Biomarkers: Recommendations for Prognosis

IAMeasurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (16,87–92).2013 recommendation remains current.
IAMeasurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (27,93–100).MODIFIED: Current recommendation emphasizes that it is admission levels of natriuretic peptide biomarkers that are useful.
See Online Data Supplements A and B.
Higher levels of natriuretic peptide biomarkers on admission are usually associated with greater risk for clinical outcomes, including all-cause and cardiovascular mortality, morbidity, and composite outcomes, across different time intervals in patients with decompensated HF (20,27,29,93–101). Similarly, abnormal levels of circulating cardiac troponin are commonly found in patients with acute decompensated HF, often without obvious myocardial ischemia or underlying coronary artery disease (CAD), and this is associated with worse clinical outcomes and higher risk of death (95,99,102,103).
Studies have demonstrated incremental prognostic value of these biomarkers to standard approaches of cardiovascular disease risk assessment (29,95). However, there were differences in the risk prediction models, assay cutpoints, and lengths of follow-up (29). Furthermore, not all patients may need biomarker measurement for prognostication, especially if they already have advanced HF with established poor prognosis or persistently elevated levels of biomarkers in former settings. Therefore, assays of natriuretic peptide biomarkers for incremental prognostication should not preclude good clinical judgment; an individualized approach to each patient is paramount.
IIaB-NRDuring a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a postdischarge prognosis (93,96,104–113).NEW: Current recommendation reflects new observational studies.
See Online Data Supplements A and B.
Predischarge natriuretic peptide biomarker levels and the relative change in levels during hospital treatment are strong predictors of the risk of death or hospital readmission for HF (93,96,104–113). Several studies have suggested that predischarge natriuretic peptide biomarker levels had higher reclassification and discrimination value than clinical variables in predicting outcomes (96,106,108–111). Patients with higher predischarge levels and patients who do not have a decrease in natriuretic peptide biomarker levels during hospitalization have worse outcomes (96,106,108–111). Although observational or retrospective studies have suggested that patients with natriuretic peptide biomarker reduction had better outcomes than those without any changes or with a biomarker rise (93,107,112,113), targeting a certain threshold, value, or relative change in these biomarker levels during hospitalization may not be practical or safe for every patient and has not been tested in a prospective large-scale trial. Clinical assessment and adherence to GDMT should be the emphasis, and the prognostic value of a predischarge value or relative changes does not imply the necessity for serial and repeated biomarker measurements during hospitalization.
IIbB-NRIn patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (27,95,98,99,103,114–119).MODIFIED: 2013 recommendations have been combined into prognosis section, resulting in LOE change from A to B-NR.
See Online Data Supplements A and B.
Biomarkers of myocardial fibrosis (e.g., soluble ST2 receptor, galectin-3, high-sensitivity cardiac troponin, and others) are predictive of hospitalization and death in patients with HF and also are additive to natriuretic peptide biomarker levels in their prognostic value (117,119–126). A combination of biomarkers may ultimately prove to be more informative than single biomarkers (127).