Emerging biomarkers
Many new players are emerging and biomarkers
of cardiac remodelling could provide additional
information to natriuretic peptides testing and
help to develop more tailor-based strategies for
treatment. 2,3 As previously mentioned, the
remodelling and fibrosis of the heart plays an
important role in the progression of HF.
Biomarkers related to cardiac hypertrophy,
cardiac fibrosis and remodeling of the
extracellular matrix could provide valuable
information for the risk stratification of HF
patients. Soluble ST2 and fibroblast growth factor
23 (FGF-23) are two good examples of biomarkers
related to remodelling, and automated assays are
emerging to facilitate their measurement in
clinical laboratories. 4–8
Soluble ST2
Interleukin 33 (IL-33) is a member of the IL-1
cytokine family acting both as a cytokine and
as an intracellular nuclear factor with
transcriptional regulatory properties. IL-33
prevents the apoptosis of cardiomyocytes and
improves cardiac function and survival after
myocardial infarction through ST2 signalling. 4,7
ST2 is a receptor encoded by IL1RL1 and for which
differential splicing of the gene can produce
a functional membrane-bound receptor (ST2L)
or a soluble decoy receptor (sST2) able to quench
the biological activity of IL-33. The increase of
circulating sST2 levels is related to cardiac
remodelling, fibrosis and HF, and measurement
of sST2 could facilitate the risk stratification and
treatment of HF with reduced ejection fraction
as well as the diagnosis and prognosis of HF with
preserved ejection fraction. 4,7,9
FGF-23
FGF-23, a key regulator of the phosphorus
homeostasis, is produced by osteocytes and binds
to renal and parathyroid FGF-Klotho receptor
heterodimers, resulting in phosphate excretion,
decreased 1-a-hydroxylation of 25-hydroxyvitamin
D and decreased parathyroid hormone (PTH)
secretion. 5,6 As for PTH, impaired homeostasis
of cations and decreased glomerular filtration
rate might contribute to the rise of FGF-23. The
amino-terminal portion of FGF-23 (amino acids
1–24) may serve as a signal peptide allowing the
secretion into the blood, and the carboxyl-
terminal portion (amino acids 180–251)
participates in its biological action. FGF-23 is also
related to the risk of cardiovascular diseases and
mortality. 5,6 FGF-23 levels are independently
associated with left ventricular mass index and
hypertrophy as well as mortality in patients with
chronic kidney disease. Increased circulating
concentrations of FGF-23 are independently
associated with the risk of developing HF in
the community and with poor clinical outcome
in HF patients, and assays for the measurement
of circulating concentrations of the intact
hormone (iFGF-23) and some against the
C-terminal fragments of FGF-23 (Ct-FGF-23) are
available.
Perspectives from emerging technologies
Progress around point of care testing (POCT)
technologies is enormous, contributing to
increased reliabilities and the number of tests
available. 2,7,10 The added value of POCT is
increasingly evident for rapid diagnosis and
might add value in primary care and pre-hospital
settings. An example is illustrated by the
integration of tele-cardiology units and central
laboratories through cardiac markers performed
with POCT technologies in the ambulance. 10
These procedures can play an important role
in the early diagnosis and treatment of acute
coronary syndrome patients related to the
pre-hospital phase. The performances of some
POCT assays are now compatible with the
enquiries of physicians for the management and
monitoring of HF, and both BNP and NT-proBNP
can be determined by POCT assays. The
implementation of POCT will of course rely on
interactions between laboratory specialists and
users to respect the requirements of accreditation
standards and to maximise the efficiency of
POCT-based protocols. 7,10
Beside the shift of paradigm for biomarker
testing, recent progress in the area of mobile
Health (mHealth) is also spectacular. 10 MHealth
describes the use of portable electronic devices
with software applications to provide health
services and manage patient information. With
approximately five billion mobile phone users
globally, mHealth technologies have the potential
to greatly impact health research, health care,
and health outcomes. Mobile phones,
smartphones, and tablets are therefore
exceptional means for the empowerment of
patients with chronic illness. The use of mHealth
technologies decreases the number of disease-
related health outcomes in patients suffering
Progress around point of care
testing is enormous, contributing
to increased reliabilities and the
number of tests available
from chronic diseases compared with regular
care. 10 In HF patients, mHealth aid in decreasing
the length of stay in hospitals and in maintaining
the activities of daily living. Studies involving
patients with hypertension also demonstrated the
ability of mHealth to reduce systolic and/or
diastolic blood pressure. 10
Innovations are also coming from the field of
data mining and integration, which will allow the
combination of clinical and biological features for
a more accurate management of patients and will
facilitate the identification of clusters of patients
at higher risk or more suitable for selection for
clinical trials.
Conclusions
To reach maximum potential, innovative
biomarkers and emerging technologies will
require a multidisciplinary assessment of
technical, clinical and economical outcomes,
meaning that the communication between
specialists in laboratory medicine and other
healthcare professionals will be needed to
ensure an efficient translation into daily
practice.
12
HHE 2019 | hospitalhealthcare.com
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