mohamed Yasar Arafath 1, K. Babu Raj 2* 1 First Year Post Graduate, 2
More informationTROPONINS HAVE THEY CHANGED YOUR
TROPONINS HAVE THEY CHANGED YOUR PRACTICE THIS WEEK? Harvey White John Neutze Scholar Green Lane Cardiovascular Service and Cardiovascular Research Unit Auckland City Hospital, Auckland, New Zealand Disclosure
More informationPravin Manga Division of Cardiology Department of Medicine University of Witwatersrand
Pravin Manga Division of Cardiology Department of Medicine University of Witwatersrand Overview Definition Epidemiology Biomarkers Treatment Clinical Heart Failure: Syndrome in which patients have typical
More informationWHY ADMINISTER CARDIOTONIC AGENTS?
Cardiac Pharmacology: Ideas For Advancing Your Clinical Practice The image cannot be displayed. Your computer may not have enough memory to open the image, or Roberta L. Hines, M.D. Nicholas M. Greene
More informationClinical Review Criteria Galectin-3 Blood Assay Test
Clinical Review Criteria Galectin-3 Blood Assay Test Kaiser Foundation Health Plan of Washington NOTICE: Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options,
More information2017 ACC/AHA/HFSA HF guidelines. Advances in the Use of Biomarkers in Heart Failure Patients. Outline
Advances in the Use of Biomarkers in Heart Failure Patients Lori B. Daniels, MD, MAS, FACC, FAHA Professor of Medicine Director, Cardiovascular Intensive Care Unit Sulpizio Cardiovascular Center UC San
More informationHeart Failure Guidelines For your Daily Practice
Heart Failure Guidelines For your Daily Practice Juan M. Aranda, Jr., MD, FACC, FHFSA Professor of Medicine Director of Heart Failure and Cardiac Transplantation University of Florida College of Medicine
More informationObjectives. Systolic Heart Failure: Definitions. Heart Failure: Historical Perspective 2/7/2009
Objectives Diastolic Heart Failure and Indications for Echocardiography in the Asian Population Damon M. Kwan, MD UCSF Asian Heart & Vascular Symposium 02.07.09 Define diastolic heart failure and differentiate
More informationINIBITORI NEPRILISINA
INIBITORI NEPRILISINA Marco Canepa, MD, PhD Università degli Studi di Genova Cardiologia, Ospedale Policlinico San Martino IRCCS marco.canepa@unige.it ARNI: ANGIOTENSIN RECEPTOR NEPRILYSIN INHIBITORS
More informationHeart Failure with preserved ejection fraction (HFpEF)
Heart Failure with preserved ejection fraction (HFpEF) Dr. Pierpaolo Pellicori Hull York Medical School Kingston-upon-Hull United Kingdom Conflict of interest: none Heart failure is a contemporary problem
More informationMario Plebani University-Hospital of Padova, Italy
Mario Plebani University-Hospital of Padova, Italy CK-MB mass assay CHF guidelines use BNP for rule out AST in AMI CK in AMI INH for CK-MB electrophoresis for CK and LD isoenzymes RIA for myoglobin WHO
More informationANGIOTENSIN RECEPTOR-NEPRILYSIN INHIBITORS IN HEART FAILURE FROM CHD
ANGIOTENSIN RECEPTOR-NEPRILYSIN INHIBITORS IN HEART FAILURE FROM CHD Karen Stout, MD FACC Professor, Medicine/Pediatrics University of Washington Seattle, WA USA No disclosures Case 35 year old man with
More informationHEART FAILURE IN WOMEN. Marian Limacher, MD Division of Cardiovascular Medicine University of Florida
HEART FAILURE IN WOMEN Marian Limacher, MD Division of Cardiovascular Medicine University of Florida Outline Epidemiology Clinical Overview Why HF is such a challenge State of the Field Heart Failure Adjudication
More informationBiomarkers in Heart Disease. Felix J. Rogers, DO, FACOI April 29, 2018
Biomarkers in Heart Disease Felix J. Rogers, DO, FACOI April 29, 2018 Biomarkers NIH: A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biological processes,
More information10 years evaluation of soluble ST2 level and incidence of diastolic
10 years evaluation of soluble ST2 level and incidence of diastolic dysfunction in EGAT study population Wisuit Katekao, MD Prin Vathesatogkit, MD Oraporn See, MD Sukit Yamwong, MD Piyamitr Sritara, MD
More informationHeart Failure with Preserved EF (HFPEF) Epidemiology and management
Heart Failure with Preserved EF (HFPEF) Epidemiology and management Karl Swedberg Senior Professor of Medicine Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden e-mail: karl.swedberg@gu.se
More informationCRS-I-Treatment. Alan Maisel MD. Director Coronary Care Unit And Heart Failure Program San Diego Veterans Hospital
CRS-I-Treatment Alan Maisel MD Professor of Medicine, University of California, San Diego Director Coronary Care Unit And Heart Failure Program San Diego Veterans Hospital Outcomes in Patients Hospitalized
More informationManagement of Advanced Systolic Heart Failure. Robert W. Hull MD FACC Associate Professor of Medicine West Virginia University
Management of Advanced Systolic Heart Failure Robert W. Hull MD FACC Associate Professor of Medicine West Virginia University American College of Cardiology Foundation (ACCF) American Heart Association
More informationACUTE HEART FAILURE. Julie Gorchynski MD, MSc, FACEP, FAAEM. Department of Emergency Medicine Emergency Residency Program UTHSC, San Antonio TCEP 2014
ACUTE HEART FAILURE Julie Gorchynski MD, MSc, FACEP, FAAEM Department of Emergency Medicine Emergency Residency Program UTHSC, San Antonio TCEP 2014 No disclosures Objectives Overview Cases Current Therapy
More informationDiagnosis is it really Heart Failure?
ESC Congress Munich - 25-29 August 2012 Heart Failure with Preserved Ejection Fraction From Bench to Bedside Diagnosis is it really Heart Failure? Prof. Burkert Pieske Department of Cardiology Med.University
More informationSystolic Dysfunction Clinical/Hemodynamic Guide for Management; New Medical and Interventional Therapeutic Challenges
Systolic Dysfunction Clinical/Hemodynamic Guide for Management; New Medical and Interventional Therapeutic Challenges Clyde W. Yancy, MD, MSc, FACC, FAHA, MACP Magerstadt Professor of Medicine Professor,
More informationTrial to Reduce. Aranesp* Therapy. Cardiovascular Events with
Trial to Reduce Cardiovascular Events with Aranesp* Therapy John J.V. McMurray, Hajime Uno, Petr Jarolim, Akshay S. Desai, Dick de Zeeuw, Kai-Uwe Eckardt, Peter Ivanovich, Andrew S. Levey, Eldrin F. Lewis,
More informationManagement of chronic heart failure: update J. Parissis Attikon University Hospital
Management of chronic heart failure: update 2015 J. Parissis Attikon University Hospital Disclosures: received honoraria for lectures from Servier, Pfizer, Novartis Discharges in Thousands Heart Failure
More information2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Developed in Collaboration With the American Academy of Family Physicians, American College of Chest
More informationPlasma MR-proADM is superior to NTproBNP for all-cause short term mortality prediction in acute pulmonary embolism.
J. Pedowska-Wloszek, M. Kostrubiec, A. Labyk, S. Pacho, O. Dzikowska-Diduch, P. Bienias, B. Lichodziejewska, P. Palczewski, M. Ciurzynski, P. Pruszczyk Plasma MR-proADM is superior to NTproBNP for all-cause
More informationTHE CORRELATION BETWEEN
THE CORRELATION BETWEEN NT Pro-BNP LEVELS AND ECHOCARDIOGRAPHIC FINDINGS IN A PATIENT WITH ACUTE ONSET DYSPNEA. Sonal Virani, Pavan Kumar. M, Sunil Dalvi 1. Assistant Professor, Department of General Medicine,
More informationStopping the Revolving Door of ADHF
Stopping the Revolving Door of ADHF Ileana L. Piña, MD, MPH Professor of Medicine and Epidemiology/Population Health Associate Chief for Academic Affairs -- Cardiology Montefiore-Einstein Medical Center
More informationHFpEF. April 26, 2018
HFpEF April 26, 2018 (J Am Coll Cardiol 2017;70:2476 86) HFpEF 50% or more (40-71%) of patients with CHF have preserved LV systolic function. HFpEF is an increasingly frequent hospital discharge. Outcomes
More informationAcute Heart Failure: Diagnosis and Risk Assessment in the Emergency Department
Acute Heart Failure: Diagnosis and Risk Assessment in the Emergency Department J. Douglas Kirk, MD Professor and Vice Chairman, Department of Emergency Medicine Director, Chest Pain Evaluation Unit, University
More informationImproving Diagnostic, Prognostic & Therapeutic Biomarkers in Heart Disease. Professor Mark Richards Medicine, University of Otago, Christchurch
Improving Diagnostic, Prognostic & Therapeutic Biomarkers in Heart Disease Professor Mark Richards Medicine, University of Otago, Christchurch BNP / NT-ProBNP H 2 N 1 Pro-BNP Cardiomyocyte 76 77 108 COOH
More informationA CLINICAL DECISION TOOL FOR DIAGNOSING ACUTE HEART FAILURE IN THE UNDIFFERENTIATED DYSPNEIC ED PATIENT
A CLINICAL DECISION TOOL FOR DIAGNOSING ACUTE HEART FAILURE IN THE UNDIFFERENTIATED DYSPNEIC ED PATIENT Brian Steinhart MD, Phillip Levy MD MPH, Hilde Vandenberghe PhD, Gordon Moe MD, Ashley Cohen MSc,
More informationTreating the patient with acute heart failure. What do we really know? Principles of acute heart failure treatment
ESC 2012 27Aug - 3Sep, 2012, Munich, Germany Treating the patient with acute heart failure. What do we really know? Principles of acute heart failure treatment Marco Metra, MD, FESC Cardiology University
More informationDECLARATION OF CONFLICT OF INTEREST
DECLARATION OF CONFLICT OF INTEREST Probing prognosis in heart failure Daniel R. Wagner CHL/INCCI/CRP-Santé Luxembourg Disclosures Grants: Cordis, Boston Scientific, Medtronic, Sorin, Hexacath, Abbott,
More informationHeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long. Case Study 2
HeFSSA Practitioners Program 2017 Theme The Patient Journey: Feel Good and Live Long Case Study 2 HEART FAILURE WITH MID-RANGE EJECTION FRACTION TREATMENT OPTIONS CLINICAL CASE MEDICAL HISTORY 59-year-old
More information