HHE Cardiovascular supplement 2018 - Page 18

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 increasing their reliability 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. 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