Biomarkers and Arrhythmias/Devices Ulrika Birgersdotter-Green, M.D.
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1 Biomarkers and Arrhythmias/Devices Ulrika Birgersdotter-Green, M.D. Professor of Medicine Division of Cardiology University of California, San Diego
2 Disclosures Honoraria, Research Grants, Medtronic Honoraria, Research Grants, St. Jude Medical Honoraria, Research Grants, Biotronik
3 Outline Biomarkers in Sudden Cardiac Death (SCD) Biomarkers in Atrial Fibrillation Biomarkers in Cardiac Resynchronization Therapy Biomarkers in Diagnosis of Device Infections
4 Biomarkers in SCD SCD is the most common cause of death in the U.S. Incidence 300,000 to 400,000 each year (U.S.) 1,000 Cardiac arrests occur daily in the U.S.
5 Incidence of Sudden Death in Specific Populations GROUP General Population Patients with high coronary-risk profile Patients with previous coronary event patients with ejection fraction <35%, Congestive heart failure Patients with previous out-of-hospital cardiac arrest Patients with previous Myocardial infarction, low ejection fraction, and ventricular tachycardia Huikuri, et al., NEJM, Vol. 345, No. 20 Nov Incidence of Sudden Death (% of group) No. of Sudden Deaths Per Year
6 Biomarkers in SCD The Implantable Cardioverter Defibrillator (ICD) remains the most effective therapy in patients with structural heart disease ICD implant criteria based on Ejection Fraction. Is has been challenging to find other/better/additional risk predictors for ventricular arrhythmias. Most biomarker studies to date involve ICD patients with retrospective analysis of BNP and ICD therapy
7 Biomarkers in Cardiovascular Death in the Heart Failure and Coronary Artery Disease Population Dhindsa et a., Biomarkers to Predict Cardiovascular Death,
8 Biomarkers in SCD Guideline Recommendations Al-Khatib SM, et al., 2017 VA/SCD Guideline: Executive Summary
9 Biomarkers in Atrial Fibrillation AF is the most common clinical arrhythmia and the prevalence is projected to increase markedly in the coming decades AF is independently associated with up to two-fold higher risk of death AF has been estimated to contribute to deaths each year Established risk score for ischemic stroke; CHA 2 DS 2 -VASc Overall, use of biomarkers has not been integrated into clinical management of AF
10 Biomarkers in Atrial Fibrillation Guideline Recommendations Recommendation for prediction of stroke and bleeding risk 2016 ESC Guidelines for Management of Atrial Fibrillation
11 Biomarkers in Atrial Fibrillation Troponin Troponin is prognostic in patients with atrial fibrillation, correlating with increased cardiovascular events such as ischemic stroke, TIA, acute coronary syndrome, acute heart failure, major bleeding and death How do you implement this finding clinically?
12 Biomarkers in Atrial Fibrillation Troponin Can troponin help detect increased risk of AF? Not enough data Can troponin help predict postop AF? No clear benefit Can troponin help in AF patients who present with chest pain, r/o MI?
13 Biomarkers in Atrial Fibrillation Troponin Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
14 Biomarkers in Atrial Fibrillation Troponin Can troponin help detect increased risk of AF? Not enough data Can troponin help predict postop AF? No clear benefit Can troponin help in AF patients who present with chest pain, r/o MI? Maybe Can troponin help in risk stratification in new onset AF?
15 Biomarkers in Atrial Fibrillation Troponin Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
16 Biomarkers in Atrial Fibrillation BNP and NT-proBNP Similar to troponin, BNP and NT-proBNP have shown to be associated with AF incidence, postoperative AF and prognosis in AF It has also been associated with diagnosis of heart failure in AF and predicting success of DC cardioversion for AF How to implement clinically?
17 Biomarkers in Atrial Fibrillation B-Type Natriuretic Peptide Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
18 Biomarkers in Atrial Fibrillation ST2 Chang, Kay-Won, et al., The American Journal of Medicine, Vol 130, No 12, December 2017
19 Biomarkers in Atrial Fibrillation ABC Death Risk Score Hijazi Z, et al., European Heart Journal (2018) 39,
20 Biomarkers in Cardiac Resynchronization Therapy Cardiac resynchronization therapy (CRT) is an effective therapy for selected patients with heart failure CRT reduces mortality and improves morbidity CRT is has a Class I indication in patients with LVEF 35%,QRS duration 150 ms with Left Bundle Branch Block (LBBB) morphology and on optimal medical therapy (OMT) However, a non-response rate of 20% 40% exists and has remained unchanged over the last decade, despite extensive research
21 Biomarkers in Cardiac Resynchronization Therapy Could biomarkers help predict reversal of adverse cardiac remodeling?
22 Biomarkers in Cardiac Resynchronization Therapy Moher D, Liberati J, Altman DG, The PRISMA Group (2009).
23 Biomarkers in Cardiac Resynchronization Therapy Results: Consistent observation in all ECM biomarker behavior before and after CRT implantation was not observed between studies. Galectin-3 did not predict response to CRT
24 Biomarkers in Cardiac Resynchronization Therapy Nauffal V, et al., PLoS One Apr 7;12(4):e
25 Biomarkers in Cardiac Resynchronization Therapy Changes in CT-apelin and NT-proBNP levels according to response to CRT Kosztin A, et al., Journal Biomarkers Vol 22, 2017 Issue 3-4.
26 Biomarkers in Cardiac Resynchronization Therapy Spinale et al.,
27 Biomarkers in Diagnosis of Device Infections Worldwide implantation rates of Cardiac Implantable Electronic Devices ( CIED) are estimated at 1, pacemakers and ICDs per year with an annual increase of about 5 % Increase implantation rates have resulted in increased complication rates and specifically a disproportionate increase in device infections CIED infections are associated with significant morbidity, higher mortality and increased costs
28 Biomarkers in Diagnosis of Device Infections In suspected device pocket infections an early diagnosis and subsequent complete device and lead removal is important to avoid progression to sepsis or endocarditis Diagnosing a pocket infection can be challenging as patients may present with mild/few symptoms or lack of clear cut signs of local infection Conventional inflammation related biomarkers such as WBC or ESR have low sensitivity to pocket infections. Are there better biomarkers?
29 Biomarkers in Diagnosis of Device Infections Comparison of sensitivity and specificity for relevant biomarkers applying established or optimized cut-off values. Lennerz C, et al., PLoS One Mar 6;12(3):e
30 Conclusions Biomarkers in SCD - Class II a recommendation exists for BNP in risk stratification for SCD Biomarkers in Atrial Fibrillation showing some promise, will be interesting to see if the ABC risk score gets clinical traction Biomarkers in Cardiac Resynchronization Therapy we are along way from identifying any biomarkers that can help predict non response Biomarkers in Diagnosis of Device Infections seems reasonable to check a PCT level in the more challenging diagnostic cases
Biomarkers and Arrhythmias/Devices Ulrika Birgersdotter-Green, MD, FHRS
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