Valor pronóstico de nuevos biomarcadores en insuficiencia cardiaca aguda

Abstract

El contenido de esta tesis esta basado en 3 trabajos previamente publicados en los que se evalúa el valor pronóstico de dos nuevos biomarcadores de función renal (cistatina C y beta-traza-proteína) y un nuevo biomarcador de remodelado cardiaco (sST2) en pacientes con insuficiencia cardiaca aguda. Los principales hallazgos de estos trabajos fueron: i) los niveles elevados de cistatina C y beta-traza proteína se asociaron de forma independiente con la incidencia de mortalidad y / o reingreso por descompensación cardiaca ii) los niveles de cistatina C y beta-traza proteína fueron superiores a los niveles séricos de creatinina, urea y MDRD para la predicción de eventos clínicos adversos, iii) el sST2 mostró significación pronóstica independiente en pacientes con insuficiencia cardiaca aguda independientemente del estado de función ventricular izquierda iV) el análisis de curvas ROC mostró diferentes puntos de corte de ST2 para la predicción de mortalidad a 1 año en pacientes con FEVI preservada (>0.35 ng/mL) y reducida (>0.56 mg//mL), los cuales tuvieron una precisión pronóstica similar (Área Bajo la Curva 0.69 vs. 0.73; p >0.05). We sought to compare the prognostic value of cystatin C over creatinine and Modified of Diet and Renal Disease (MDRD) equation, and to evaluate whether it provides complementary information to cardiac biomarkers in the risk stratification of an unselected cohort of patients with acute heart failure (AHF). We prospectively studied consecutive hospitalized patients with an established AHF diagnosis. Blood samples were collected on hospital arrival to determine cystatin C, cTnT and NT-proBNP. Clinical follow-up was obtained and the occurrence of mortality and/or heart failure (HF) readmission was registered. One-hundred thirty-eight patients (74 [67-80] years, 54% male) were studied. During a median follow up of 261 [161-449] days, 60 patients (43.5%) presented adverse events. After multivariable adjustment cystatin C, NTproBNP, cTnT, New York Heart Association Functional Classification class III/IV and diabetes mellitus were identified as independent predictors of mortality and/or HF readmission. In contrast to creatinine and MDRD, the highest cystatin C tertile (>1.50 mg/L) was a significant independent risk factor for adverse events (Hazard Ratio (HR) 3.08 95%CI 1.54-6.14;p=0.004). A multimarker approach combining cTnT, NT-proBNP and cystatin C improved risk stratification further, showing that patients with two (HR 2.37, 95%CI 1.10-5.71) or three (HR 3.64, 95%CI 1.55-8.56) elevated biomarkers had a higher risk of adverse events than patients with no elevated biomarkers (p for trend=0.015). In this unselected cohort, cystatin C was a stronger predictor of adverse events than conventional measures of kidney function. In addition, cystatin C offered complementary prognostic information to cardiac biomarkers and could help clinicians to perform a more accurate risk stratification of patients with AHF