U.S. patent application number 17/162140 was filed with the patent office on 2021-06-03 for use of biomarkers in the assessment of the early transition from arterial hypertension to heart failure.
This patent application is currently assigned to Roche Diagnostics Operations, Inc.. The applicant listed for this patent is Roche Diagnostics Operations, Inc.. Invention is credited to Dirk Block, Christine Boehm, Georg Hess, Hendrik Heudig, Andrea Horsch, Sabine Vogel-Ziebolz, Ursula-Henrike Wienhues-Thelen, Dietmar Zdunek.
Application Number | 20210164969 17/162140 |
Document ID | / |
Family ID | 1000005387089 |
Filed Date | 2021-06-03 |
United States Patent
Application |
20210164969 |
Kind Code |
A1 |
Wienhues-Thelen; Ursula-Henrike ;
et al. |
June 3, 2021 |
Use of Biomarkers in the Assessment of the Early Transition from
Arterial Hypertension to Heart Failure
Abstract
Methods and systems for diagnosing functional and/or structural
abnormalities of the heart preceding heart failure, and for
predicting the risk of developing heart failure, in a subject
comprising measuring a cardiac troponin in a sample and comparing
the measurement to a reference value. Other markers, including
GDF15 and IGFBP7 are also measured in some embodiments.
Inventors: |
Wienhues-Thelen;
Ursula-Henrike; (Krailling, DE) ; Block; Dirk;
(Bichl, DE) ; Heudig; Hendrik; (Penzberg, DE)
; Vogel-Ziebolz; Sabine; (Munchen, DE) ; Boehm;
Christine; (Huenenberg, DE) ; Hess; Georg;
(Mainz, DE) ; Horsch; Andrea; (Luzern, CH)
; Zdunek; Dietmar; (Tutzing, DE) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Roche Diagnostics Operations, Inc. |
Indianapolis |
IN |
US |
|
|
Assignee: |
Roche Diagnostics Operations,
Inc.
Indianapolis
IN
|
Family ID: |
1000005387089 |
Appl. No.: |
17/162140 |
Filed: |
January 29, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14549632 |
Nov 21, 2014 |
10942175 |
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17162140 |
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13776314 |
Feb 25, 2013 |
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14549632 |
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PCT/EP2011/063398 |
Aug 3, 2011 |
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13776314 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
G01N 2333/495 20130101;
G01N 2800/325 20130101; G01N 33/6887 20130101; G01N 2333/58
20130101; G01N 2800/50 20130101; G01N 2800/52 20130101; G01N
33/6893 20130101; G01N 33/54306 20130101; G01N 2333/4712
20130101 |
International
Class: |
G01N 33/543 20060101
G01N033/543; G01N 33/68 20060101 G01N033/68 |
Foreign Application Data
Date |
Code |
Application Number |
Aug 26, 2010 |
EP |
10174182.5 |
Oct 6, 2010 |
EP |
10186710.9 |
Claims
1. A method of diagnosing a heart functional or structural
abnormality preceding heart failure in a subject, the method
comprising the steps of: a) contacting, in vitro, a portion of a
sample of the subject with an antibody having specific binding
affinity for an epitope of a cardiac troponin marker or variant
thereof, whereby a complex of the antibody and the cardiac troponin
marker or variant thereof is formed; b) calculating a concentration
of the cardiac troponin marker or variant thereof in the sample
based on an amount of complex formed in said step of contacting; c)
comparing the concentration of the cardiac troponin marker or
variant thereof determined in said step of calculating with a
cardiac troponin marker reference value; and d) diagnosing a heart
functional or structural abnormality preceding heart failure in the
subject if the concentration of the cardiac troponin marker or
variant thereof in the sample is greater than the cardiac troponin
marker reference value.
2. The method of claim 1, wherein the sample is selected from the
group consisting of blood, serum and plasma.
3. The method of claim 1, wherein the antibody comprises a
detectable label.
4. The method of claim 3, wherein the detectable label is one of a
radioactive and a fluorescent label.
5. The method of claim 1, further comprising the step of
contacting, in vitro, a portion of the sample of the subject with a
second antibody having specific binding affinity for a second
epitope of the cardiac troponin marker or variant thereof, whereby
a complex of the antibody, the cardiac troponin marker or variant
thereof, and the second antibody is formed.
6. The method of claim 5, wherein the second antibody comprises a
detectable label.
7. The method of claim 6, wherein the detectable label is one of a
radioactive and a fluorescent label.
8. The method of claim 5, wherein the cardiac troponin marker or
variant thereof is cardiac troponin T marker or variant
thereof.
9. The method of claim 8, wherein the epitope of the cardiac
troponin marker or variant thereof consists of amino acids 125-131
and the second epitope of the cardiac troponin marker or variant
thereof consists of amino acids 136-147.
10. The method according to claim 1, wherein the cardiac troponin
marker or variant thereof is cardiac troponin I or a variant
thereof.
11. The method according to claim 1, wherein prior to performing
steps a)-d), the subject is known to suffer from one of
hypertension and diabetes.
12. The method of claim 1, wherein the functional and/or structural
abnormality is an increased septum diameter.
13. The method of claim 1, wherein the cardiac troponin reference
value is an amount at least 20% greater than a concentration of the
cardiac troponing marker of a population of healthy
individuals.
14. The method of claim 1, wherein the antibody is bound to a solid
phase and the second antibody is not bound to a solid phase.
15. The method of claim 1, further comprising the steps of:
contacting, in vitro, a portion of the sample of the subject with
an antibody having specific binding affinity for an epitope of
insulin-like growth factor-binding protein 7 marker or variant
thereof, whereby a complex of the antibody and the insulin-like
growth factor-binding protein 7 marker or variant thereof is
formed; calculating a concentration of the insulin-like growth
factor-binding protein 7 marker or variant thereof in the sample
based on an amount of complex formed in said step of contacting;
and comparing the concentration of the insulin-like growth
factor-binding protein 7 marker or variant thereof to an
insulin-like growth factor-binding protein 7 reference value,
wherein said step of diagnosing further comprises diagnosing a
heart functional or structural abnormality preceding heart failure
in the subject only if the concentration of the cardiac troponin
marker or variant thereof in the sample is greater than the cardiac
troponin marker reference value and the concentration of the
insulin-like growth factor-binding protein 7 marker of variant
thereof in the sample is greater than the insulin-like growth
factor-binding protein 7 reference value.
16. A device adapted for diagnosing a heart functional or
structural abnormality preceding heart failure in a subject, the
device comprising: means for determining an amount of a cardiac
troponin marker of variant thereof in a sample from the subject,
implemented rules for comparing the determined amount of the
cardiac troponin marker of variant thereof to a cardiac troponin
marker reference value, the cardiac troponin marker reference value
existing as a stored value; and means for implementing the rules,
wherein an amount of the cardiac troponin marker or variant thereof
greater than the cardiac troponin marker reference value is
indicative of a heart functional or structural abnormality
preceding heart failure.
17. The device of claim 16, wherein the sample is one of blood,
plasma and serum.
18. The device of claim 16, wherein said means for determining the
amount of the cardiac troponin marker of variant thereof in the
sample comprises an antibody having specific binding affinity for
an epitope of the cardiac troponin marker of variant thereof.
19. The device of claim 18, wherein said means for determining the
amount of the cardiac troponin marker of variant thereof in the
sample further comprises a second antibody having specific binding
affinity for a second epitope of the cardiac troponing marker or
variant thereof.
20. The device of claim 19, wherein the epitope of the cardiac
troponin marker or variant thereof consists of amino acids 125-131
and the second epitope of the cardiac troponin marker or variant
thereof consists of amino acids 136-147.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation of U.S. application Ser.
No. 14/549,632 filed Nov. 21, 2014, which is a continuation of U.S.
application Ser. No. 13/776,314 filed Feb. 25, 2013, now abandoned,
which is a continuation of International Application No.
PCT/EP2011/063398, filed Aug. 3, 2011, which claims the benefit of
European Patent Application No. 10174182.5, filed Aug. 26, 2010,
and European Patent Application No. 10186710.9, filed Oct. 6, 2010,
the disclosures of which are hereby incorporated by reference in
their entirety.
BACKGROUND OF THE DISCLOSURE
[0002] An aim of modern medicine is to provide personalized or
individualized treatment regimens. Those are treatment regimens
which take into account a patient's individual needs or risks.
Personalized or individual treatment regimens may even be taken
into account for measures where it is required to decide on
potential treatment regimens.
[0003] Heart failure (HF) is a major and growing public health
problem. It is estimated that approximately 5 million patients in
the USA have HF, more than 500 000 patients are diagnosed with HF
for the first time each year, and more than 50.000 patients in the
US die each year of HF as a primary cause. Heart failure (HF) is
one of the main causes of morbidity and mortality in developed
countries. Because of aging of the population and greater longevity
of patients with cardiovascular disease incidence and prevalence of
HF are increasing.
[0004] In general, HF is diagnosed by e.g. echocardiography and
Doppler sonography which, however, only permit to diagnose
symptomatic later stages of HF. Individuals suffering from
presymptomatic forms of HF cannot be diagnosed by these established
methods. Poor diagnostic capabilities is one of the reasons that
the survival rate for individuals diagnosed for HF is only 50% for
5 years.
BRIEF SUMMARY OF THE DISCLOSURE
[0005] The present disclosure relates to a method for predicting
risk of an individual bearing risk factors of developing heart
failure, to suffer from heart failure. The present disclosure
further relates to diagnosing early stages of functional and/or
structural abnormalities of the heart preceding left ventricular
hypertrophy (LVH) and/or heart failure in an individual bearing
risk factors of developing heart failure. In an embodiment, the
subject suffers from hypertension and/or diabetes. In another
embodiment, the subject suffers from diastolic dysfunction. In yet
another embodiment the subject is female. In particular, the
present disclosure provides a method of predicting the risk of
heart failure before left ventricular hypertrophy (LVH) is apparent
(i.e. visible by e.g. echocardiography or ECG). The present
disclosure, furthermore, relates to a method of predicting the risk
of such an individual to suffer from heart failure as a consequence
of the presence of functional and/or structural abnormalities of
the heart. The present disclosure further relates to a method of
predicting the risk of a female subject to suffer from left
ventricular hypertrophy. The present disclosure, furthermore,
relates to a method of predicting the risk of such an individual to
suffer from cardiovascular and renal events preceding heart
failure: Ischemic stroke, detrimental non-fatal stroke, myocardial
ischemia/myocardial infarction, arterial aneurysm, chronic kidney
failure and finally heart failure. The diagnosis is carried out by
measuring the concentrations of at least one cardiac troponin. As
the case may be, optionally one further marker selected from GDF-15
and IGFBP7 is determined. The method can also be used for deciding
on a possible treatment of an individual bearing risk factors of
suffering from heart failure and/or having been diagnosed for
functional and/or structural abnormalities of the heart preceding
heart failure and/or predicted an elevated risk of suffering from
heart failure. Moreover, the present disclosure relates to a device
and a kit adapted to carry out the method of the present
disclosure. Also encompassed by the present disclosure is the use
of the above-specified plurality of markers for diagnosing and/or
predicting, in an individual bearing risk factors of developing
heart failure, the above-referenced health states.
[0006] According to some embodiments, a method of diagnosing a
heart functional or structural abnormality preceding heart failure
in a subject is provided. Embodiments of the method include the
steps of contacting, in vitro, a portion of a sample of the subject
with an antibody having specific binding affinity for an epitope of
a cardiac troponin marker or variant thereof, whereby a complex of
the antibody and the cardiac troponin marker or variant thereof is
formed; calculating a concentration of the cardiac troponin marker
or variant thereof in the sample based on an amount of complex
formed in said step of contacting; comparing the concentration of
the cardiac troponin marker or variant thereof determined in said
step of calculating with a cardiac troponin marker reference value;
and diagnosing a heart functional or structural abnormality
preceding heart failure in the subject if the concentration of the
cardiac troponin marker or variant thereof in the sample is greater
than the cardiac troponin marker reference value.
[0007] In some embodiments of the method provided herein, the
method further comprises the step of contacting, in vitro, a
portion of the sample of the subject with a second antibody having
specific binding affinity for a second epitope of the cardiac
troponin marker or variant thereof, whereby a complex of the
antibody, the cardiac troponin marker or variant thereof, and the
second antibody is formed.
[0008] According to yet further embodiments of the instant
disclosure, a device adapted for diagnosing a heart functional or
structural abnormality preceding heart failure in a subject is
provided. Embodiments of the device include means for determining
an amount of a cardiac troponin marker of variant thereof in a
sample from the subject; implemented rules for comparing the
determined amount of the cardiac troponin marker of variant thereof
to a cardiac troponin marker reference value, the cardiac troponin
marker reference value existing as a stored value; and means for
implementing the rules, wherein an amount of the cardiac troponin
marker or variant thereof greater than the cardiac troponin marker
reference value is indicative of a heart functional or structural
abnormality preceding heart failure.
[0009] According to some embodiments of the device, the means for
determining the amount of the cardiac troponin marker of variant
thereof in the sample comprises an antibody having specific binding
affinity for an epitope of the cardiac troponin marker of variant
thereof. According to some further embodiments of devices disclosed
herein, said means for determining the amount of the cardiac
troponin marker of variant thereof in the sample further comprises
a second antibody having specific binding affinity for a second
epitope of the cardiac troponing marker or variant thereof. In yet
further embodiments, the epitope of the cardiac troponin marker or
variant thereof consists of amino acids 125-131 and the second
epitope of the cardiac troponin marker or variant thereof consists
of amino acids 136-147
BRIEF DESCRIPTION OF THE FIGURES
[0010] The features of this disclosure, and the manner of attaining
them, will become more apparent and the disclosure itself will be
better understood by reference to the following description of
embodiments of the disclosure taken in conjunction with the
accompanying drawing.
[0011] FIG. 1 is a bar graph presenting the values of troponin T in
patients belonging to group 1, 2, 3 or 4 as described in the
Examples.
[0012] FIG. 2 is a bar graph presenting the values of GDF-15 in
patients belonging to group 1, 2, 3 or 4 as described in the
Examples.
[0013] FIG. 3 is a bar graph presenting the values of IFGBP7 in
patients belonging to group 1, 2, 3 or 4 as described in the
Examples.
[0014] FIG. 4 is a bar graph presenting the values of NT-proBNP in
patients belonging to group 1, 2, 3 or 4 as described in the
Examples.
[0015] Corresponding reference characters indicate corresponding
parts throughout the several views. Although the drawings represent
embodiments of the present disclosure, the drawings are not
necessarily to scale and certain features may be exaggerated in
order to better illustrate and explain the present disclosure. The
exemplifications set out herein illustrate an exemplary embodiment
of the disclosure, in one form, and such exemplifications are not
to be construed as limiting the scope of the disclosure in any
manner.
DETAILED DESCRIPTION OF THE DISCLOSURE
[0016] The embodiments disclosed herein are not intended to be
exhaustive or limit the disclosure to the precise form disclosed in
the following detailed description. Rather, the embodiments are
chosen and described so that others skilled in the art may utilize
their teachings.
[0017] Heart failure is a complex clinical syndrome that can result
from any structural or functional cardiac disorder that impairs the
ability of the ventricle to fill with or eject blood and to ensure
the body's metabolic needs for supply with blood/oxygen. In such
cases, the body tries to compensate lack of supply by structural
changes of the myocardium (e.g. fibrosis, apoptosis, necrosis)
aiming at maintaining the required supply. First structural changes
to the myocardium are, in general, reversible changes but which,
when untreated, turn to non reversible permanent changes which
finally lead to chronic HF with the final stage of terminal HF.
[0018] HF is classified into various degrees of severity. One
classification is the so-called NYHA (New York Heart Association)
classification. Heart failure patients are classified NYHA classes
I, II, III and IV. A patient having heart failure has already
experienced structural and functional changes to his pericardium,
myocardium, coronary circulation or cardiac valves. He will not be
able to fully restore his health, and is in need of a therapeutical
treatment. Patients of NYHA Class I have no obvious symptoms of
cardiovascular disease but already have objective evidence of
functional impairment. Patients of NYHA class II have slight
limitation of physical activity. Patients of NYHA class III show a
marked limitation of physical activity. Patients of NYHA class IV
are unable to carry out any physical activity without discomfort.
They show symptoms of cardiac insufficiency at rest.
[0019] This functional classification is supplemented by the more
recent classification by the American College of Cardiology and the
American Heart Association (see J. Am. Coll. Cardiol. 2001; 38;
2101-2113, updated in 2005, see J. Am. Coll. Cardiol. 2005; 46;
e1-e82). 4 stages A, B, C and D are defined. Stages A and B are not
HF but are considered to help identify patients early before
developing "truly" HF. Stages A and B patients are best defined as
those with risk factors for the development of HF. For example,
patients with coronary artery disease, hypertension, or diabetes
mellitus who do not yet demonstrate impaired left ventricular (LV)
function, hypertrophy, or geometric chamber distortion would be
considered stage A, whereas patients who are asymptomatic but
demonstrate LV hypertrophy (LVH, a phenomenon in which the walls of
the ventricles thicken) and/or impaired LV function would be
designated as stage B. Stage C then denotes patients with current
or past symptoms of HF associated with underlying structural heart
disease (the bulk of patients with HF), and stage D designates
patients with truly refractory HF.
[0020] Arterial hypertension places increased tension on the left
ventricular myocardium that is manifested as stiffness and
hypertrophy. Independently thereof, atherosclerosis develops within
the coronary vessels as a consequence of hypertension. Subjects
with hypertension have increased risk of detrimental non-fatal
stroke. Antihypertensive medication may help to reduce the risk of
detrimental non-fatal stroke. It is known that subjects suffering
from diabetes mellitus are at an elevated risk of suffering from
atherosclerosis. Subjects suffering from atherosclerosis are at an
elevated risk of ischemic stroke. Antihypertensive medication may
help to reduce the risk of ischemic stroke and ischemic heart
disease.
[0021] Systolic dysfunction has been found to be associated with an
increased risk to develop symptomatic systolic HF. Diastolic
dysfunction is believed to be a precursor of diastolic HF. Early
treatment of hypertension may improve diastolic function. A large
number of individuals with left ventricular dysfunction, systolic
as well as diastolic dysfunction, remain undiagnosed and untreated,
although early therapy may improve outcome. Untreated hypertension
is associated with an increased risk to develop heart failure,
which is often is preceded by other cardiovascular and renal
events: Hypertension or diabetes leading to ischemic stroke,
detrimental non-fatal stroke, myocardial ischemia/myocardial
infarction, arterial aneurysm and finally heart failure, if the
patient lives long enough. Persistent hypertension is a leading
cause of chronic kidney failure. Early treatment of hypertension
may help to prevent disease progression to a variety of
cardiovascular as well as renal death risks
[0022] Accordingly, there is a strong need to have methods and
means at hand which allow to identify in subjects functional and/or
structural abnormalities of the heart preceding heart failure
caused by functional and/or structural changes to their myocardium,
before the patient develops symptoms of overt heart failure (e.g.
those typical for stages C or D of the ACC/AHA classification). In
some embodiments, the methods and means shall permit to identify
subjects at an early stage of impaired cardiac function, i.e. the
subjects are about to develop impaired cardiac function. According
to some embodiments, the subjects should be at a stage where
minimum functional and/or structural changes to the patient's
pericardium, myocardium, coronary circulation or cardiac valves
(e.g. structural changes to the patient's left ventricle) have
occurred, at least in some cases before left ventricular
hypertrophy becomes apparent. According to some embodiments, the
subject should be about to leave stage A of the ACC/AHA
classification and be about to enter stage B of the ACC/AHA
classification. The method and means permit the identification of
subjects at increased risk of developing HF and associated further
cardiovascular and renal diseases and improved risk stratification
in patients with early functional and/or structural abnormalities
of the heart preceding heart failure (stages A/B according to
AHA/ACC classification) in order to initiate appropriate preventive
treatment before non-reversible progression of HF or major
complications occur. The methods and means shall permit to make
early decisions on an appropriate treatment of the respective
individual/subject and to monitor the treatment.
[0023] In the studies carried out in the context of the present
disclosure, it was surprisingly found that the determination of the
concentration of a cardiac troponin allows for the identification
of subjects at early stage B even before hypertrophy becomes
apparent, and thus, of subjects having risk factors of suffering
from heart failure and showing first structural changes to the left
ventricle and/or diastolic dysfunction, but not suffering from left
ventricular hypertrophy. Thus, the determination of a cardiac
troponin allows for differentiating between subjects with first
structural changes to the left ventricle and/or diastolic
dysfunction and subjects without first structural changes to the
left ventricle and/or diastolic dysfunction. In particular, the
determination of a cardiac troponin allows identification of female
subjects at early stage B.
[0024] In contrast, the studies carried out in the context of the
present disclosure further showed that NT-proBNP, i.e. a well-known
marker for the diagnosis of heart failure, failed to identify
subjects with first structural changes to the left ventricle and/or
diastolic dysfunction. Rather, NT-proBNP was only increased in
patients with left ventricular hypertrophy (LVH). The level of
NT-proBNP was not increased in patients without LVH, and thus in
patients with a left ventricular mass index below cutoff used to
define LVH. Thus, in contrast to NT-proBNP, cardiac troponins are
valuable markers for the diagnosis of first functional and/or
structural abnormalities of the heart preceding LVH and heart
failure (and, thus, in subjects without LVH).
[0025] The findings of the present disclosure are advantageous
since they allow for an early diagnosis of structural and/or
functional abnormalities of the heart preceding heart failure
and/or preceding left ventricular hypertrophy. Early functional
and/or structural abnormalities of the heart and heart failure
often remain undiagnosed, particularly in women. First structural
changes to the heart are, in general, reversible changes but which,
when untreated, turn to non reversible permanent changes which
finally may lead to chronic HF with the final stage of terminal HF.
Therefore, the early diagnosis of structural changes to the heart
since appropriate preventive treatment can be initiated before
progression to LVH and/or to HF or other major complications
occur.
[0026] Method of diagnosing. Accordingly, the present disclosure
relates to a method of diagnosing in a subject functional and/or
structural abnormalities of the heart typically heart failure,
based on the comparison of the concentrations of at least on
cardiac troponin or a variant thereof, and optionally of one or
more other markers of heart failure, to the concentration of this
or these marker(s) in a control sample.
[0027] The method of the disclosure may comprise the following
steps: a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure; and c) diagnosing the
said functional and/or structural abnormalities by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts, e.g
to the concentration of this marker or these markers as established
in a control sample.
[0028] Therefore, the present disclosure provides a method of
diagnosing in a subject functional and/or structural abnormalities
of the heart preceding heart failure, the method comprising the
steps of [0029] a) measuring in a sample obtained from the subject
the concentration of at least one cardiac troponin or a variant
thereof, [0030] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0031] c) diagnosing said functional and/or structural
abnormalities by comparing the concentration determined in step (a)
and optionally the concentration(s) determined in step (b) with a
reference amount.
[0032] In general, the subject does not suffer from heart failure,
i.e. the patient has not experienced permanent structural or
functional damages to his myocardium. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also according to some embodiments, the
subject does not show overt signs and/or symptoms of heart failure.
In some embodiments, the subject does not show LVH.
[0033] According to some embodiments, the subject suffers from
hypertension, diabetes, obesity, metabolic syndrome and/or a
history of smoking (i.e. the subject has a history of smoking). In
an exemplary embodiment, the subject suffers from hypertension
and/or diabetes.
[0034] According to some embodiments, the structural and/or
functional abnormality of the heart preceding heart failure and/or
left ventricular hypertrophy is an abnormality selected from left
ventricular structural changes, an increased septum diameter,
increased posterial wall diameter, and diastolic dysfunction.
[0035] In some embodiments, the subject is female.
[0036] Accordingly, the present disclosure particularly relates to
a method of diagnosing functional and/or structural abnormalities
of the heart preceding heart failure and/or preceding left
ventricular hypertrophy in a subject suffering from hypertension,
diabetes, obesity, metabolic syndrome and/or having a history of
smoking, the method comprising the steps of: [0037] a) measuring in
a sample obtained from the subject the concentration of at least
one cardiac troponin or a variant thereof, [0038] b) optionally
measuring in the sample the concentration of one or more other
marker(s) of heart failure, and [0039] c) diagnosing said
functional and/or structural abnormalities by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) with a reference amount
[0040] wherein the subject does not show left ventricular
hypertrophy, and [0041] wherein the structural and/or functional
abnormalities of the heart preceding heart failure and/or left
ventricular hypertrophy comprise an abnormality selected from a
left ventricular structural change, an increased septum diameter,
an increased posterial wall diameter, and diastolic
dysfunction.
[0042] Method of differentiating. In a further embodiment, the
present disclosure relates to a method of differentiating between a
subject only bearing risk factors of developing heart failure and a
subject not only bearing risk factors but already suffering from
functional and/or structural abnormalities of the heart preceding
heart failure, based on the comparison of the concentrations of at
least on cardiac troponin or a variant thereof, and optionally of
one or more other markers of heart failure, to the concentration of
this or these marker(s) in a control sample.
[0043] The method of the disclosure may comprise the following
steps: a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure; and c) assessing the
said functional and/or structural abnormalities by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts, e.g.
to the concentration of this marker or these markers as established
in a control sample.
[0044] Accordingly, the present disclosure provides a method of
differentiating between a subject only bearing risk factors of
developing heart failure and a subject not only bearing risk
factors but already suffering from functional and/or structural
abnormalities of the heart preceding left venricular hypertrophy
and/or preceding heart failure, the method comprising the steps of:
[0045] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof, [0046] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0047] c) differentiating between said subjects (i.e. those only
bearing risk factors of developing heart failure and those not only
bearing risk factors but already suffering from functional and/or
structural abnormalities of the heart preceding heart failure) by
comparing the concentration determined in step (a) and optionally
the concentration(s) determined in step (b) with a reference
amount.
[0048] In general, the subject (i.e. the individual bearing risk
factors and/or suffering from functional and/or structural
abnormalities of the heart preceding heart failure) does not suffer
from heart failure, i.e. the patient has not experienced permanent
structural or functional damages to his myocardium, and he will be
able to fully restore his health, and he is not classified into
stage C or D of the ACC/AHA classification. The risk factors for
heart failure are known to the person skilled in the art and
include e.g. hypertension and diabetes. Also in some embodiments,
the subject does not show overt signs and/or symptoms of heart
failure. According to some embodiments, the subject does not show
LVH.
[0049] According to some embodiments, the structural and/or
functional abnormality of the heart preceding heart failure and/or
preceding left ventricular hypertrophy is an abnormality selected
from left ventricular structural changes, an increased septum
diameter, increased posterial wall diameter, and diastolic
dysfunction.
[0050] Thus, the present disclosure also relates to a method of
differentiating between a subject only bearing risk factors of
developing heart failure and a subject not only bearing risk
factors but already suffering from functional and/or structural
abnormalities of the heart preceding heart failure and/or preceding
left ventricular hypertrophy, the method comprising the steps of:
[0051] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof, [0052] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0053] c) differentiating between said subjects by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) with a reference amount,
[0054] wherein the subject may not show left ventricular
hypertrophy [0055] wherein the structural and/or functional
abnormalities of the heart preceding heart failure and/or preceding
left ventricular hypertrophy comprise an abnormality selected from
a left ventricular structural change, an increased septum diameter,
an increased posterial wall diameter, and diastolic
dysfunction.
[0056] The present disclosure also provides methods and means to
predict the risk of subjects to suffer from heart failure.
According to some embodiments, the subjects bear risk factors of
developing heart failure and are subjects classified in stage A.
The present disclosure provides methods and means to predict the
risk of heart failure before left ventricular hypertrophy (LVH) is
apparent.
[0057] The present disclosure also provides methods and means to
diagnose subjects in stage A which are about to enter into stage B
(ACC/AHA classification), in particular when left ventricular
hypertrophy is not apparent (not identifiable by e.g.
echocardiography and/or ECG), and which are at a high risk to
progress to left ventricular hypertrophy within the next months or
years.
[0058] The individual bearing risk factors may have experienced
physiological changes towards functional and/or structural
abnormalities of the heart preceding heart failure, such as left
ventricular diastolic dysfunction, or left ventricular diastolic
dysfunction with a preserved left ventricular ejection fraction
(LVEF). These functional/structural abnormalities of the heart
preceding heart failure are diagnosed by the methods of the present
disclosure, which will be explained in greater detail below, in the
following paragraphs.
[0059] The individual bearing risk factors may in particular have
experienced physiological changes towards functional and/or
structural abnormalities of the heart preceding heart failure
without LVH being apparent, for example ventricular structural
changes without LVH, in particular left ventricular diastolic
dysfunction without LVH, but also functional and/or structural
damage of the myocardium, epicardium, valves, or coronary
circulation. These functional/structural abnormalities of the heart
preceding heart failure, but without LVH being apparent are
diagnosed by the methods of the present disclosure, which will be
explained in greater detail below, in the following paragraphs.
[0060] In a further embodiment, the present disclosure provides
methods and means to stratify these subjects for treatment with
antihypertensive drugs, in particular as a consequence of early
diagnosis of functional and/or structural abnormalities of the
heart and thereby prediction of heart failure even before LVH is
apparent (in particular, even before LVH is visible by e.g.
echocardiography or ECG).
[0061] The methods and means of the present disclosure permit to
diagnose, in a straightforward and simple manner, if a subject
suffers from functional and/or structural abnormalities of the
heart preceding heart failure. In particular, the present
disclosure advantageously permits to diagnose early stages of
functional and/or structural abnormalities of the heart preceding
heart failure in a subject, as defined below, in particular before
left ventricular hypertrophy LVH becomes apparent. Accordingly, the
present disclosure also provides a method of differentiating
between risk factors of developing heart failure (subjects bearing
risk factors of developing heart failure) and functional and/or
structural abnormalities of the heart preceding heart failure.
[0062] The methods and means of the present disclosure permit to
predict the risk of an individual bearing risk factors of
developing heart failure to suffer from heart failure. In
particular the present disclosure advantageously permits to predict
the risk of heart failure before left ventricular hypertrophy (LVH)
is apparent. Further methods of the present disclosure permit
therapy adaption of subjects at risk of heart failure before LVH
becomes apparent as a consequence of diagnosing functional and/or
structural abnormalities of the heart preceding heart failure.
[0063] Further methods of the present disclosure include methods of
deciding on the therapy and monitoring the therapy of an individual
having been identified to suffer from functional and/or structural
abnormalities of the heart preceding heart failure. These
embodiments will become apparent from studying the present
application in its entirety. For reasons of clarity, the principles
of the present disclosure including its exemplified embodiments
will be laid out hereinafter in the context of the methods of the
present disclosure which have been cited in the form of an
independent claim beforehand (diagnosing functional and/or
structural abnormalities of the heart preceding heart failure and
differentiating between individuals having the said functional
and/or structural abnormalities of the heart and those only bearing
risk factors). If not stated otherwise, these principles and
embodiments also apply in respect to the further methods belonging
to the present disclosure.
[0064] General definitions. Heart failure can be classified into a
functional classification system according to the New York Heart
Association (NYHA). Patients of NYHA Class I have no obvious
symptoms of cardiovascular disease but already have objective
evidence of functional impairment. Physical activity is not
limited, and ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnea (shortness of breath). Patients of
NYHA class II have slight limitation of physical activity. They are
comfortable at rest, but ordinary physical activity results in
fatigue, palpitation, or dyspnea. Patients of NYHA class III show a
marked limitation of physical activity. They are comfortable at
rest, but less than ordinary activity causes fatigue, palpitation,
or dyspnea. Patients of NYHA class IV are unable to carry out any
physical activity without discomfort. They show symptoms of cardiac
insufficiency at rest. Heart failure, i.e., an impaired systolic
and/or diastolic function of the heart, can be determined also by,
for example, echocardiography, angiography, scintigraphy, or
magnetic resonance imaging. This functional impairment can be
accompanied by symptoms of heart failure as outlined above (NYHA
class II-IV), although some patients may present without
significant symptoms (NYHA I).
[0065] The present disclosure refers to the more recent ACC/AHA
classification of heart failure, identifying 4 stages involved in
the development of the HF syndrome. The first 2 stages (A and B)
are clearly not HF but are an attempt to help healthcare providers
identify patients early who are at risk for developing HF. Stages A
and B patients are best defined as those with risk factors that
clearly predispose toward the development of HF. Stage C then
denotes patients with current or past symptoms of HF associated
with underlying structural heart disease, and Stage D designates
patients with truly refractory HF who might be eligible for
specialized, advanced treatment strategies such as mechanical
circulatory support, procedures to facilitate fluid removal,
continuous inotropic infusions, or cardiac transplantation or other
innovative or experimental surgical procedures, or for end-of-life
care, such as hospice. This classification recognizes that there
are established risk factors and structural prerequisites for the
development of HF and that therapeutic interventions introduced
even before the appearance of LV dysfunction or symptoms can reduce
the population morbidity and mortality of HF.
[0066] The definition of the various stages is as follows (taken
from the ACC/AHA guidelines for the evaluation and management of
chronic heart failure in the adult, J. Am. Coll. Cardiol. 2001; 38;
2101-2113). The following includes a description of the stage and
examples for pathophysiological states in individuals which would
be classified in the respective stage.
[0067] Stage A. Description: Patients at high risk of developing HF
because of the presence of conditions that are strongly associated
with the development of HF. Such patients have no identified
structural or functional abnormalities of the pericardium,
myocardium, coronary circulation or cardiac valves and have never
shown signs or symptoms of HF.
[0068] Examples: Systemic hypertension; coronary artery disease;
diabetes mellitus; history of cardiotoxic drug therapy or alcohol
abuse; personal history of rheumatic fever; family history of
cardiomyopathy.
[0069] Stacie B. Description: Patients who have developed
structural heart disease that is strongly associated with the
development of HF but who have never shown signs or symptoms of
HF.
[0070] Examples: Left ventricular hypertrophy or fibrosis; left
ventricular dilatation or hypocontractility; asymptomatic valvular
heart disease; previous myocardial infarction.
[0071] Stacie C. Description: Patients who have current or prior
symptoms of HF associated with underlying structural heart
disease.
[0072] Examples: Dyspnea or fatigue due to left ventricular
systolic dysfunction; asymptomatic patients who are undergoing
treatment for prior symptoms of HF.
[0073] Stage D. Description: Patients with advanced structural
heart disease and marked symptoms of HF at rest despite maximal
medical therapy and who require specialized interventions.
[0074] Examples: Patients who are frequently hospitalized for HF or
cannot be safely discharged from the hospital; patients in the
hospital awaiting heart transplantation; patients at home receiving
continuous intravenous support for symptom relief or being
supported with a mechanical circulatory assist device; patients in
a hospice setting for the management of HF.
[0075] The ACC/AHA stages A, B, C and D specified beforehand are
referred to in the context of the present disclosure as "stage A",
"stage B", "stage C", and "stage D".
[0076] In the context of the present disclosure, subjects of stage
A having risk factors typically associated with the development of
heart failure but no identified structural or functional
abnormalities of the pericardium, myocardium, cardiac valves or
coronary circulation are subjects not having functional and/or
structural abnormalities of the heart preceding heart failure.
Subjects of stage B who have developed functional and/or structural
heart disease that is strongly associated with the development of
and typically precedes HF but who have never shown signs or
symptoms of HF are subjects having functional and/or structural
damage of the myocardium, epicardium, valves, or coronary
circulation. The present disclosure advantageously diagnoses early
stages of functional and/or structural abnormalities of the heart
preceding heart failure (early stage B) and even preceding LVH
(late stage B). The present disclosure also differentiates between
early stages of functional and/or structural abnormalities of the
heart preceding heart failure (early stage B) and later stages of
functional and/or structural abnormalities of the heart preceding
heart failure (late stage B).
[0077] Functional and/or structural abnormalities of the heart
preceding heart failure. In the context of the methods of the
present disclosure, functional and/or structural abnormalities of
the heart preceding heart failure and/or preceding left ventricular
hypertrophy shall be diagnosed. The term "abnormalities" as used
herein, is intended to mean "at least one abnormality". Thus, one
abnormality or more than one abnormality may be diagnosed in the
context of the methods described herein.
[0078] The term "functional and/or structural abnormalities of the
heart preceding heart failure" relates to several pathological
states of the myocardium which are known in the art to typically
occur prior to heart failure (i.e. they typically precede heart
failure). Functional and/or structural abnormalities of the heart
preceding heart failure, in the sense of the present disclosure,
are generally symptomless functional and/or structural
abnormalities of the heart preceding heart failure. Functional
and/or structural abnormalities of the heart preceding heart
failure may disappear after removing the underlying cause or by
training exercise. Functional and/or structural abnormalities of
the heart preceding heart failure, in particular symptomless
functional and/or structural abnormalities of the heart preceding
heart failure, may also develop into heart failure.
[0079] The term "functional and/or structural abnormalities of the
heart preceding heart failure" as used in the present disclosure
relates to functional and/or structural change and/or a functional
and/or structural damage of the myocardium, epicardium, coronary
circulation or valves, and is to be regarded as a functional
abnormality of the heart and/or a structural abnormality of the
heart. An example for a functional abnormality of the heart is an
impaired pumping or filling capacity, often a systolic or a
diastolic impairment. An example for a structural abnormality of
the heart is a change in the geometry of the left ventricle. Often,
the structural and/or functional heart abnormality/impairment is
reversible when the underlying cause is remedied (e.g. when
appropriately treated) without leaving permanent structural or
functional damage to the myocardium typical for heart failure (i.e.
an individual classified in stage B can enter back into stage A).
An individual having functional and/or structural abnormalities of
the heart preceding heart failure does not show signs of heart
failure (thus the individual may be apparently healthy).
[0080] Heart failure often starts with a change in the geometry of
the left ventricle, changing potentially both systolic and
diastolic function (left ventricular dysfunction LVD). LVD is
sub-divided into systolic LVD and diastolic LVD. LVD may develop
into left ventricular hypertrophy (LVH) in which the walls of the
ventricle thicken.
[0081] Left ventricular dysfunction begins with stress or injury to
the myocardium and is generally a progressive process, resulting in
a change in the geometry and structure of the LV. The chamber
dilates and/or hypertrophies and becomes more spherical. This
process is generally referred to as cardiac remodeling. This change
in chamber size and structure increases the hemodynamic stresses on
the walls of the (failing) heart and depresses its mechanical
performance. Furthermore, this may also increase regurgitant flow
through the mitral valve, sustaining and exacerbating the
remodeling process. Cardiac remodeling generally precedes the
development of symptoms (which may take months or even years),
continues after the appearance of symptoms, and contributes
substantially to worsening of symptoms. Progression of coronary
artery disease, diabetes mellitus, hypertension, or the onset of
atrial fibrillation may also contribute to the progression of
HF.
[0082] In the context of the methods of the present disclosure,
functional and/or structural abnormalities of the heart preceding
heart failure can be diagnosed even before the subject suffers from
left ventricular hypertrophy. Thus, the method of the present
disclosure allows for diagnosing structural abnormalities of the
heart preceding heart failure and/or preceding left ventricular
hypertrophy. The term "left ventricular hypertrophy" is well known
in the art. A detailed overview on left ventricular hypertrophy can
be, e.g. found in standard text books (see Swamy Curr Cardiol Rep
(2010) 12:277-282). LVH can be detected by electrocardiography,
echocardiography, or cardiac magnetic resonance imaging (MRI).
According to some embodiments, LVH is detected by echocardiography.
Moreover, criteria for the diagnosis of LVH are well known in the
art (Mancia et al., European Heart J. 2007, 28: 1462, Die Innere
Medizin: Referenzwerk fur den Facharzt--Wolfgang Gerok--2007, page
293., Swamy Curr Cardiol Rep (2010) 12:277-282).
[0083] The diagnosis of LVH, may include measurements of the septum
diameter, left ventricular posterial wall thickness and end
diastolic diameter, with calculation of left ventricular mass
according to formulae known in the art. Exemplary criteria for
diagnosing LVH are e.g. disclosed in the guidelines (Mancia et al.,
European Heart J. 2007, 28: 1462).
[0084] According to some embodiments, the Cornell voltage criteria,
the Cornell product criteria, the Sokolow-Lyon voltage criteria or
the Romhilt-Estes point score system is/are used (Mancia et al.,
European Heart J. 2007, 28: 1462).
[0085] The term "left ventricular hypertrophy" (abbreviated "LVH")
as used herein, may relate to a thickening of the walls of the
ventricles. LVH is, for example, a response to a chronically
increased workload on the heart. LVH is found in patients suffering
from arterial hypertension is a disease requiring treatment. In the
context of the present disclosure functional and/or structural
abnormalities of the heart typically precedes left ventricular
hypertrophy and/or heart failure.
[0086] Hypertrophy as a response to the increased afterload
associated with elevated systemic vascular resistance is necessary
and protective up to a certain point. Beyond that point, a variety
of dysfunctions accompany LVH, including lower coronary
vasodilatory capacity, depressed left ventricular wall mechanics,
and abnormal left ventricular diastolic filling pattern.
[0087] According to some embodiments, a male subject shows LVH
(and, thus, may suffer from LVH) if the ratio of the left
ventricular mass to body surface is larger than 112 g/m.sup.2, or,
for example, if the ratio is larger than 125 g/m.sup.2. According
to some embodiments, a female subject shows LVH (and, thus, may
suffer from LVH) if the ratio of the left ventricular mass to body
surface is larger than 89 g/m.sup.2, or more in some cases, if the
ratio is larger than 110 g/m.sup.2. (see, e.g. Drazner M H, Dries D
L, Peshock R M, Cooper R S, Klassen C, Kazi F, Willett D, Victor R
G. Left ventricular hypertrophy is more prevalent in blacks than
whites in the general population: the Dallas Heart Study.
Hypertension. 2005; 46:124-129).
[0088] In the context of the method of the present disclosure, the
term LVH may also include concentric or eccentric hypertrophy. It
is known that treatment of arterial hypertension will cause LVH to
regress. Treatment with antihypertensive drugs has been shown to
cause LVH regression. With regression, left ventricular function
usually improves and cardiovascular morbidity decreases.
[0089] The present disclosure refers to a subject who is known to
bear at least one risk factor as specified elsewhere in the present
application for developing heart failure and who has entered into
the state of functional and/or structural abnormalities of the
heart preceding heart failure. The functional and/or structural
abnormality can be an early or a late functional and/or structural
abnormality of the heart preceding heart failure.
[0090] In an embodiment of the present disclosure, the individual
has previously been classified into stage A and has entered into
functional and/or structural abnormalities of the heart preceding
heart failure (late stage B). In an exemplary embodiment, the
individual is about to enter into functional and/or structural
abnormalities of the heart preceding heart failure (early stage
B).
[0091] Accordingly, the method of the present disclosure permits to
identify individuals suffering from any functional and/or
structural abnormalities of the heart typically preceding left
ventricular hypertrophy and typically preceding heart failure,
including those with advanced structural heart disease typical for
advanced stage B.
[0092] Individuals having entered into functional and/or structural
abnormalities of the heart preceding heart failure typically
proceed to heart failure via suffering from one or more of the
following structural abnormalities of the heart which are known to
precede heart failure. The list below includes early and late
stages of functional and/or structural abnormalities of the heart.
The individuals may belong to class B of the ACC/AHA classification
including early and late stages of stage B: systolic and diastolic
irregularities; geometric chamber distortion; left ventricular
enlargement; cardiac remodeling; left ventricular hypertrophy;
concentric hypertrophy, left ventricular fibrosis; left ventricular
hypocontractility; asymptomatic valvular heart disease; regional
wall-motion abnormality, left ventricular systolic dysfunction, for
example with a LVEF of .ltoreq.50%; left ventricular diastolic
dysfunction (DD), for example mild DD as an abnormal relaxation
without increased LV end-diastolic filling pressure (decreased E/A
ratio<0.75) or moderate or pseudonormal" DD as an abnormal
relaxation with increased LV end-diastolic filling pressure (E/A
0.75 to 1.5, deceleration time>140 ms, and 2 other Doppler
indices of elevated LV end-diastolic filling pressure); DD as
myocardial dysfunction with preserved ejection fraction, cardiac
dysfunction as six minutes walk test, cardiac dysfunction as
detectable with coronary catheterization; previous myocardial
infarction.
[0093] According to some embodiments, the functional and/or
structural abnormalities of the heart preceding heart failure as
referred to herein are early (early stage) functional and/or
structural abnormalities. According to some embodiments, early
(early stage) functional and/or structural abnormalities of the
heart precede heart failure and left ventricular hypertrophy.
[0094] In the context of the present disclosure, early stage
functional and/or structural abnormalities of the heart preceding
heart failure individuals (for example early stage B) in general
suffer from at least one of the following functional and/or
structural abnormalities of the heart: functional and/or structural
damage of the myocardium, epicardium, valves, or coronary
circulation; impaired pumping or filling capacity, often a systolic
or a diastolic impairment; change in the geometry of the left
ventricle; hypertension associated with geometric chamber
distortion; hypertension associated with left ventricular
structural changes without developing or developed left ventricular
hypertrophy, hypertension associated with increased septum diameter
(or septum enlargement) without hypertrophy; hypertension
associated with increased posterial wall diameter, hypertension
associated with concentric increased myocardial enlargement,
hypertension associated with eccentric increased myocardial
enlargement, asymptomatic diastolic left ventricular dysfunction
with preserved left ventricular ejection fraction (LVEF), in
particular a LVEF of >50%.
[0095] In an exemplary embodiment, the functional and/or structural
abnormality of the heart preceding heart failure and/or left
ventricular hypertrophy is at least one abnormality selected from:
left ventricular structural changes, an increased septum diameter
(and/or septum enlargement), in particular hypertension associated
with increased septum diameter (or septum enlargement), increased
posterial wall diameter, in particular hypertension associated with
increased posterial wall diameter, and diastolic dysfunction, in
particular with preserved ejection fraction.
[0096] According to some embodiments, the diastolic dysfunction is
asymptomatic diastolic left ventricular dysfunction with preserved
left ventricular ejection fraction (LVEF), in particular a LVEF of
>50%.
[0097] Thus, an exemplary structural abnormality of the heart
preceding heart failure and/or left ventricular hypertrophy is
selected from left ventricular structural changes, an increased
septum diameter (and/or septum enlargement), and increased
posterial wall diameter.
[0098] Thus, an exemplary functional abnormality of the heart
preceding heart failure is diastolic dysfunction, in particular
diastolic dysfunction with preserved ejection fraction.
[0099] According to some embodiments, the septum diameter is
increased (and/or the septum is enlarged), if the septum wall is
thicker than 11 mm. According to some embodiments, the septum
diameter is increased (and/or the septum is enlarged) if the
thickness of the septum wall is larger than 11 but lower than 16
mm, or if the thickness is between 12 and 16 mm, for example.
[0100] According to some embodiments, the posterial wall diameter
is increased, if the posterial wall is thicker than 11 mm.
According to some embodiments, the posterial wall diameter is
increased if the thickness of the posterial wall is larger than 11
but lower than 16 mm, or if the thickness is between 12 and 16 mm,
for example.
[0101] According to some embodiments of the present disclosure, the
patient having early stage functional and/or structural
abnormalities of the heart preceding heart failure (early stage B)
shows the following risk factors of suffering from heart failure:
history of cigarette smoking, obesity, metabolic syndrome, diabetes
type 1 and type 2, arterial hypertension. Thus, the subject may be
suffering from hypertension, diabetes, obesity, metabolic syndrome
and/or a history of smoking (and, thus, has a history of smoking).
In an exemplary embodiment, the subject suffers from hypertension
and/or diabetes.
[0102] Diastolic dysfunction. According to some embodiments of the
present disclosure, the method permits to diagnose asymptomatic
diastolic dysfunction in the individual having early stage
functional and/or structural abnormalities of the heart preceding
heart failure (early stage B). The individual may also suffer from
systolic dysfunction. Furthermore, the individual may suffer from
morphological changes in its left ventricle. According to some
embodiments, the individual suffering from diastolic dysfunction
does not suffer from a reduced left ventricular ejection fraction
LVEF (i.e. the individual has a preserved LVEF). In an exemplary
embodiment, the individual suffering from diastolic dysfunction
does not suffer from systolic dysfunction. The individual, in
particular, does not suffer from left ventricular hypertrophy
LVH.
[0103] According to some embodiments of the present disclosure, the
patient having early stage functional and/or structural
abnormalities of the heart preceding heart failure (early stage B)
and suffering from diastolic dysfunction, as specified in the
preceding paragraph, shows at least one of the following risk
factors of suffering from heart failure: history of cigarette
smoking, obesity, metabolic syndrome, diabetes type 1 and type 2,
arterial hypertension, in particular arterial hypertension.
[0104] Heart failure. Heart failure is a condition that can result
from any structural or functional cardiac disorder that impairs the
ability of the heart to fill with or pump a sufficient amount of
blood throughout the body. Heart failure is a chronic disease; it
can, inter alia, occur either following an acute cardiovascular
event (like myocardial infarction), or it can occur e.g. as a
consequence of inflammatory or degenerative changes in myocardial
tissue.
[0105] Functional and/or structural functional and/or structural
abnormalities of the heart and heart failure often remain
undiagnosed, particularly when the condition is considered "mild".
A patient having heart failure, however, will not be able to fully
restore his health. Even with the best therapy, heart failure is
associated with an annual mortality of about 10%.
[0106] The term "heart failure" as used herein relates to an
impaired systolic and/or diastolic function of the heart being
accompanied by overt signs of heart failure as known to the person
skilled in the art. According to some embodiments, heart failure
referred to herein is also chronic heart failure. Heart failure
according to the present disclosure includes overt and/or advanced
heart failure. In overt heart failure, the subject shows symptoms
of heart failure as known to the person skilled in the art.
[0107] The term "heart failure" as used herein refers to stages C
and D of the ACC/AHA classification; in these stages, the subject
shows typical symptoms of heart failure. i.e. the subject is not
apparently healthy. The subject having heart failure and being
classified into stage C or D has undergone permanent, non
reversible structural and/or functional changes to his myocardium,
and as a consequence of these changes, full health restoration is
not possible. A subject having attained stage C or even D of the
ACC/AHA classification cannot go back to stage B or even A.
[0108] Permanent structural or functional damages to the myocardium
which are typical for heart failure are known to the person skilled
in the art and include a variety of molecular cardiac remodelling
processes, such as interstitial fibrosis, inflammation,
infiltration, scar formation, apoptosis, necrosis.
[0109] A stiffer ventricular wall due to interstitial fibrosis
causes inadequate filling of the ventricle in diastolic
dysfunction. Permanent structural or functional damages to the
myocardium are caused by dysfunction or destruction of cardiac
myocytes. Myocytes and their components can be damaged by
inflammation or by infiltration. Toxins and pharmacological agents
(such as ethanol, cocaine, and amphetamines) cause intracellular
damage and oxidative stress. A common mechanism of damage is
ischemia causing infarction and scar formation. After myocardial
infarction, dead myocytes are replaced by scar tissue,
deleteriously affecting the function of the myocardium. On
echocardiogram, this is manifest by abnormal or absent wall
motion.
[0110] Manifestations (symptoms) of HF are dyspnea and fatigue and
fluid retention, which may lead to pulmonary congestion and
peripheral edema, typical signs on the physical examination are
edema and rales. There is no single diagnostic test for HF because
it is largely a clinical diagnosis that is based on a careful
history and physical examination.
[0111] The clinical syndrome of HF may result from disorders of the
pericardium, myocardium, endocardium, or great vessels, but the
majority of patients with HF suffers from an impairment of LV
myocardial function. Heart failure may be associated with a wide
spectrum of LV functional abnormalities, ranging from e.g. normal
LV size and preserved EF to severe dilatation and/or markedly
reduced EF. In most patients, abnormalities of systolic and
diastolic dysfunction coexist. Patients with normal EF may have a
different natural history and may require different treatment
strategies than patients with reduced EF. The various alterations
of systolic and diastolic function seen with LVH obviously can
progress into congestive heart failure (CHF).
[0112] Systolic and diastolic heart failure can be diagnosed by
methods known to the person skilled in the artsuch as by
echocardiography or tissue Doppler echocardiography (TD). In
general, systolic heart failure is apparent by a reduced left
ventricular ejection fraction (LVEF). In an embodiment of the
present disclosure, heart failure as used herein is accompanied by
a left ventricular ejection fraction (LVEF) of less than 50% or
midwall fractional shortening (MFS)<15%.
[0113] Diastolic heart failure (DHF) is supposed to account for
more than 50% of all heart failure patients and is also referred to
as heart failure with normal LVEF ejection fraction (HFNEF). The
diagnosis of HFNEF requires the following conditions to be
satisfied: (i) signs or symptoms of heart failure; (ii) normal or
mildly abnormal systolic LV function; (iii) evidence of diastolic
LV dysfunction. Normal or mildly abnormal systolic LV function
implies both an LVEF>50% and an LV end-diastolic volume index
(LVEDVI)<97 mL/m.sup.2. Diastolic LV dysfunction is preferably
diagnosed by tissue Doppler (TD), wherein a ration E/E'>15 is
regarded as diagnostic evidence for diastolic LV dysfunction (E
being early mitral valve flow velocity; and E' being early TD
lengthening velocity) If TD yields an E/E' ratio suggestive of
diastolic LV dysfunction (15>E/E'>8), additional non-invasive
investigations are required for diagnostic evidence of diastolic LV
dysfunction. (e.g. Doppler of the lateral mitral annulus, Doppler
of mitral valve or pulmonary veins, echo measures of LV mass index
or left atrial volume index, electrocardiographic evidence of
atrial fibrillation). For more detailed information on diastolic LV
dysfunction, reference is made to the Consensus statement on the
diagnosis of heart failure with normal left ventricular ejection
fraction by the Heart Failure and Echocardiography Associations of
the European Society of Cardiology, European Heart Journal 2007,
28, 2359-2550.
[0114] Risk factors. In general, prior to carrying out the methods
of the present disclosure, the respective individual is diagnosed
for risk factors of developing heart failure. Risk factors are
known to the person skilled in the art and include the following:
hypertension; age, systolic and diastolic hypertension; coronary
artery disease (CAD); subclinical organ damage, e.g. of the heart,
brain, kidneys, blood vessels; obesity, such as obesity defined as
body mass index BMI<25 kg/m.sup.2; adipositas; metabolic
syndrome; diabetes mellitus type 1 or type 2, in particular type 2
diabetes mellitus; type 1 diabetes with microalbuminuria, cigarette
smoking; history of revascularization; history of cardiotoxic drug
therapy or alcohol abuse; dyslipidemia; total cholesterol, total
cholesterol/HDL-cholesterol ratio, personal history of rheumatic
fever; family history of cardiomyopathy.
[0115] It is to be understood that the above list is not
exhaustive. A more exhaustive citation of risk factors is found in
the 2007 Guidelines for the Management of Arterial Hypertension,
European Heart Journal (2007) 28, 1462-1536 which is incorporated
herein in its entirety in respect to the risk factors, in
particular tables 1, 2 and 3 and FIG. 1.
[0116] Individual risk factors comprise the risk of CVD and of
developing fatal atherosclerotic events, which is calculated using
the SCORE system available from the European Society of
Hypertension (European Society of Hypertension Scientific
Newsletter 2010, 11, No 48). According to the recommended scoring
system of the ESC of Hypertension based on the number and levels of
risk factors different risk groups are formed (low, low-moderate .
. . ) and accordingly therapy is adapted. The disclosure of the
European Society of Hypertension Scientific Newsletter 2010, 11, No
48 is incorporated by reference in its entirety in the present
application.
[0117] The term "subclinical organ damage" as used herein refers to
a pathophysiological state (damage) of an organ. The term is known
to the person skilled in the art. Subclinical organ damage may be
caused by various reason, e.g. by one or more risk factors of
suffering from heart failure as specified above, in particular
arterial hypertension, does not give rise to clinical symptoms and
cannot be recognized by the person skilled in the art without
referring to an established diagnostic method (e.g. cardiac
hypertrophy, low grade albuminuria, pulse wave velocity, . . . ).
For a more detailed definition of subclinical organ damage,
reference is made to the European Heart Journal (2007) 28,
1462-1536 which is incorporated herein in its entirety in respect
to the risk factors, in particular chapter 3.6 including box 7.
[0118] It is to be understood that the above list is not
exhaustive. Furthermore, the respective individual may show one
risk factor, or 2 or even more risk factors. For example, it is
known that diabetes mellitus in general triggers CAD and/or
hypertension; coronary artery disease, irrespective of the
existence of diabetes mellitus, often leads to hypertension.
[0119] An individual suffering from one or more of the risk factors
as specified beforehand and not having symptoms of heart failure
(apparently healthy) will in general and may be classified into
ACC/AHA stage A in case no functional and/or structural
abnormalities of the heart preceding heart failure is diagnosed in
the individual.
[0120] It is important to note that the criteria are not ambiguous
and the classification of an individual may vary depending on the
physician carrying out examination. The first criterium for the
classification of an individual in stage A (and also in stages B, C
and D) of the ACC/AHA classification is the description of the
patient (see the above definition of the ACC/AHA classification, as
taken from the original publication of the Guidelines). The
examples for risk factors/pathophysiological state of each stage
cannot be exhaustive, as becomes clear from an inspection of the
original publications. This means that, in the context of the
present disclosure, an individual will in general and may be
classified into stage A of the ACC/AHA classification even in case
the risk factors which the individual bears are not explicitly
cited in the guidelines.
[0121] In an embodiment of the present disclosure, the individual
bearing risk factors of developing heart failure is an individual
which has been classified into ACC/AHA stage A prior to carrying
out the methods according to the present disclosure. The individual
classified in stage A may have experienced physiological changes
towards pathophysiological states belonging to ACC/AHA stage B
(i.e. functional and/or structural abnormalities of the heart
preceding heart failure). In the context of the present disclosure,
this state is referred to as "early stage of functional and/or
structural abnormalities of the heart preceding heart failure"
(early stage B) and is different from a "late stages of functional
and/or structural abnormalities of the heart preceding heart
failure" (late stage B). According to some embodiments, the
individual does not show obvious symptoms of heart failure.
According to some embodiments the individual does not show left
ventricular hypertrophy (i.e. the individual is apparently
healthy).
[0122] As the individual, in some cases, does not show obvious or
overt signs of heart failure a (for example, of left ventricular
hypertrophy, i.e. the individual is apparently healthy) the
physiological changes which may have occurred are not diagnosed
without carrying out a detailed diagnosis, either with the methods
known in the art (which are onerous, costly and time-consuming) or
with the methods of the present disclosure.
[0123] According to some embodiments, the subject suffers from
hypertension, in particular from arterial hypertension. In the
context of the present disclosure, an individual suffering from
hypertension will be referred to as "hypertensive individual". The
hypertension can be any form of hypertension known to the person
skilled in the art. Non-limiting examples include subjects suited
for anti-hypertensive medication due to their cardiovascular risk
profile according to the recommendations of the guidelines as well
as subjects already at anti-hypertensive medication. In this
respect, reference is made to the 2007 Guidelines for the
Management of Arterial Hypertension, European Heart Journal (2007)
28, 1462-1536 and the European Society of Hypertension Scientific
Newsletter 2010, 11, No 48).
[0124] According to some embodiments of the present disclosure, the
individual suffers from arterial hypertension, systolic and/and or
diastolic hypertension. Hypertension may be accompanied by one or
more of the above-referenced further risk factors. Thus, a subject
bearing risk factors of heart failure may suffer from hypertension
accompanied by one or more of the above-referenced further risk
factors. However, it is also contemplated that said subject suffers
from hypertension alone.
[0125] In another embodiment of the present disclosure, the
individual suffers from diabetes mellitus, in particular diabetes
mellitus type 2. In yet another embodiment, the individual suffers
from obesity. In yet another embodiment, the individual suffers
from metabolic syndrome. In yet another embodiment the individual
suffers from low, moderate, high or very high risk according to the
risk chart of the European Society of Hypertension.
[0126] Diagnosis of risk factors generally occurs by methods known
to the person skilled in the art, in general cardiac auscultation
and/or ECG and/or chest x-ray and/or echocardiography, tissue
Doppler echocardiography, coronary catheterization, determination
of blood pressure, determination of pulse wave velocity,
determination of intima media thickness, determination of diabetes
mellitus, determination of metabolic syndrome, determination of
body mass index, determination of smoking habitus, determination of
total cholesterol, determination of LDL-cholesterol, determination
of blood glucose determination of cardiovascular risk profile
according to risk chart of the European Society of Hypertension and
according to the Guidelines for the Management of Arterial
Hypertension, European Heart Journal (2007) 28, 1462-1536 and the
European Society of Hypertension Scientific Newsletter 2010, 11, No
48).
[0127] In another embodiment one or more of the additional
diagnostic steps cited beforehand are a part of the present
disclosure, i.e. these additional steps may be carried out in
addition to the method of the present disclosure making use of a
cardiac troponin or a variant thereof for diagnosing functional
and/or structural abnormalities of the heart preceding heart
failure. This also applies for the other methods of the present
disclosure.
[0128] Accordingly, the present disclosure relates to a method of
diagnosing in a subject functional and/or structural abnormalities
of the heart preceding heart failure, based on the diagnosis of
risk factors of developing heart failure by a method or methods
known to the person skilled in the art and, furthermore, comparison
of the concentrations of at least on cardiac troponin or a variant
thereof, and optionally of one or more other markers of heart
failure, to the concentration of this or these marker(s) in a
control sample.
[0129] The method of the disclosure may comprise the following
steps: [0130] a) diagnosing risk factors of developing heart
failure by a method or methods known to the person skilled in the
art, [0131] b) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; c) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure; and d) assessing the
said functional and/or structural abnormalities by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to the concentration of
this marker or these markers to reference amounts, e.g. to the
concentration of this marker or these markers as established in a
control sample.
[0132] The present disclosure provides a method of diagnosing in a
subject functional and/or structural abnormalities of the heart
preceding heart failure, the method comprising the steps of [0133]
a) diagnosing risk factors of developing heart failure by a method
or methods known to the person skilled in the art, [0134] b)
measuring in a sample obtained from the subject the concentration
of at least one cardiac troponin or a variant thereof, [0135] c)
optionally measuring in the sample the concentration of one or more
other marker(s) of heart failure, and [0136] d) assessing the said
functional and/or structural abnormalities by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts.
[0137] The methods known to the person skilled in the art are the
following: cardiac auscultation and/or ECG and/or chest x-ray
and/or echocardiography, tissue Doppler echocardiography, coronary
catheterization, determination of blood pressure, determination of
pulse wave velocity, determination of intima media thickness,
determination of diabetes mellitus, determination of metabolic
syndrome, determination of body mass index, determination of
smoking habitus, determination of total cholesterol, determination
of LDL-cholesterol, determination of blood glucose determination of
cardiovascular risk profile according to risk chart of the European
Society of Hypertension and according to the Guidelines for the
Management of Arterial Hypertension, European Heart Journal (2007)
28, 1462-1536 and the European Society of Hypertension Scientific
Newsletter 2010, 11, No 48).
[0138] In the above method, step a) and step b), or step a) and
steps b) to d) can be carried out simultaneously (i.e. at the same
point in time) or subsequently (i.e. at different points in time).
In case the steps are carried out subsequently, the time interval
between the steps is not long enough to allow a change in the
pathophysiological state of the subject.
[0139] In accordance with the present disclosure, an increased
concentration of cardiac troponin or a variant thereof, in
particular troponin T or a variant thereof is indicative for
functional and/or structural abnormalities of the heart preceding
heart failure. The subject bears risk factors of developing heart
failure, for example, and may be an asymptomatic subject, or may be
suffering from left ventricular dysfunction (LVD), diastolic left
ventricular dysfunction, or even diastolic left ventricular
dysfunction with preserved left ventricular systolic function. For
example, the individual has not developed LVH (i.e. LVH is not
apparent). A decreased concentration of a cardiac troponin, such as
troponin T or a variant thereof or Troponin I or a variant thereof,
which is indicative for the absence of heart disease.
[0140] In accordance with the foregoing, troponin T concentrations
of .gtoreq. (equal to or higher than) about 5.0 pg/mL,
.gtoreq.about 6.0 pg/mL, or .gtoreq.about 7.0 pg/mL are increased
troponin T concentrations which are indicative for functional
and/or structural abnormalities of the heart preceding heart
failure and/or preceding left ventricular hypertrophy, as laid out
in the preceding paragraph. Moreover troponin T concentrations of
equal to or higher than about 3.3 pg/ml or of equal or higher than
about 3.5 pg/ml are increased troponin T concentrations which are
indicative for functional and/or structural abnormalities of the
heart preceding heart failure and/or left ventricular
hypertrophy.
[0141] Moreover, troponin I concentrations of equal or higher than
0.2-9.0 pg/ml, or of equal to or higher than about 9 pg/ml are
increased troponin I concentrations which are indicative for
functional and/or structural abnormalities of the heart preceding
heart failure and/or left ventricular hypertrophy. A concentration
of a cardiac troponin, such as troponin T or I, lower of the
aforementioned concentrations, is indicative for the absence of
functional and/or structural abnormalities of the heart preceding
heart failure and/or left ventricular hypertrophy.
[0142] In the studies carried out in the context of the present
disclosure, it was surprisingly found, that an increase of a
cardiac troponin, in particular of troponin T, that is at least 20%
or of at least 30% larger than the amount of a cardiac troponin, in
particular of troponin T, is indicative for the diagnosis of
functional and/or structural abnormalities preceding heart failure
and/or preceding left ventricular hypertrophy. According to the
explanation of the terms "decreased" or "increased", as used in the
context of the present disclosure, denotes with an increase or
decrease of at least 10%, of at least 20%, at least 30%, in respect
to the amount/concentration of the marker in a sample from a
healthy individual/subject and/or from healthy
individuals/subjects. In respect to reference amounts no increase
of Nt-ProBNP was observed in the in the subjects belonging to
groups 1 to 3 described in Example 1.
[0143] In the studies carried out in the context of the present
disclosure, it was further surprisingly found, that an increase of
a cardiac troponin, such as of troponin T, in a sample that is
derived from a female subject that is at least 30%, or more or at
least 50% larger than the amount of a cardiac troponin, in
particular of troponin T, in a sample of a healthy female subject
(or group of healthy female subjects) is indicative for the
diagnosis of functional and/or structural abnormalities preceding
heart failure and/or preceding left ventricular hypertrophy.
[0144] If the amount of troponin T is measured, the reference
amount serving as a cut-off is within a range of 2 to 14 pg/ml.
According to some embodiments, the reference amount, serving as
cut-off for Troponin is within a range of 3.2 to 4 pg/ml. According
to some embodiments reference amounts of troponin T that may serve
as cut-off amount include, 3.2, 3.4 and 4.2 pg/ml. According to
some embodiments a reference amount of troponin I that may serve as
cut-off amount is 9.0 pg/ml. An amount of a cardiac troponin in
sample, such as in a serum or plasma sample, of a subject larger
than the reference amount, is indicative for the diagnosis of
functional and/or structural abnormalities preceding heart failure
and/or preceding left ventricular hypertrophy. An amount of a
cardiac troponin in sample, for example a serum or plasma sample,
of subject lower than the reference amount, indicates that the
subject has no functional and/or structural abnormalities preceding
heart failure and/or preceding left ventricular hypertrophy.
[0145] The above values were established using Roche's
electrochemiluminescence ELISA sandwich test Elecsys.TM. Troponin T
hs (high sensitive) STAT (Short Turn Around Time) assay, as
specified in the examples, under "Methods". Moreover, it has been
found that each of said biomarkers is statistically independent
from each other.
[0146] The present disclosure relates to a method which permits to
diagnose or assess or evaluate if a subject who is bearing risk
factors for heart failure only bears risk factors or if the risk
factors have developed into functional and/or structural
abnormalities of the heart preceding heart failure.
[0147] An individual suffering from functional and/or structural
abnormalities of the heart preceding heart failure as specified
beforehand and not having symptoms of heart failure (apparently
healthy) will in general be classified into ACC/AHA stage B in case
heart failure is not diagnosed in the individual. According to the
instant disclosure, the criteria are not ambiguous and the
classification of an individual may vary depending on the physician
carrying out examination. The first criterium for the
classification of an individual in stage B (and also in stages A, C
and D) of the ACC/AHA classification is the description of the
patient (see the above definition of the ACC/AHA classification, as
taken from the original publication of the Guidelines). The
examples for risk factors/pathophysiological state of each stage
cannot be exhaustive, as becomes clear from an inspection of the
original publications. According to the present disclosure, an
individual will in general and may be classified into stage B of
the ACC/AHA classification even in case functional and/or
structural abnormalities of the heart preceding heart failure which
the individual bears is not explicitly cited in the guidelines.
[0148] The proteins which are measured in the context of the
present disclosure can be measured in one single sample or various
samples of the subject, e.g. 2, 3, 4 or 5 samples. The samples may
be obtained at the same time or at different time points. For
example, the samples may be collected before and/or during and/or
after therapy of the patient.
[0149] According to some embodiments, the cardiac troponin is
troponin T or a variant thereof or troponin I or a variant thereof.
In further embodiments of the present disclosure, at least one
further marker to the marker selected from cardiac troponins,
namely at least on further marker of heart failure, is used in the
methods of the present disclosure. The at least one marker of heart
failure is selected from GDF-15 and variants thereof and IGFBP7 and
variants thereof. In an embodiment of the present disclosure, the
cardiac troponin is selected from troponin T and variants thereof
and troponin I and variants thereof, in particular the cardiac
troponin is troponin T or a variant thereof. In one embodiment of
the present disclosure, the following markers are determined in
combination: the cardiac troponin is selected from troponin T and
troponin I and variants thereof, in particular the cardiac troponin
is troponin T or a variant thereof; GDF-15 or a variant thereof;
and IGFBP7 or a variant thereof.
[0150] The term "diagnosing" as used herein means assessing,
identifying, evaluating or classifying if a subject suffers from
functional and/or structural abnormalities of the heart preceding
heart failure. The term "diagnosing" also refers to distinguishing
between a subject only bearing risk factors of developing heart
failure, or already suffering from functional and/or structural
abnormalities of the heart preceding heart failure.
[0151] The person skilled in the art is aware of methods to
diagnose if a subject suffers from functional and/or structural
abnormalities of the heart preceding heart failure or is about to
develop functional and/or structural abnormalities of the heart
preceding heart failure, where the subject is classified into
ACC/AHA stage A. This diagnosis is in general costly,
time-consuming and requires medical skill and experience. Methods
of evaluation are known to the person skilled in the art and are
typically based on medical history, further evaluation includes
examination using diagnostic apparatuses/devices (cardiac
auscultation, ECG, echocardiography, chest x-ray, radionuclide
imaging, ventriculography, CT scan, MRI and/or stress testing,
coronary angiography, ultrasonography, coronary catheterization).
Other tests may be done as needed to determine the cause. Treatment
depends on the specific type and severeness of the functional
and/or structural abnormalities of the heart preceding heart
failure.
[0152] For example, a preliminary diagnosis of left ventricular
hypertrophy can usually be made based on the results of a physical
examination. The heart sounds heard through a stethoscope are
usually characteristic. Echocardiography is the best way to confirm
the diagnosis. Electrocardiography (ECG) and a chest x-ray are also
helpful. Cardiac catheterization, an invasive procedure, is
performed to measure pressures in the heart chambers only if
surgery is being considered.
[0153] The diagnostic methods listed above can be used
supplementary/complementary with the methods of the present
disclosure based on the determination of the cited markers.
[0154] The markers (peptides) which are used in the present
disclosure can also be used, in further embodiments of the present
disclosure, for the confirmation of a diagnosis established by a
conventional diagnostic method known in the art, and vice versa.
Accordingly, the present disclosure also relates to a method of
confirming a diagnosis which is not or only partly-based on the
determination of the markers used in the present disclosure, by
determining the concentration of the markers used in the present
disclosure, comparing these to the concentration of said marker in
a control sample, and confirming or not confirming the diagnosis
obtained by methods according to the state of the art.
[0155] Confirmation. In a further embodiment, the present
disclosure relates to a method of confirming in a subject
functional and/or structural abnormalities of the heart preceding
heart failure, based on the diagnosis of risk factors of developing
heart failure by a method or methods known to the person skilled in
the art and, furthermore, comparison of the concentrations of at
least on cardiac troponin or a variant thereof, and optionally of
one or more other markers of heart failure, to the concentration of
this or these marker(s) in a control sample.
[0156] The method of the disclosure may comprise the following
steps: [0157] a) diagnosing risk factors of developing heart
failure by a method or methods known to the person skilled in the
art, [0158] b) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; [0159] c) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure; and
[0160] d) confirming the said functional and/or structural
abnormalities by comparing the concentration determined in step (a)
and optionally the concentration(s) determined in step (b) to
reference amounts, e.g to the concentration of this marker or these
markers as established in a control sample.
[0161] Accordingly, the present disclosure provides a method of
confirming in a subject functional and/or structural abnormalities
of the heart preceding heart failure, the method comprising the
steps of: [0162] a) diagnosing in the subject risk factors of
developing heart failure by a method or methods known to the person
skilled in the art, [0163] b) measuring in a sample obtained from
the subject the concentration of at least one cardiac troponin or a
variant thereof, [0164] c) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0165] d) confirming the said functional and/or structural
abnormalities by comparing the concentration determined in step (a)
and optionally the concentration(s) determined in step (b) to
reference amounts.
[0166] The methods known to the person skilled in the art generally
use diagnostic apparatusses/devices and are selected from the
following: transvenous endomyocardial biopsy, cardiac
catheterization, cardiac auscultation, ECG, echocardiography, chest
x-ray, radionuclide imaging, ventriculography, CT scan, MRI and/or
stress testing, coronary angiography, ultrasonography,
[0167] In the above method, step a) and step d), or steps a) to c)
and step d) can be carried out simultaneously (i.e. at the same
point in time) or subsequently (i.e. at different points in time).
In case the steps are carried out subsequently, the time interval
between the steps is not long enough to allow a change in the
pathophysiological state of the subject.
[0168] As already mentioned beforehand, more than one
pathomechanism may be the cause for the occurrence of pathological
left ventricular hypertrophy in a subject.
[0169] Risk prediction. In a further embodiment, the present
disclosure provides a method of predicting the risk of a subject to
suffer from heart failure, or respective cardiovascular and renal
events preceding heart failure, based on the comparison of the
concentrations of at least on cardiac troponin or a variant
thereof, and optionally of one or more other markers of heart
failure, to the concentration of this or these marker(s) in a
control sample.
[0170] The method of the disclosure may comprise the following
steps: [0171] a) measuring in a sample obtained from the subject
the concentration of at least one cardiac troponin or a variant
thereof; [0172] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure; and
[0173] c) predicting the risk of the subjects to suffer from heart
failure or from cardiovascular and renal events, by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts, e.g
to the concentration of this marker or these markers as established
in a control sample.
[0174] Accordingly, the present disclosure provides a method of
predicting the risk of a subject to suffer from heart failure, or
respective cardiovascular and renal events preceding heart failure,
the method comprising the steps of: [0175] a) measuring in a sample
obtained from the subject the concentration of at least one cardiac
troponin or a variant thereof, [0176] b) optionally measuring in
the sample the concentration of one or more other marker(s) of
heart failure, and [0177] c) predicting the risk of the subjects to
suffer from heart failure or from cardiovascular and renal events
by comparing the concentration determined in step (a) and
optionally the concentration(s) determined in step (b) with a
reference amount.
[0178] The above method of predicting may comprise an optional step
bb) of diagnosing functional and/or structural abnormalities of the
heart preceding heart failure. This step bb) may identify any of
the heart diseases cited beforehand, including for example those
found in early stage functional and/or structural abnormalities of
the heart preceding heart failure.
[0179] According to some embodiments of the present disclosure, the
individual is an individual for whom the risk of suffering from
heart failure is determined is an individual wherein LVH is not
apparent.
[0180] Method of predicting prior to LVH. Therefore, in a further
embodiment, the present disclosure provides a method of predicting
the risk of heart failure in a subject before left ventricular
hypertrophy (LVH) is apparent, based on the comparison of the
concentrations of at least on cardiac troponin or a variant
thereof, and optionally of one or more other markers of heart
failure, to the concentration of this or these marker(s) in a
control sample.
[0181] The method of the disclosure may comprise the following
steps: a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure; and c) predicting the
risk of the subjects to suffer from heart failure by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts, e.g.
to the concentration of this marker or these markers as established
in a control sample.
[0182] Accordingly, the present disclosure provides a method of
predicting the risk of heart failure in a subject before left
ventricular hypertrophy (LVH) is apparent, the method comprising
the steps of: [0183] a) measuring in a sample obtained from the
subject the concentration of at least one cardiac troponin or a
variant thereof, [0184] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0185] c) predicting the risk of the subjects to suffer from heart
failure by comparing the concentration determined in step (a) and
optionally the concentration(s) determined in step (b) to reference
amounts.
[0186] The subject may bears risk factors for heart failure, e.g.
hypertension and diabetes. Also according to some embodiments, the
subject does not show overt signs and/or symptoms of heart
failure.
[0187] Diastolic dysfunction. According to some embodiments of the
present disclosure, the above method permits to predict the risk of
suffering from heart failure in an individual having early stage
functional and/or structural abnormalities of the heart preceding
heart failure (early stage B) and suffering from asymptomatic
diastolic dysfunction. The individual may also suffer from systolic
dysfunction. Furthermore, the individual may suffer from
morphological changes in its left ventricle. According to some
embodiments, the individual suffering from diastolic dysfunction
does not suffer from a reduced left ventricular ejection fraction
LVEF (i.e. the individual has a preserved LVEF). According to some
embodiments, the individual suffering from diastolic dysfunction
does not suffer from systolic dysfunction. The individual, for
example, may not suffer from left ventricular hypertrophy LVH.
[0188] According to some embodiments of the above method, the
patient having early stage functional and/or structural
abnormalities of the heart preceding heart failure (early stage B)
and/or suffering from diastolic dysfunction, as specified in the
preceding paragraph, shows the following risk factors of suffering
from heart failure: history of cigarette smoking, obesity,
metabolic syndrome, diabetes type 1 and type 2, arterial
hypertension, in particular arterial hypertension.
[0189] In case of a prediction in a subject having a diastolic
dysfunction, the method of prediction according to the disclosure
may comprise an optional step bb) of diagnosing (asymptomatic)
diastolic dysfunction. This step bb) may identify any of the
functional and/or structural abnormalities of the heart cited
beforehand, including for example those found in early stage
functional and/or structural abnormalities of the heart preceding
heart failure.
[0190] It is known in the art that individuals having a diastolic
dysfunction are predisposed to suffer from heart failure as a
consequence of the diastolic dysfunction. This is published, for
example, in; Med Clin North Am. 2009 May; 93(3):647-64; Am J
Hypertens. 2001 February; 14(2):106-13; Hypertension. 2002;
40:136-14.
[0191] Prediction of early stage B. According to some embodiments
of the present disclosure, the above method permits to predict the
risk of an individual having risk factors of developing heart
failure (stage A) to suffer from functional and/or structural
abnormalities of the heart preceding heart failure (stage B) and/or
preceding left ventricular hypertrophy. According to some
embodiments of the above method, the risk to suffer from a left
ventricular dysfunction, in particular a diastolic dysfunction, of
the individual having risk factors is predicted. According to some
embodiments, the individual suffering from diastolic dysfunction
does not suffer from a reduced left ventricular ejection fraction
LVEF (i.e. the individual has a preserved LVEF). In some
embodiments, the individual suffering from diastolic dysfunction
does not suffer from systolic dysfunction. In further embodiments
of the above method, the risk to suffer from a structural change of
the left ventriculum is predicted. In particular, the risk is
predicted before the individual suffers from LVH (i.e. the risk of
an individual having risk factors of developing heart failure
(stage A) to suffer from early stage functional and/or structural
abnormalities of the heart (early stage B) typically preceding
heart failure left ventricular hypertrophy (late stage B), is
predicted.
[0192] According to some embodiments of the above method, the
subject having risk factors of suffering from heart failure (stage
A) or to suffer from functional and/or structural abnormalities of
the heart preceding heart failure (stage B), as specified in the
preceding paragraphs, shows the following risk factors of suffering
from heart failure: history of cigarette smoking, obesity,
metabolic syndrome, diabetes type 1 and type 2, arterial
hypertension, in particular arterial hypertension.
[0193] In case of a prediction in a subject having a diastolic
dysfunction, the method of prediction according to the disclosure
may comprise an optional step bb) of diagnosing (asymptomatic)
diastolic dysfunction. This step bb) may identify any of the
functional and/or structural abnormalities of the heart cited
beforehand, including those found in early stage functional and/or
structural abnormalities of the heart preceding heart failure.
[0194] Method of predicting the risk of a female subject to suffer
from LVH. The definitions and explanation given herein, may apply
mutatis mutandis to the following:
[0195] Moreover, the present disclosure relates to a method of
predicting the risk of a female subject to suffer from left
ventricular hypertrophy, the method comprising the steps of: [0196]
a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof, [0197] b) optionally measuring in the sample the
concentration of one or more other marker(s) of heart failure, and
[0198] c) predicting the risk of the subjects to suffer from left
ventricular hypertrophy by comparing the concentration determined
in step (a) and optionally the concentration(s) determined in step
(b) with a reference amount.
[0199] The method of the present disclosure, is an ex vivo method.
Moreover, it may comprise steps in addition to those explicitly
mentioned above. For example, further steps may relate to sample
pre-treatments or evaluation of the results obtained by the method.
The method may be carried out manually or assisted by automation.
The steps may in total or in part be assisted by automation, e.g.,
by a suitable robotic and sensory equipment for the determination
or a computer-implemented comparison based on said comparison.
According to some embodiments, the method is carried out entirely
in an automated manner. In such a case, the prognostic result which
is established in step c) is generated in a suitable output format
so that it can be used as an aid for establishing the final
clinical prognosis by, e.g., a medical practitioner.
[0200] In the context of the aforementioned method of the present
disclosure, the risk of a female subject to suffer from LVH shall
be predicted. The term "predicting the risk" as used herein, may
refer to assessing the probability according to which the female
subject as referred to herein will suffer from left ventricular
hypertrophy. According to some embodiments, the risk/probability to
suffer from left ventricular hypertrophy within a certain time
window is predicted. According to some embodiments of the present
disclosure, the predictive window, for example, is an interval of
at least 6 month, at least 9 month, at least 1 year, at least 2
years, at least 3 years, at least 4 years, at least 5 years, at
least 10 years, at least 15 years or any intermitting time range.
In a particular embodiment of the present disclosure, the
predictive window, is an interval of 10 years, an in some cases of
5 years. According to some embodiments, said predictive window is
calculated from the time point at which the sample to be tested has
been obtained.
[0201] As will be understood by those skilled in the art, the
aforementioned prediction is usually not intended to be correct for
100% of the subjects to be analyzed. The term, however, requires
that the assessment will be valid for a statistically significant
portion of the subjects to be analyzed. Whether a portion is
statistically significant can be determined without further ado by
the person skilled in the art using various well known statistic
evaluation tools, e.g., determination of confidence intervals,
p-value determination, Student's t-test, Mann-Whitney test, etc.
Details are found in Dowdy and Wearden, Statistics for Research,
John Wiley & Sons, New York 1983. Exemplary confidence
intervals include at least 90%, at least 95%, at least 97%, at
least 98% or at least 99%.
[0202] The term "predicting", according to some embodiments,
relates to assessing whether a subject is at risk or not at risk to
suffer from left ventricular hypertrophy (the term left ventricular
hypertrophy has been defined elsewhere herein, the definition
applies accordingly). According to some embodiments, it shall be
assessed whether a female risk is at elevated risk or at reduced
risk as compared to the average risk in a population of subjects.
The term "predicting the risk to suffer from left ventricular
hypertrophy" as used herein means that the subject to be analyzed
by the method of the present disclosure is allocated either into
the group of subjects being at risk to suffer from left ventricular
hypertrophy, or into a group of subjects being not at risk to
suffer from left ventricular hypertrophy. Having a risk to suffer
from left ventricular hypertrophy as referred to in accordance with
the present disclosure, means that the risk to suffer from left
ventricular hypertrophy is increased (for example, within the
predictive window). Said risk may be elevated as compared to the
average risk in a cohort of female subjects, in particular in a
cohort of subjects bearing at least one risk factor to suffer from
heart failure (for example, the same risk factor(s) as the test
subject). A subject who is not at risk to suffer from left
ventricular hypertrophy as referred to in accordance with the
present disclosure, may have a reduced risk to suffer from left
ventricular hypertrophy (for example, within the predictive
window). According to some embodiments, said risk is reduced as
compared to the average risk in a cohort of female subjects, in
particular in a cohort of subjects bearing at least one risk factor
(for example, the same risk factor(s) as the test subject) to
suffer from heart failure. A subject who is at risk to suffer from
left ventricular hypertrophy may have a risk of 10-20%, or larger,
or, for example of 20% or larger to suffer from left ventricular
hypertrophy, for example, within a predictive window of 5 years. A
subject who is not at risk to suffer from left ventricular
hypertrophy, may have a risk to suffer from left ventricular
hypertrophy of lower than 10%, and in some cases of lower than, 5%
or lower even, within a predictive window of 10 years.
[0203] The term "subject" has been described elsewhere herein. The
definition applies accordingly. The subject in accordance with the
aforementioned method may be a female subject. According to some
embodiments of the aforementioned method, the female subject to be
tested shows at least one (and, thus, one or more than one) risk
factor of suffering from heart failure. In particular, the female
subject to be tested, may show at least one risk factor selected
from the group consisting of history of cigarette smoking, obesity,
metabolic syndrome, diabetes type 1 and type 2, and hypertension,
in particular arterial hypertension. Thus, the female subject may,
suffer from hypertension (in particular arterial hypertension),
diabetes, obesity, metabolic syndrome and/or a history of smoking
(i.e. the subject has history of smoking). In some particular
embodiments, the female subject bearing at least one risk factor of
heart failure suffers from hypertension (such as arterial
hypertension) and/or diabetes.
[0204] The term "reference amount" has been described elsewhere
herein. The definition applies accordingly. Moreover, the term
"reference amounts" or "reference values" as used herein in the
context of the aforementioned method refers to an amount of the
polypeptides which allow to predict the risk to suffer from LVH.
Therefore, the reference amounts will in general be derived from a
subject known to be at risk to suffer from LVH or from a subject
known to be at not at risk to suffer from LVH.
[0205] According to some embodiments, an increased amount for a
cardiac troponin or a variant thereof as measured from a sample
derived from a female subject to be tested indicates that the
female subject is at risk to suffer from LVH. Also, an increased
amount of GDF15 or a variant thereof and IGFBP7 or a variant
thereof as measured from a sample derived from a female subject to
be tested is indicative for the risk to suffer from LVH. According
to some embodiments increased amounts with respect to the reference
amount are indicative for the risk to suffer from LVH.
[0206] The amounts for cardiac troponin or a variant thereof, GDF15
or a variant thereof and IGFBP7 or a variant thereof as measured in
a control group or a control population are for example used to
establish a cut-off amount or a reference range. An amount above
such cut-off amount or out-side the reference range and its higher
end is considered as elevated.
[0207] In a one embodiment a fixed cut-off value is established.
Such cut-off value is chosen to match the diagnostic question of
interest.
[0208] In the context of the aforementioned method, the terms
"decreased" and "increased" may refer to amounts that are increased
or decreased with respect to the average amount in a population of
subjects, in particular the median amount. According to some
embodiments, said population is a population of healthy
subjects.
[0209] According to some embodiments, an amount of a cardiac
troponin, such as of troponin T, in a sample of female subject that
is at least 30%, or for example, at least 50% larger than the
amount of a cardiac troponin, in particular of troponin T, in a
sample of a female subject (or group of female subjects) who is
(are) not at risk to suffer from LVH indicates that the test female
subject is at risk of suffer from LVH. A subject who is not at risk
of suffering from LVH may be a subject without functional and
structural abnormalities of the heart preceding heart failure
and/or preceding left ventricular hypertrophy (for a definition of
this term, see elsewhere). Said subject may bear at least one risk
factor for heart failure (and, thus may be in stage A as described
elsewhere herein). According to some embodiments, however, the
subject who is not at risk to suffer from LVH is a healthy subject.
Preferably, the sample is serum or plasma sample.
[0210] Thus, the reference amount is derived from a healthy female
subject (or from a group thereof). According to some embodiments,
an increase of a cardiac troponin (in particular of troponin T) of
at least 30%, for example, of at least 50% as compared to the
amount in a healthy female subject (or to the median amount in
group of healthy female subjects) is indicative for a risk of the
subject to suffer from left ventricular hypertrophy.
[0211] If the amount of troponin T is measured, the reference
amount serving as a cut-off may be within a range of 2 to 14 pg/ml.
According to some embodiments, the reference amount, serving for
troponin T as cut-off is within a range of 3.2 to 4 pg/ml.
According to some embodiments reference amounts of troponin T that
may serve as cut-off amount include 3.2, 3.4 and 4.2 pg/ml. A
exemplary reference amount of troponin I that may serve as cut-off
amount is within a range of 0.2 to 9.0 pg/ml. A further exemplary
reference amount of troponin I that may serve as cut-off amount is
9.0 pg/ml. An amount of a cardiac troponin in sample, such as a
serum or plasma sample, of a female subject larger than the
reference amount indicates that the subject is a risk to suffer
from LVH. An amount of a cardiac troponin in sample, such as a
serum or plasma sample, of a female subject lower than the
reference amount indicates that the subject is not a risk to suffer
from LVH.
[0212] If the amount of IGFBP7 is measured, the reference amount
serving as a cut-off may be within a range of 33.3 pg/ml to 46.2
pg/ml. According to some embodiments, the reference amount, serving
for IGFBP7 as cut-off is within a range of 42.6 to 46.2 pg/ml.
According to some embodiments reference amounts of IGFBP7 that may
serve as cut-off amount include 42.6 pg/ml and 46.2 pg/ml.
[0213] In an embodiment of the methods and uses of the present
disclosure IGFBP7 can also used as single marker instead of the
cardiac Troponin (thus, IGFBP7 may replace the cardiac
Troponin).
[0214] In a further embodiment, the present disclosure provides a
method of diagnosing heart failure in a subject, the method
comprising the steps of: [0215] a) measuring in a sample obtained
from the subject the concentration of at least one cardiac troponin
or a variant thereof, [0216] b) optionally measuring in the sample
the concentration of one or more other marker(s) of heart failure,
and [0217] c) assessing heart failure by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) to reference amounts.
[0218] Methods of the present disclosure include in vitro methods.
According to some embodiments, the concentrations of at least one
marker are determined in a sample obtained from said subject.
Moreover, it may comprise steps in addition to those explicitly
mentioned above. For example, further steps may relate to sample
pre-treatments or evaluation of the results obtained by the method.
The method of the present disclosure may be also used for
monitoring, confirmation, and subclassification of the subject. The
method may be carried out manually or assisted by automation.
According to some embodiments, the step of determining the
concentration of at least one cardiac troponin in at least one
sample of said subject, the step of comparing the thus determined
concentration of the said marker(s) as determined in the preceding
step to the concentration of this marker established in a control
sample, and/or the step of diagnosing/differentiating/predicting
may in total or in part be assisted by automation, e.g., by a
suitable robotic and sensory equipment.
[0219] As will be understood by those skilled in the art, such an
assessment is usually not intended to be correct for all (i.e.
100%) of the subjects to be identified. The term, however, requires
that a statistically significant portion of subjects can be
identified (e.g. a cohort in a cohort study). Whether a portion is
statistically significant can be determined by the person skilled
in the art using various well known statistic evaluation tools,
e.g., determination of confidence intervals, p-value determination,
Student's t-test, Mann-Whitney test etc. Details are found in Dowdy
and Wearden, Statistics for Research, John Wiley & Sons, New
York 1983. Exemplary confidence intervals are at least 90%, at
least 95%, at least 97%, at least 98% or at least 99%. The
p-values, according to some embodiments include 0.1, 0.05, 0.01,
0.005, or 0.0001. According to some embodiments, at least 60%, at
least 70%, at least 80% or at least 90% of the subjects of a
population can be properly identified by the method of the present
disclosure.
[0220] The terms "individual", "subject" and "patient" may be used
interchangeably herein and relate to an animal, for example a
mammal such as a human. The subject may be a male or a female
subject.
[0221] It is envisaged in accordance with the aforementioned method
of the present disclosure that the subject shall be a subject
belonging to ACC/AHA stage A, and showing one or more of the risk
factors for developing HF. Furthermore, the subject may have
entered into stage B or may be about to enter into stage B (early
stage B) of the ACC/AHA classification. Said subject shall not
exhibit symptoms and/or physical signs known to be associated with
HF (i.e. the subject is apparently healthy).
[0222] The method of the present disclosure makes use of so-called
"markers" or "molecular markers". These terms are known to the
person skilled in the art and refer to polypeptides or proteins
which are expressed in the body of the subject. On the one hand,
the expression or elevated expression can be the consequence of a
pathophysiological state which has occurred or is occurring in the
subject, and an elevated concentration, in respect to "normal"
values (which, as the case may be, can be zero) measured in a
physiologically healthy subject, is indicative of the
pathophysiological state (or the "disease") occurring in the
subject. On the other hand, the protein can be expressed in certain
concentrations in physiologically healthy subjects, and the
expression is raised in consequence of a pathophysiological state
which has occurred or is occurring in the subject.
[0223] In the context of the present disclosure, the markers which
are measured all belong to the first group, i.e. they are expressed
or expressed in higher concentrations than normal if the subject
suffers from a pathophysiological state or disease. All the marker
types and markers employed in the present disclosure are known to
the person skilled in the art.
[0224] The present disclosure makes use of cardiac troponins and
variants thereof. It is known that patients suffering from
myocardial infarction MI can be diagnosed using cardiac troponins,
for example troponin T or I. Myocardial infarction is regarded as
being caused by a necrotic state of the myocard, i.e. cell death.
Cardiac troponins are released following cell death and can hence
be used for the diagnosis of MI. If the concentration of Troponin T
in the blood is elevated, i.e. above 0.1 ng/ml, an acute
cardiovascular event is assumed and the patient is treated
accordingly. However, it is known that cardiac troponins are also
released (in small concentrations) in pathological states preceding
cell death, e.g. ischemia.
[0225] The term "cardiac Troponin" refers to all Troponin isoforms
expressed in cells of the heart and for example the subendocardial
cells. These isoforms are well characterized in the art as
described, e.g., in Anderson 1995, Circulation Research, vol. 76,
no. 4: 681-686 and Ferrieres 1998, Clinical Chemistry, 44: 487-493.
According to some embodiments, cardiac Troponin refers to Troponin
T and/or Troponin I, and most preferably, to Troponin T. It is to
be understood that isoforms of Troponins may be determined in the
method of the present disclosure together, i.e. simultaneously or
sequentially, or individually, i.e. without determining the other
isoform at all. Amino acid sequences for human Troponin T and human
Troponin I are disclosed in Anderson, loc cit and Ferrieres 1998,
Clinical Chemistry, 44: 487-493.
[0226] The term "cardiac Troponin" encompasses also variants of the
aforementioned specific Troponins, such as Troponin I and Troponin
T. Such variants have at least the same essential biological and
immunological properties as the specific cardiac Troponins. In
particular, they share the same essential biological and
immunological properties if they are detectable by the same
specific assays referred to in this specification, e.g., by ELISA
Assays using polyclonal or monoclonal antibodies specifically
recognizing the said cardiac Troponins. Moreover, it is to be
understood that a variant as referred to in accordance with the
present disclosure shall have an amino acid sequence which differs
due to at least one amino acid substitution, deletion and/or
addition wherein the amino acid sequence of the variant is still,
at least about 50%, at least about 60%, at least about 70%, at
least about 80%, at least about 85%, at least about 90%, at least
about 92%, at least about 95%, at least about 97%, at least about
98%, or at least about 99% identical with the amino sequence of the
specific Troponin. Variants may be allelic variants or any other
species specific homologs, paralogs, or orthologs. Moreover, the
variants referred to herein include fragments of the specific
cardiac Troponins or the aforementioned types of variants as long
as these fragments have the essential immunological and biological
properties as referred to above. According to some embodiments, the
cardiac troponin variants have immunological properties (i.e.
epitope composition) comparable to those of human troponin T or
troponin I. Thus, the variants shall be recognizable by the
aforementioned means or ligands used for determination of the
concentration of the cardiac troponins. Thus, the variants shall be
recognizable by the aforementioned means or ligands used for
determination of the concentration of the cardiac troponins. Such
fragments may be, e.g., degradation products of the Troponins.
Further included are variants which differ due to posttranslational
modifications such as phosphorylation or myristylation. According
to some embodiments the biological property of troponin I and its
variant is the ability to inhibit actomyosin ATPase or to inhibit
angiogenesis in vivo and in vitro, which may e.g. be detected based
on the assay described by Moses et al. 1999 PNAS USA 96 (6):
2645-2650). According to some embodiments the biological property
of troponin T and its variant is the ability to form a complex with
troponin C and I, to bind calcium ions or to bind to tropomyosin,
if present as a complex of troponin C, I and T or a complex formed
by troponin C, troponin I and a variant of troponin T. It is known
that low concentrations of circulating cardiac troponin may be
detected in subjects at various conditions, but further studies are
required to understand their respective role and rate (Masson et
al., Curr Heart Fail Rep (2010) 7:15-21).
[0227] The term "Growth-Differentiation Factor-15" or "GDF-15"
relates to a polypeptide being a member of the transforming growth
factor (TGF)-.beta. cytokine superfamily. The terms polypeptide,
peptide and protein are used interchangeable throughout this
specification. GDF-15 was originally cloned as
macrophage-inhibitory cytokine-1 and later also identified as
placental transforming growth factor-.beta., placental bone
morphogenetic protein, non-steroidal anti-inflammatory
drug-activated gene-1, and prostate-derived factor (Bootcov loc
cit; Hromas, 1997 Biochim Biophys Acta 1354:40-44; Lawton 1997,
Gene 203:17-26; Yokoyama-Kobayashi 1997, J Biochem (Tokyo),
122:622-626; Paralkar 1998, J Biol Chem 273:13760-13767). Similar
to other TGF-.beta.-related cytokines, GDF-15 is synthesized as an
inactive precursor protein, which undergoes disulfide-linked
homodimerization. Upon proteolytic cleavage of the N-terminal
pro-peptide, GDF-15 is secreted as a .about.28 kDa dimeric protein
(Bauskin 2000, Embo J 19:2212-2220). Amino acid sequences for
GDF-15 are disclosed in WO99/06445, WO00/70051, WO2005/113585,
Bottner 1999, Gene 237: 105-111, Bootcov loc. cit, Tan loc. cit.,
Baek 2001, Mol Pharmacol 59: 901-908, Hromas loc cit, Paralkar loc
cit, Morrish 1996, Placenta 17:431-441 or Yokoyama-Kobayashi loc
cit. GDF-15 as used herein encompasses also variants of the
aforementioned specific GDF-15 polypeptides. Such variants have at
least the same essential biological and immunological properties as
the specific GDF-15 polypeptides. In particular, they share the
same essential biological and immunological properties if they are
detectable by the same specific assays referred to in this
specification, e.g., by ELISA assays using polyclonal or monoclonal
antibodies specifically recognizing the said GDF-15 polypeptides.
An exemplary assay is described in the accompanying Examples.
Moreover, it is to be understood that a variant as referred to in
accordance with the present disclosure shall have an amino acid
sequence which differs due to at least one amino acid substitution,
deletion and/or addition wherein the amino acid sequence of the
variant is still, for example, at least about 50%, at least about
60%, at least about 70%, at least about 80%, at least about 85%, at
least about 90%, at least about 92%, at least about 95%, at least
about 97%, at least about 98%, or at least about 99% identical with
the amino sequence of the specific GDF-15 polypeptides, for example
with the amino acid sequence of human GDF-15, for example over the
entire length of the specific GDF-15, e.g. of human GDF-15. The
degree of identity between two amino acid sequences can be
determined by algorithms well known in the art. According to some
embodiments, the degree of identity is to be determined by
comparing two optimally aligned sequences over a comparison window,
where the fragment of amino acid sequence in the comparison window
may comprise additions or deletions (e.g., gaps or overhangs) as
compared to the reference sequence (which does not comprise
additions or deletions) for optimal alignment. The percentage is
calculated by determining the number of positions at which the
identical amino acid residue occurs in both sequences to yield the
number of matched positions, dividing the number of matched
positions by the total number of positions in the window of
comparison and multiplying the result by 100 to yield the
percentage of sequence identity. Optimal alignment of sequences for
comparison may be conducted by the local homology algorithm of
Smith and Waterman Add. APL. Math. 2:482 (1981), by the homology
alignment algorithm of Needleman and Wunsch J. Mol. Biol. 48:443
(1970), by the search for similarity method of Pearson and Lipman
Proc. Natl. Acad. Sci. (USA) 85: 2444 (1988), by computerized
implementations of these algorithms (GAP, BESTFIT, BLAST, PASTA,
and TFASTA in the Wisconsin Genetics Software Package, Genetics
Computer Group (GCG), 575 Science Dr., Madison, Wis.), or by visual
inspection. Given that two sequences have been identified for
comparison, GAP and BESTFIT may be employed to determine their
optimal alignment and, thus, the degree of identity. According to
some embodiments, the default values of 5.00 for gap weight and
0.30 for gap weight length are used. Variants referred to above may
be allelic variants or any other species specific homologs,
paralogs, or orthologs. Moreover, the variants referred to herein
include fragments of the specific GDF-15 polypeptides or the
aforementioned types of variants as long as these fragments have
the essential immunological and biological properties as referred
to above. Such fragments may be, e.g., degradation products of the
GDF-15 polypeptides. Further included are variants which differ due
to posttranslational modifications such as phosphorylation or
myristylation.
[0228] The Insulin like growth factor binding protein (IGFBP)
system plays an important role in cell growth and differentiation.
It comprises two ligands, IGF-I and IGF-II, two receptors, type 1
and type 2 IGF receptors, and as of 1995 six IGF-binding proteins
(IGFBPs), IGFBP-1 to -6 (Jones, J. I., et al., Endocr. Rev. 16
(1995) 3-34). Recently the IGFBP family has been expanded to
include the IGFBP-related proteins (IGFBP-rPs), which have
significant structural similarities with the IGFBPs (Hwa, V., et
al., Endocr. Rev 20 (1999) 761-787). Thus, the IGFBP superfamily
includes the six conventional IGFBPs, which have high affinity for
IGFs, and at least 10 IGFBP-rPs, which not only share the conserved
amino-terminal domain of the IGFBPs but also show some degree of
affinity for IGFs and insulin. The IGFBP-rPs are a group of
cysteine-rich proteins that control diverse cellular functions,
such as cellular growth, cell adhesion and migration, and synthesis
of the extracellular matrix. In addition, these proteins might be
involved in biological processes like tissue proliferation and
differentiation, reproduction, angiogenesis, wound repair,
inflammation, fibrosis, and tumorigenesis (Hwa, V., et al., Endocr.
Rev 20 (1999) 761-787).
[0229] IGF binding protein 7 (=IGFBP7) is a 30-kDa modular
glycoprotein known to be secreted by endothelial cells, vascular
smooth muscle cells, fibroblasts, and epithelial cells (Ono, Y., et
al., Biochem Biophys Res Comm 202 (1994) 1490-1496). In the
literature this molecule has also been denominated as FSTL2; IBP 7;
IGF binding protein related protein I; IGFBP 7; IGFBP 7v; IGFBP
rPI; IGFBP7; IGFBPRP1; insulin like growth factor binding protein
7; insulin like growth factor binding protein 7 precursor; MAC25;
MAC25 protein; PGI2 stimulating factor; and PSF or Prostacyclin
stimulating factor. Northern blot studies revealed a wide
expression of this gene in human tissues, including heart, brain,
placenta, liver, skeletal muscle, and pancreas (Oh, Y., et al., J.
Biol. Chem. 271 (1996) 30322-30325).
[0230] IGFBP7 was initially identified as a gene differentially
expressed in normal leptomeningeal and mammary epithelial cells,
compared with their counterpart tumor cells, and named
meningioma-associated cDNA (MAC25) (Burger, A. M., et al., Oncogene
16 (1998) 2459-2467). The expressed protein was independently
purified as a tumor derived adhesion factor (later renamed
angiomodulin) (Sprenger, C. C., et al., Cancer Res 59 (1999)
2370-2375) and as a prostacyclin stimulating factor (Akaogi, K., et
al., Proc Natl Acad Sci USA 93 (1996) 8384-8389). It has
additionally been reported as T1Al2, a gene down-regulated in
breast carcinomas (StCroix, B., et al., Science 289 (2000)
1197-1202).
[0231] The biological roles of IGFBP7 have not yet been clearly
established. Preliminary experimental data are somewhat
controversial and relate to diverse actions for IGFBP7, such as
tumor suppression (Sprenger, C. C., et al., Cancer Res 59 (1999)
2370-2375), tumor growth promotion (Lopez-Bermejo, A., et al., J.
Clinical Endocrinology and Metabolism 88 (2003) 3401-3408,
stimulation of prostacyclin (Akaogi, K., et al., Proc. Natl. Acad.
Sci. USA 93 (1996) 8384-8389) and involvement in angiogenesis
(Yamauchi, T., et al., Biochem J. 303 (1994) 591-598) and
senescence (Lopez-Bermejo, A., et al., Endocrinology 141 (2000)
4072-4080).
[0232] Differential expression of IGFBP7 mRNA was measured in
patients suffering from various diseases including cardiac disease,
kidney disease, inflammatory diseases (U.S. Pat. No. 6,709,855 to
Scios Inc.) and vascular graft disease (US 2006/0,003,338).
[0233] A number of different assays has been described and used to
test for the hormone binding properties of IGFBP7. Low affinity IGF
binding was analyzed via competitive affinity cross-linking assays.
Recombinant human mac25 protein specifically binds IGF-I and -II
(Oh, Y., et al., J. Biol. Chem. 271 (1996) 20322-20325; Kim, H. S.,
et al., Proc. Natl. Acad. Sci USA 94 (1997) 12981-12986.) IGFBP
activity can also be detected by measuring the ability of the
protein to bind radiolabeled IGF in Western ligand blotting.
[0234] Immunological determination of circulating IGFBP7 was
performed recently. Low levels of this analyte were detected in
random human sera and increased serum levels have been seen in
association with insulin-resistance (Lopez-Bermejo, A., et al., J.
Clinical Endocrinology and Metabolism 88 (2003) 3401-3408,
Lopez-Bermejo, A., et al., Diabetes 55 (2006) 2333-2339).
[0235] The term "reference amounts" or "reference values" as used
herein in this embodiment of the disclosure refers to amounts of
the polypeptides which allow to diagnose if the respective
individual classified in ACC/AHA class A has developed heart
disease typically preceding heart failure or is about to develop
heart disease typically preceding heart failure.
[0236] Therefore, the reference amounts will in general be derived
from a subject known to have heart disease typically preceding
heart failure and/or being about to develop heart disease typically
preceding heart failure. In an embodiment of the present
disclosure, subject is classified in ACC/AHA class A.
[0237] The expression "comparing the concentration . . . to the
concentration as established in a control sample" is merely used to
further illustrate what is obvious to the skilled artisan anyway.
The control sample may be an internal or an external control
sample. In one embodiment an internal control sample is used, i.e.
the marker level(s) is(are) assessed in the test sample as well as
in one or more other sample(s) taken from the same subject to
determine if there are any changes in the level(s) of said
marker(s). In another embodiment an external control sample is
used. For an external control sample the presence or concentration
of a marker in a sample derived from the individual is compared to
its presence or concentration in an individual known to suffer
from, or known to be at risk of, a given condition; or an
individual known to be free of a given condition, i.e., "normal
individual". For example, a marker level in a patient sample can be
compared to a level known to be associated with a specific course
of disease in HF. Usually the sample's marker level is directly or
indirectly correlated with a diagnosis and the marker level is e.g.
used to determine whether an individual is at risk for HF.
Alternatively, the sample's marker level can e.g. be compared to a
marker level known to be associated with a response to therapy in
patients suffering from structural and/or functional abnormalities
of the heart preceding heart failure, the differential diagnosis of
risk factors for developing heart failure and structural and/or
functional abnormalities of the heart preceding heart failure, the
guidance for selecting an appropriate drug to treat structural
and/or functional abnormalities of the heart preceding heart
failure, in particular early stages, in judging the risk of disease
progression, or in the follow-up of patients having structural
and/or functional abnormalities of the heart preceding heart
failure. Depending on the intended diagnostic use an appropriate
control sample is chosen and a control or reference value for the
marker established therein. It will be appreciated by the skilled
artisan that such control sample in one embodiment is obtained from
a reference population that is age-matched and free of confounding
diseases. As also clear to the skilled artisan, the absolute marker
values established in a control sample will be dependent on the
assay used. According to some embodiments samples from 100
well-characterized individuals from the appropriate reference
population are used to establish a control (reference) value. Also
in some instances the reference population may be chosen to consist
of 20, 30, 50, 200, 500 or 1000 individuals. Healthy individuals
represent an exemplary reference population for establishing a
control value.
[0238] An increased value for cardiac troponin or a variant thereof
as measured from a sample derived from an individual indicates
structural and/or functional abnormalities of the heart preceding
heart failure, an increased value of GDF15 or a variant thereof and
IGFBP7 or a variant thereof as measured from a sample derived from
an individual is indicative for heart failure. The values for
cardiac troponin or a variant thereof, GDF15 or a variant thereof
and IGFBP7 or a variant thereof as measured in a control group or a
control population are for example used to establish a cut-off
value or a reference range. A value above such cut-off value or
out-side the reference range and its higher end is considered as
elevated. In a one embodiment a fixed cut-off value is established.
Such cut-off value is chosen to match the diagnostic question of
interest.
[0239] In one embodiment values for cardiac troponin or a variant
thereof, GDF15 or a variant thereof and IGFBP7 or a variant thereof
as measured in a control group or a control population are used to
establish a reference range. In another embodiment an cardiac
troponin or a variant thereof, GDF15 or a variant thereof and
IGFBP7 or a variant thereof concentration is considered as elevated
if the value measured is above the 90%-percentile of the reference
range. In further embodiments an cardiac troponin or a variant
thereof, GDF15 or a variant thereof and IGFBP7 or a variant thereof
concentration is considered as elevated if the value measured is
above the 95%-percentile, the 96%-percentile, the 97%-percentile or
the 99%-percentile of the reference range.
[0240] In one embodiment the control sample will be an internal
control sample. In this embodiment serial samples are obtained from
the individual under investigation and the marker levels are
compared. This may for example be useful in assessing the efficacy
of therapy.
[0241] The sensitivity and specificity of a diagnostic and/or
prognostic test depends on more than just the analytical "quality"
of the test-they also depend on the definition of what constitutes
an abnormal result. In practice, Receiver Operating Characteristic
curves, or "ROC" curves, are typically calculated by plotting the
value of a variable versus its relative frequency in "normal" and
"disease" populations. For any particular marker of the disclosure,
a distribution of marker levels for subjects with and without a
disease will likely overlap. Under such conditions, a test does not
absolutely distinguish normal from disease with 100% accuracy, and
the area of overlap indicates where the test cannot distinguish
normal from disease. A threshold is selected, above which (or below
which, depending on how a marker changes with the disease) the test
is considered to be abnormal and below which the test is considered
to be normal. The area under the ROC curve is a measure of the
probability that the perceived measurement will allow correct
identification of a condition. ROC curves can be used even when
test results don't necessarily give an accurate number. As long as
one can rank results, one can create an ROC curve. For example,
results of a test on "disease" samples might be ranked according to
degree (say 1=low, 2=normal, and 3=high). This ranking can be
correlated to results in the "normal" population, and a ROC curve
created. These methods are well known in the art. See, e.g., Hanley
et al, Radiology 143: 29-36 (1982).
[0242] In certain embodiments, markers and/or marker panels are
selected to exhibit at least about 70% sensitivity, at least about
80% sensitivity, at least about 85% sensitivity, at least about 90%
sensitivity, and even at least about 95% sensitivity, combined with
at least about 70% specificity, at least about 80% specificity, at
least about 85% specificity, at least about 90% specificity, and
even at least about 95% specificity. In some embodiments, both the
sensitivity and specificity are at least about 75%, at least about
80%, at least about 85%, at least about 90%, and even at least
about 95%. The term "about" in this context refers to +/-5% of a
given measurement.
[0243] In other embodiments, a positive likelihood ratio, negative
likelihood ratio, odds ratio, or hazard ratio is used as a measure
of a test's ability to predict risk or diagnose a disease. In the
case of a positive likelihood ratio, a value of 1 indicates that a
positive result is equally likely among subjects in both the
"diseased" and "control" groups; a value greater than 1 indicates
that a positive result is more likely in the diseased group; and a
value less than 1 indicates that a positive result is more likely
in the control group. In the case of a negative likelihood ratio, a
value of 1 indicates that a negative result is equally likely among
subjects in both the "diseased" and "control" groups; a value
greater than 1 indicates that a negative result is more likely in
the test group; and a value less than 1 indicates that a negative
result is more likely in the control group. In certain embodiments,
markers and/or marker panels are preferably selected to exhibit a
positive or negative likelihood ratio of at least about 1.5 or more
or about 0.67 or less, at least about 2 or more or about 0.5 or
less, at least about 5 or more or about 0.2 or less, at least about
10 or more or about 0.1 or less, and even at least about 20 or more
or about 0.05 or less. The term "about" in this context refers to
+/-5% of a given measurement.
[0244] In the case of an odds ratio, a value of 1 indicates that a
positive result is equally likely among subjects in both the
"diseased" and "control" groups; a value greater than 1 indicates
that a positive result is more likely in the diseased group; and a
value less than 1 indicates that a positive result is more likely
in the control group. In certain embodiments, markers and/or marker
panels are selected to exhibit an odds ratio of at least about 2 or
more or about 0.5 or less, at least about 3 or more or about 0.33
or less, at least about 4 or more or about 0.25 or less, at least
about 5 or more or about 0.2 or less, and even at least about 10 or
more or about 0.1 or less. The term "about" in this context refers
to +/-5% of a given measurement.
[0245] In the case of a hazard ratio, a value of 1 indicates that
the relative risk of an endpoint (e.g., death) is equal in both the
"diseased" and "control" groups; a value greater than 1 indicates
that the risk is greater in the diseased group; and a value less
than 1 indicates that the risk is greater in the control group. In
certain embodiments, markers and/or marker panels are selected to
exhibit a hazard ratio of at least about 1.1 or more or about 0.91
or less, at least about 1.25 or more or about 0.8 or less, at least
about 1.5 or more or about 0.67 or less, at least about 2 or more
or about 0.5 or less, and even at least about 2.5 or more or about
0.4 or less. The term "about" in this context refers to +/-5% of a
given measurement.
[0246] While exemplary panels are described herein, one or more
markers may be replaced, added, or subtracted from these exemplary
panels while still providing clinically useful results. Panels may
comprise both specific markers of a disease (e.g., markers that are
increased or decreased in bacterial infection, but not in other
disease states) and/or non-specific markers (e.g., markers that are
increased or decreased due to inflammation, regardless of the
cause; markers that are increased or decreased due to changes in
hemostasis, regardless of the cause, etc.). While certain markers
may not individually be definitive in the methods described herein,
a particular "fingerprint" pattern of changes may, in effect, act
as a specific indicator of disease state. As discussed above, that
pattern of changes may be obtained from a single sample, or may
optionally consider temporal changes in one or more members of the
panel (or temporal changes in a panel response value).
[0247] The diagnosis if individuals are healthy or suffer from a
certain pathophysiological state is made by established methods
known to the person skilled in the art. The methods differ in
respect to the individual pathophysiological state.
[0248] The algorithms to establish the desired diagnosis are laid
out in the present application, in the passages referring to the
respective embodiment, to which reference is made.
[0249] Accordingly, the present disclosure also comprises a method
of determining the threshold level indicative for a physiological
and/or a pathological state and/or a certain pathological state,
comprising the steps of determining in appropriate patient groups
the levels of the appropriate marker(s), collecting the data and
analyzing the data by statistical methods and establishing the
threshold values.
[0250] In the present disclosure, the appropriate markers are
cardiac troponins and variants thereof, including troponin T or a
variant thereof or troponin I or a variant thereof, and optionally
at least one further marker selected from GDF-15 or a variant
thereof and IGFBP7 or a variant thereof.
[0251] The present disclosure also relates to a method of deciding
on the therapy of a subject as referred to above based on the
aforementioned steps. Therefore, the method of the present
disclosure allows to decide which kind of intervention or which
pharmaceutical or pharmaceuticals should be taken by a subject
suffering from functional and/or structural abnormalities of the
heart preceding heart failure or being about to develop functional
and/or structural abnormalities of the heart preceding heart
failure, where the subject is classified into ACC/AHA stage A.
Treatment can aim at treating the functional and/or structural
abnormalities of the heart preceding heart failure as such, or to
preventing further deterioration of the functional and/or
structural abnormalities of the heart preceding heart failure.
[0252] Treatment decision. Accordingly, the present disclosure
relates to a method of deciding on the treatment of functional
and/or structural abnormalities of the heart preceding heart
failure in a subject, based on the comparison of the concentrations
of at least on cardiac troponin or a variant thereof, and
optionally of one or more other markers of heart failure, to the
concentration of this or these marker(s) in a control sample.
[0253] The method of the disclosure may comprise the following
steps: a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure; c) comparing the thus
determined concentration to reference amounts, e.g. to the
concentration of this marker or these markers as established in a
control sample.
[0254] According to some embodiments, the therapy decision is taken
by comparing the determined concentrations with a reference
amount.
[0255] The present disclosure therefore provides a method of
deciding on the treatment of functional and/or structural
abnormalities of the heart preceding heart failure in a subject,
the method comprising the steps of [0256] a) measuring in a sample
obtained from the subject the concentration of at least one cardiac
troponin or a variant thereof, [0257] b) optionally measuring in
the sample the concentration of one or more other marker(s) of
heart failure, and [0258] c) deciding on treatment of the subject
by comparing the thus determined concentration with a reference
amount.
[0259] According to some embodiments, before deciding on the
treatment, it is diagnosed if the subject suffers from functional
and/or structural abnormalities of the heart preceding heart
failure and/or preceding left ventricular hypertrophy.
[0260] In general, the subject does not suffer from heart failure,
i.e. the patient has not experienced permanent structural or
functional damages to his myocardium. According to some embodiments
the subject has a left ventricular mass index below the criteria
used to define left ventricular hypertrophy. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also in some embodiments, the subject
does not show overt signs and/or symptoms of heart failure. The
subject may be classified into ACC/AHA stage A, prior to carrying
out the method of the present disclosure.
[0261] The person skilled in the art is aware of methods to
diagnose if a subject suffers from functional and/or structural
abnormalities of the heart preceding heart failure or is about to
develop functional and/or structural abnormalities of the heart
preceding heart failure, where the subject is classified into
ACC/AHA stage A. This diagnosis is in general costly,
time-consuming and requires medical skill and experience. Thus
early functional and/or structural abnormalities often remain
underdiagnosed. Methods of evaluation are known to the person
skilled in the art and are typically based on medical history,
further evaluation includes examination using diagnostic
apparatuses/devices (cardiac auscultation, ECG, echocardiography,
chest x-ray, radionuclide imaging, ventriculography, CT scan, MRI
and/or stress testing, coronary angiography, ultrasonography,
coronary catheterization. Other tests may be done as needed to
determine the cause. Methods described above are applied reluctant,
because of limited sensitivity to detect structural and/or
functional abnormalities of the heart preceding LVH and/or heart
failure. Treatment depends on the specific type and severity of the
functional and/or structural abnormalities of the heart preceding
heart failure. Preventive treatment may be initiated before
progression to LVH and/or to HF or other major complications. As a
consequence of diagnosing first structural abnormalities in
subjects with arterial hypertension or diabetes, these patients,
that may rapidly progress to LVH need more intensive medication or
adaption of medication and more intensive monitoring.
[0262] In an exemplary embodiment, the present disclosure provides
a method of therapy adaption a consequence of diagnosis of early
functional and/or structural abnormalities of the heart preceding
heart failure, in particular preceding LVH. The therapeutic
consequence is a change of antihypertensive medication, for example
angiotensin-converting enzyme (ACE) inhibitors,
Angiotensin-II-receptor blocker (ARB), aldosteron antagonists, beta
blockers versus diuretics and Calcium antagonists. Accordingly, the
administration of angiotensin-converting enzyme (ACE) inhibitors,
Angiotensin-II-receptor blocker (ARB), and/or aldosteron
antagonists are, in some instances, recommended, if early
functional and/or structural abnormalities of the heart preceding
heart failure are diagnosed.
[0263] In a further embodiment of the present disclosure, the
supplementary/complementary methods as laid out beforehand can be
used for the methods of deciding on the treatment of a subject as
referred to above, based on the aforementioned steps. These methods
are laid out further below in the present application and allow to
decide which pharmaceutical or pharmaceuticals should be taken by
said subject or which other therapy the subject should undergo.
[0264] The disclosure also encompasses the use of at least one
marker selected from cardiac troponins and variants thereof, and,
optionally, at least one marker selected from: GDF-15 or a variant
thereof and IGFBP7 or a variant thereof, for deciding on the
treatment of functional and/or structural abnormalities of the
heart preceding heart failure in a subject bearing risk factors of
developing heart failure but not showing overt signs of heart
failure.
[0265] In an embodiment of the present disclosure, the cardiac
troponin is selected from troponin T or a variant thereof and
troponin I or a variant thereof, in particular the cardiac troponin
is troponin T or a variant thereof. In one embodiment of the
present disclosure, the following markers are determined in
combination: the cardiac troponin is selected from troponin T or a
variant thereof and troponin I or a variant thereof, in particular
the cardiac troponin is troponin T or a variant thereof; GDF-15 or
a variant thereof; and IGFBP7 or a variant thereof.
[0266] The term "deciding" as used herein means assessing as to
whether a certain medication or treatment should be administered to
a subject having undergone the test according to the present
disclosure.
[0267] Therapy, treatment. The term "therapy" as used in the
context of the present disclosure encompasses life style changes,
diet regimen, interventions on the body as well as administration
of appropriate drugs for the treatment of a subject according to
the present disclosure. The subject suffers from functional and/or
structural abnormalities of the heart preceding left ventricular
hypertrophy and/or heart failure or is about to develop functional
and/or structural abnormalities of the heart preceding heart
failure, and the subject may be classified into ACC/AHA stage A.
According to some embodiments, the subject has arterial
hypertension, systolic and/and or diastolic hypertension, obesity,
metabolic syndrome, and/or diabetes mellitus (e.g., type 2 diabetes
mellitus). In yet another embodiment the individual suffers from
low, moderate, high or very high risk according to the risk chart
of the European Society of Hypertension.
[0268] Pharmaceuticals suitable for the treatment of functional
and/or structural abnormalities of the heart preceding heart
failure are well known in the art, see e.g. Heart Disease, 2008,
8th Edition, Eds. Braunwald, Elsevier Sounders, chapter 24 (in
respect to heart failure) and chapter 41 (in respect to
hypertension). These treatments are a part of the present
disclosure. According to some embodiments, the administration of
such pharmaceuticals aims to treat the symptoms and signs of
functional and/or structural abnormalities of the heart preceding
heart failure caused and which aim to prevent a further progression
of functional and/or structural abnormalities of the heart
preceding heart failure and/or development of heart failure.
Accordingly, also contemplated are pharmaceuticals that aim to
treat functional and/or structural abnormalities of the heart
preceding left ventricular hypertrophy and/or heart failure and/or
left ventricular dysfunction and/or heart failure.
[0269] Life style changes include smoking cessation, moderation of
alcohol consumption, increased physical activity, weight loss,
sodium (salt) restriction, weight management and healthy eating,
daily fish oil, salt restriction.
[0270] The therapy may also include interventions. One exemplary
intervention in the context of the present disclosure is
administration of antihypertensive medication with such as
angiotensin-converting enzyme (ACE) inhibitors,
Angiotensin-II-receptor blocker (ARB), aldosteron antagonists, beta
blockers versus diuretics and Calcium antagonists. In an exemplary
embodiment, the present disclosure provides a method of therapy
adaption a consequence of diagnosis of early functional and/or
structural abnormalities of the heart preceding heart failure
and/or in particular even preceding LVH. The therapeutic
consequence is a change of antihypertensive medication for example
with angiotensin-converting enzyme (ACE) inhibitors,
Angiotensin-II-receptor blocker (ARB), aldosteron antagonists, beta
blockers versus diuretics and Calcium antagonists.
[0271] When a level of a cardiac troponin or variants thereof, in
particular Troponin T or a variant thereof, indicates that the
subject has functional and/or structural abnormalities of the heart
preceding left ventricular hypertrophy and/or preceding heart
failure, one or more of the following drugs should be administered:
[0272] diuretics like loop diuretics, thiazide and thiazide-like
diuretics, K-sparing diuretics, type I mineralocorticoid receptor
antagonists, antialdosterone, carbonic anhydrase inhibitors,
vasopressure antagonists; [0273] Beta blockers like proprenolol,
metoprolol, bisoprolol, carvedilol, bucindolol, nebivolol; [0274]
calcium antagonists like dihydropyridines, verapamil, diltiazem;
[0275] adrenergic agonists, like dobutamine, dopamine, epinephrine,
isoprotenerol, norepinephrine, phenylephrine; [0276] positive
inotropic agents, like digoxin, digitoxin; [0277] ACE inhibitors
like Enalapril, Captopril, Ramipril, Trandolapril; [0278]
angiotensin receptor antagonists like Losartan, Valsartan,
Irbesartan, Candesartan, Telmisartan, Eprosartan; [0279]
aldosterone antagonists like Eplerone, Spironolactone, Canrenone,
Mexrenone, Prorenone; [0280] statines, in particular Atorvastatin,
Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin, Simvastatin;
[0281] hydazaline and isosorbide dinitrate.
[0282] When a level of a cardiac troponin or a variant thereof, for
example troponin T or a variant thereof, indicates that the subject
suffers from early stage functional and/or structural abnormalities
of the heart preceding heart failure (e.g., early stage B) and/or
does not show LVH and/or diastolic dysfunction without LVH, one or
more of the following drugs should be administered: [0283] Beta
blockers like proprenolol, metoprolol, bisoprolol, carvedilol,
bucindolol, nebivolol; [0284] adrenergic agonists, like dobutamine,
dopamine, epinephrine, isoprotenerol, norepinephrine,
phenylephrine; [0285] aldosterone antagonists like Eplerone,
Spironolactone, Canrenone, Mexrenone, Prorenone.
[0286] Exemplary therapeutics according to some embodiments
include: [0287] ACE inhibitors like Enalapril, Captopril, Ramipril,
Trandolapril; and [0288] angiotensin receptor antagonists like
Losartan, Valsartan, Irbesartan, Candesartan, Telmisartan,
Eprosartan.
[0289] Treatment monitoring. Furthermore, the present disclosure
provides a method of monitoring treatment of functional and/or
structural abnormalities of the heart preceding heart failure in a
subject, based on the comparison of the concentrations of at least
one cardiac troponin or a variant thereof and repeatedly
determined, and optionally of one or more other markers of heart
failure and repeatedly determined, to the concentration of this or
these marker(s) in a control sample.
[0290] The method of the disclosure may comprise the following
steps: [0291] a) repeatedly determining, within given time
intervals, the concentration of at least one cardiac troponin or a
variant thereof, [0292] b) optionally repeatedly measuring in the
sample the concentration of one or more other marker(s) of heart
failure, and [0293] c) comparing the thus determined concentration
of the said markers as determined in step a) to its concentration
in a control sample, and [0294] d) assessing, based on the
differences in the determined concentrations in one or more of the
above-cited markers, whether the subject has undergone a change in
its pathophysiological state.
[0295] According to some embodiments, the assessment is carried out
by comparing the thus determined concentration of the said markers
as determined in step a) and optionally step b) to its
concentration in a control sample
[0296] The present disclosure therefore provides a method of
monitoring treatment of functional and/or structural abnormalities
of the heart preceding heart failure in a subject, the method
comprising the steps of: [0297] a) determining the concentration of
at least one cardiac troponin or a variant thereof, [0298] b)
optionally measuring in the sample the concentration of one or more
other marker(s) of heart failure, and [0299] c) assessing whether
the subject has undergone a change in its pathophysiological state
by comparing the thus determined concentration of the said markers
as determined in step a) to its concentration in a control
sample.
[0300] According to some embodiments of the present disclosure, the
determination of the cardiac troponin and, optionally, the one or
more other markers of heart failure is carried out repeatedly, i.e.
at least 2 times, and, in some cases, within a given time interval
or time intervals.
[0301] In general, the subject does not suffer from heart failure,
i.e. the patient has not experienced permanent structural or
functional damages to his myocardium. Preferably, the subject bears
risk factors for heart failure. These are known to the person
skilled in the art and include e.g. hypertension and diabetes. Also
in some cases, the subject does not show overt signs and/or
symptoms of heart failure.
[0302] The concentration cited in step b) may be the concentration
cited in the present application in respect to the therapy decision
beforehand, or may be the concentrations determined before the
therapy was initiated, or both.
[0303] In general, prior to carrying out the monitoring method of
some embodiments of the present disclosure, the method of deciding
on the therapy of treating left ventricular hypertrophy is carried
out.
[0304] Therapy adaptation. In a further embodiment of the present
disclosure provides a method of therapy adaption a consequence of
predicting the risk of heart failure in a subject with diagnosed
functional and/or structural abnormalities of the heart preceding
heart failure, in particular when LVH is not apparent. In case of
risk of heart failure, the therapeutic consequence is a change of
antihypertensive medication to, for example, angiotensin-converting
enzyme (ACE) inhibitors, Angiotensin-II-receptor blocker (ARB),
aldosteron antagonists, beta blockers versus diuretics and Calcium
antagonists. The methods of the present disclosure provide
antihypertensive therapy adaption of subjects with stage A and/or
early stage B HF as a consequence of diagnosis of structural
changes preceding left ventricular hypertrophy and/or heart failure
to, for example, angiotensin-converting enzyme (ACE) inhibitors,
Angiotensin-II-receptor blocker (ARB), aldosteron antagonists, beta
blockers versus diuretics and Calcium antagonists. Advantageously
further progression to left ventricular hypertrophy and/or heart
failure may be prevented.
[0305] Determining the concentration of a cardiac troponin or a
variant thereof and, as the case may be, GDF-15 or a variant
thereof, or IGFBP7 or a variant thereof, or any other peptide or
polypeptide referred to in this specification relates to measuring
the concentration or concentration, either semi-quantitatively or
quantitatively. Measuring can be done directly or indirectly.
Direct measuring relates to measuring the concentration or
concentration of the peptide or polypeptide based on a signal which
is obtained from the peptide or polypeptide itself and the
intensity of which directly correlates with the number of molecules
of the peptide present in the sample. Such a signal--sometimes
referred to herein as intensity signal may be obtained, e.g., by
measuring an intensity value of a specific physical or chemical
property of the peptide or polypeptide. Indirect measuring includes
measuring of a signal obtained from a secondary component (i.e. a
component not being the peptide or polypeptide itself) or a
biological read out system, e.g., measurable cellular responses,
ligands, labels, or enzymatic reaction products.
[0306] In a further embodiment of the present disclosure, there are
provided methods of therapy monitoring and therapy adaptation in a
subject receiving administration of a medicament selected from ACE
inhibitors, angiotensin receptor blockers and aldosterone
antagonists, or any combination of the aforecited documents and, as
the case may be, in addition to any further medicament or
combination of medicaments known for the treatment of the
hereinafter cited diseases. The method according to this embodiment
of the present disclosure, in particular, permits to decide on the
administration of aldosterone antagonists, optionally in addition
to ACE inhibitors and angiotensin receptor blockers and, as the
case may be, in addition to any further medicament known for the
treatment of heart failure and/or structural and/or functional
abnormalities of the heart preceding heart failure.
[0307] In one embodiment, the subject has heart failure, in
particular the subject is classified into stage C of the ACC/AHA
system. In a further embodiment, the individual suffers from
structural and/or functional abnormalities of the heart preceding
heart failure.
[0308] Currently, it is recommended to treat patients at risk of
heart failure with ACE inhibitors and/or angiotensin receptor
blockers. This includes patients classified into stages A and B
according to the ACC/AHA guidelines.
[0309] Starting from stage C (which includes patients with
structural heart disease having prior or current symptoms of heart
disease) diuretics are recommended which include aldosterone
antagonists in selected patients according to the ACC/AHA
guidelines. Selected patients include those with moderate to severe
heart failure and evidence of recent decompensation (see ACC/AHA
guidelines).
[0310] It is appreciated that the effect of ACE inhibitors as well
as of angiotensin receptor blockers is affected by functional
polymorphisms (see McNamara, Heart Failure Clin 6 (2010), p 35-43,
in particular Table 1). It has been shown that the prevalence of
aldosterone escape on ACE inhibitors is greatest in the ACE DD
genotype (Mc Namara et al, p. 39), supporting the rationale for the
use of aldosterone antagonists.
[0311] Collagen formation in heart tissue is preceded by
inflammation. It is known that inflammation is present in heart
failure patients through activation of the
renin-angiotension-aldosterone (RAAS) system, supporting the use of
aldosterone antagonists in heart failure. Previously it has been
shown that the aldosterone antagonist eplerone reduces collagen
formation in heart failure patients as indicated by PIIINP levels
(see G. Mak et al, JACC vol 54, no 18, 2009, p 1674-1682, in
particular FIG. 2). This is further supported by ongoing studies to
test the use of aldosterone antagonists in NYHA class II patients
(Mc Murray NEJM 362, 228-238, 2010, in particular p 236, "Areas of
uncertainty"). This is however consistent with a recent review
indicating that aldosterone promotes collagen synthesis in the
heart and promotes maladaptive cardiac remodelling (KIM Y. S.,
Current Treatment Options in Cardiovascular Medicine 11, 455-466,
2009, in particular p. 462, "ARAs").
[0312] It was found by the present inventors that cardiac troponins
and variants thereof, including troponin T or a variant thereof or
troponin I or a variant thereof, in particular troponin T or a
variant thereof, and GDF-15 or a variant thereof and, optionally, a
natriuretic peptide selected from ANP type and BNP type natriuretic
peptides and variants thereof, including BNP or a variant thereof
or NT-proBNP or a variant thereof, in particular NT-proBNP or a
variant thereof, give relevant information on the efficacy of
treatment of the aforementioned subjects. On the one hand, these
subjects are those having heart failure, in particular being
classified into stage C of the ACC/AHA system. On the other hand,
the subjects may have risk factors of suffering from heart failure
and may be classified into stage A of the ACC/AHA classification,
or suffer from structural and/or functional abnormalities of the
heart preceding heart failure and may be classified into stage B of
the ACC/AHA classification.
[0313] In particular, the amounts of GDF-15, NT-proBNP and Troponin
T were determined in 97 patients with overt heart failure. All
patients were on beta blocker as well as on ACE inhibitor therapy,
59 patients were on aldosterone antagonists, 38 did not receive
aldosterone antagonists After the determination of the amounts of
the aforementioned markers, the ratio of NT-pro BNP and GDF 15 and
the ratio of Troponin T and GDF-15 was formed. Interestingly, it
was found that the ratios in the group of aldosterone antagonist
group were higher than in the group of patients not treated with
aldosterone antagonists. Therefore, the determination of the GDF-15
in combination with a natriuretic peptide or a cardiac Troponin
shall allow for making decisions on the therapy adaption in
patients treated with an ACE inhibitor, an angiotensin receptor
antagonist, or aldosterone antagonists (or combinations thereof).
In particular, said determination shall allow for making decisions
on the therapy adaption in patients treated with an ACE inhibitor.
The aforementioned medicaments, in particular ACE inhibitors,
sometimes become less effective resulting in an increased level of
inflammation. In this case, a therapy adaptation with aldosterone
antagonists as described herein below would be useful since
aldosterone antagonists allow for reducing the level of
inflammation. The methods described herein below allow for
identifying subjects which may benefit from a therapy
adaptation.
[0314] While ACE inhibitors and angiotension receptor blockers
(ARBs) have been shown to be effective in large randomized trials
there is currently no method available to diagnose the
effectiveness of these drugs in the individual patient. This is in
contrast to the application of these drugs in patients with kidney
disease where the decrease of urinary albumin can be used to verify
treatment success. Thus the method described offers for the first
time a method for the diagnosis of treatment failure and provides
guidance for improved treatment using aldosterone inhibitors or in
the future drugs that inhibit synthesis of aldosterone.
[0315] In one embodiment of the disclosure, a medication which has
been initiated in a subject according to the disclosure is
monitored (i.e. it is assessed whether the medication is
effective). In a further embodiment of the disclosure, a decision
on the adaptation of the medication is made, for example, in
accordance with the results of the monitoring of the medication. In
an exemplary embodiment, it is decided if administration of an
aldosterone antagonists is appropriate. It may also be conceived to
administrate one or more aldosterone synthetase inhibitors, see
Roumen L. et al J Medical Chemistry 2010, 53 1712-25.
[0316] The present disclosure therefore furthermore provides a
method of monitoring a medication which has been initiated in a
subject suffering from heart failure or stages preceding left
ventricular hypertrophy and/or preceding heart failure including
risk factors for heart failure, based on the comparison of the
concentrations of at least on cardiac troponin or a variant
thereof, and optionally of one or more other markers of heart
failure, to the concentration of this or these marker(s) in a
control sample.
[0317] The method of the disclosure may comprise the following
steps: a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof; b) measuring in a sample the concentration of GDF-15 or a
variant thereof, c) monitoring the medication by comparing the thus
determined concentrations with a reference amount, e.g. in a
control sample. According to some embodiments, monitoring is
carried out by comparing the determined concentrations with a
reference amount.
[0318] Accordingly, the present disclosure provides a method of
monitoring a medication to which a subject suffering from heart
failure or stages preceding left ventricular hypertrophy and/or
heart failure including risk factors for heart failure is
subjected, the method comprising the steps of: [0319] a) measuring
in a sample obtained from the subject the concentration of at least
one cardiac troponin or a variant thereof and/or a natriuretic
peptide or a variant thereof, [0320] b) measuring in a sample the
concentration of GDF-15 or a variant thereof, [0321] c) monitoring
the medication by comparing the thus determined concentrations with
a reference amount.
[0322] The present disclosure furthermore provides a method of
decision on the adaptation of a medication which has been initiated
in a subject suffering from heart failure or stages preceding heart
failure including risk factors for heart failure, based on the
comparison of the concentrations of at least on cardiac troponin or
a variant thereof, and optionally of one or more other markers of
heart failure, to the concentration of this or these marker(s) in a
control sample.
[0323] The method of the disclosure may comprise the following
steps: a) repeatedly measuring in a sample obtained from the
subject the concentrations of at least one cardiac troponin or a
variant thereof; b) repeatedly measuring in a sample the
concentration of GDF-15 or a variant thereof, c) deciding on the
adaptation of the medication by comparing the thus determined
concentrations with a reference amount. According to some
embodiments, the decision on adaptation is carried out by comparing
the determined concentrations with a reference amount.
[0324] The present disclosure therefore also provides a method of
deciding on the adaptation of a medication in a subject subjected
to said medication and suffering from heart failure or stages
preceding heart failure including risk factors for heart failure,
the method comprising the steps of: [0325] a) measuring in a sample
obtained from the subject the concentrations of at least one
cardiac troponin or a variant thereof and/or a natriuretic peptide
or a variant thereof, [0326] b) measuring in a sample the
concentration of GDF-15 or a variant thereof, and [0327] c)
deciding on the adaptation of the medication by comparing the thus
determined concentrations with a reference amount.
[0328] According to some embodiments of the present disclosure, the
determination of the cardiac troponin and, optionally, the one or
more other markers of heart failure is carried out repeatedly, i.e.
at least 2 times, and in some cases within a given time interval or
time intervals.
[0329] A definition of the term "subject" has been given elsewhere
herein. The definition applies accordingly. According to some
embodiments, the subject in the context of the method of deciding
on the adaptation of a medication and the subject in the context of
the method of monitoring a medication (both methods based on the
determination of the amount of GDF-15 in combination with a
natriuretic peptide and a cardiac Troponin), according to some
embodiments may not have exhibited and acute coronary syndrome
within at least 2 weeks, or, even within at least 4 week before the
sample for carrying out the method has been obtained. Also in some
embodiments, the subject does not suffer from acute inflammation,
in particular from the systemic inflammatory response syndrome
(SIRS), at the time at which the sample for carrying out the method
has been obtained.
[0330] According to some embodiments, the medication is selected
from ACE inhibitors, angiotension receptor blockers and aldosterone
antagonists. In particular, the medication is an ACE inhibitor.
[0331] Examples for these classes of drugs are the following:
[0332] ACE inhibitors: Enalapril, Captopril, Ramipril,
Trandolapril; Enalapril [0333] angiotensin receptor blockers:
Losartan, Valsartan, Irbesartan, Candesartan, Telmisartan,
Eprosartan; Losartan [0334] aldosterone antagonists: Eplerenone,
Spironolactone, Canrenone, Mexrenone, Prorenone, Spironolactone,
Eplerenone.
[0335] As described above the recommendation of ACE inhibitors in
stages A and B suggests the need for antiinflammatory treatment,
however because of polymorphisms this appears not to be effective
in all cases. Aldosterone antagonists are considered to be useful
also in patients belonging to stages A and B of the ACC/AHA
classification, for example in cases where ACE inhibitors and
angiotensin receptor blockers are not effective.
[0336] Lack of effectiveness of ACE inhibitors and angiotensin
receptor blockers can be identified by the present method of the
disclosure. This applies, on the one hand, for subjects not
suffering from heart failure, but having risk factors of developing
heart failure, subjects classified in stage A; on the other hand,
the method applies to subjects suffering from functional and/or
structural abnormalities of the heart preceding heart failure,
subjects classified in stage B. The method of the present
disclosure also lends itself for subjects having non reversible
structural damage of the heart (i.e. heart failure), subjects
classified in stage C.
[0337] In the context of the present disclosure, effectiveness of
treatment with a medicament from the group ACE inhibitors,
angiotensin receptor blockers and aldosterone antagonists is
assessed by the concentrations of a cardiac troponin and variants
thereof, including troponin T or a variant thereof or troponin I or
a variant thereof, in connection with the concentrations of GDF-15
or a variant thereof. In a further embodiment, effectiveness of
treatment is assessed by the concentrations of a natriuretic
peptide, including BNP or NT-proBNP, in connection with the
concentrations of GDF-15.
[0338] As clear from the foregoing, increased concentrations of a
cardiac troponin in a subject indicate that the subject either
suffers from functional and/or structural abnormalities of the
heart preceding heart failure, or is already suffering from heart
failure. Increased concentrations of a cardiac troponin may also
indicate that the subject suffers from coronary artery disease; as
known to the person skilled in the art, here the concentrations of
a cardiac troponin may be increased in respect to healthy
individuals.
[0339] Increased concentrations of a natriuretic peptide in a
subject indicate that the subject either suffers from functional
and/or structural abnormalities of the heart preceding heart
failure, or is already suffering from heart failure. Increased
concentrations of a natriuretic peptide may also indicate that the
subject suffers from coronary artery disease; as known to the
person skilled in the art, here the concentrations of a natriuretic
peptide may be increased in respect to healthy individuals.
[0340] It is also clear from the foregoing that an increased
concentration of GDF-15 in a subject is not only indicative of
heart failure, but also indicates inflammatory processes occurring
in the myocardium of the individual. Accordingly, if the
concentration of GDF-15 is not increased or only slightly increased
in respect to healthy individuals, this is indicative for no or a
low number of inflammatory processes occurring in the myocardium.
On the contrary, increased or highly increased concentrations of
GDF-15 or a variant thereof in a subject show the occurrence of
inflammatory processes in the individual's myocardium.
[0341] The person skilled in the art is able to conclude the
information necessary for the therapy monitoring and/or therapy
adaptation from the respective values of the cardiac troponin or a
variant thereof and concentrations of GDF-15 and variants thereof.
For example, a only slightly increased concentration (in respect to
healthy individuals) of a cardiac troponin or a variant thereof,
for example troponin I or a variant thereof or troponin I or a
variant thereof, in connection with an increased or even highly
increased concentration of GDF-15 or a variant thereof indicates
that the subject does not suffer from heart failure, but that a
considerable number of inflammatory processes are ongoing in his
myocardium, pointing to the danger of development of heart failure
and that medication is not effective, with an adaptation being
recommended (for an explanation of the therapy adaptation, please
see elsewhere herein). Accordingly, an increased level (or highly
increased level) of GDF-15 in combination with a slightly increased
level of a cardiac troponin indicates that the therapy, in
particular the therapy with an ACE inhibitor, shall be adapted.
[0342] On the other hand, a highly increased concentration (in
respect to healthy individuals) of a cardiac troponin, for example
troponin I or troponin I, or a variant thereof respectively, in
connection with an only slightly increased concentration of GDF-15
or a variant thereof indicates that the subject suffers from heart
failure, but that inflammatory processes are moderate and that
medication is effective and an adaptation is not necessary.
Accordingly, a highly increased level of a cardiac Troponin in
combination with a slightly increased level of GDF-15 indicates
that the therapy, in particular the therapy with an ACE inhibitor,
that an adaption of the therapy is not necessary, and, thus, that
the therapy can be continued.
[0343] The person skilled in the art is aware that various
intermediate constellations of the concentrations of the
above-cited markers exist, indicating various degrees of efficacy
of medicament administration.
[0344] In an exemplary embodiment of the instant embodiment of the
present disclosure, the ratio cardiac troponin/GDF 15 is formed,
with the cardiac troponin being troponin T or troponin I, for
example. By this, often a more profound information in respect to
the treatment of the respective subject can be obtained. In
general, a high ratio cardiac troponin/GDF-15 is often indicative
of an appropriate medication suppressing inflammatory processes.
Accordingly, a high ratio of the amount of a cardiac troponin to
the amount of GDF-15, may indicate that no adaption of the therapy
is necessary, and, thus, that the therapy can be continued.
Accordingly, a low ratio of the amount of a cardiac troponin to the
amount of GDF-15 indicates that the therapy should be adapted.
[0345] In an exemplary embodiment of the aforementioned method the
ratio of the amount of a cardiac troponin to the amount of GDF-15
is formed, and compared to a reference ratio of the amount of a
cardiac troponin to the amount of GDF-15. According to some
embodiments, the reference ratio is derived from a subject for whom
no therapy adaptation is necessary, or from a subject for whom the
therapy shall be adapted (and, thus, from a subject who will
benefit from therapy adaptation).
[0346] Preferably, an increased ratio of the amount of a cardiac
troponin to the amount of GDF-15 in the sample from the subject to
be tested as compared to the reference ratio indicates that no
adaption of the therapy is necessary, and, thus, that the therapy
can be continued (and thus, that the therapy shall not be changed),
whereas a decreased ratio of the amount of a cardiac troponin to
the amount of GDF-15 in the sample from the subject to be tested as
compared to the reference ratio indicates that the therapy shall be
adapted. Exemplary reference ratios are mentioned herein below.
[0347] In an exemplary embodiment of the present disclosure, the
above mentioned ratio cardiac troponin/GDF 15 is used in connection
with the individual concentrations. In general, a ratio troponin
T/GDF-15 of .gtoreq. (equal to or higher than) about 0.01, such as
about 0.017, is indicative that the medication is appropriate and
should not be changed. On the contrary, a ratio troponin T/GDF-15
of < (lower than) about 0.01, such as about 0.005 is indicative
that the medication is not appropriate and should be adapted.
[0348] In a further embodiment of the present disclosure, the ratio
natriuretic peptide/GDF-15 is formed. The natriuretic peptide may
be a BNP type or an ANP type natriuretic peptide, or BNP or
NT-proBNP.
[0349] According to some embodiments of the aforementioned method
the ratio of the amount of a natriuretic peptide to the amount of
GDF-15 is formed, and compared to a reference ratio of the amount
of a natriuretic peptide to the amount of GDF-15. According to some
embodiments, the reference ratio is derived from a subject for
which no therapy adaptation is necessary, or from a subject for
which the therapy shall be adapted (and, thus, a subject who will
benefit from therapy adaptation).
[0350] According to some embodiments, an increased ratio of the
amount of a natriuretic peptide to the amount of GDF-15 in the
sample from the subject to be tested as compared to the reference
ratio indicates that no an adaption of the therapy is necessary,
and, thus, that the therapy can be continued (and thus, shall not
be changed), whereas a decreased ratio of the amount of a
natriuretic peptide to the amount of GDF-15 in the sample from the
subject to be tested as compared to the reference ratio indicates
that the therapy shall be adapted. Exemplary reference ratios are
mentioned herein below.
[0351] In general, a ratio NT-proBNP/GDF-15 of .gtoreq. (equal to
or higher than) about 0.8, for example about 1.9, is indicative
that the medication is appropriate and should not be changed. On
the contrary, a ratio NT-proBNP/GDF-15 of < (lower than) about
0.7, for example about 0.4 is indicative that the medication is not
appropriate and should be adapted.
[0352] In the context of the method of monitoring a medication in a
subject subjected to said medication and suffering from heart
failure or stages preceding heart failure including risk factors
for heart failure, at least in some cases, the following
applies:
[0353] According to some embodiments, the ratio cardiac
troponin/GDF 15 is formed, with the cardiac troponin being
preferably troponin T or troponin I. By this, often a more profound
information in respect to the treatment of the respective subject
can be obtained. In general, a high ratio cardiac troponin/GDF-15
is often indicative of an appropriate medication suppressing
inflammatory processes. Accordingly, a high ratio of the amount of
a cardiac troponin to the amount of GDF-15, indicates that the
therapy is appropriate, and, thus, that the therapy can be
continued. Accordingly, a low ratio of the amount of a cardiac
troponin to the amount of GDF-15 indicates that the therapy is not
appropriate.
[0354] According to some embodiments of the aforementioned method
the ratio of the amount of a cardiac troponin to the amount of
GDF-15 is formed, and compared to a reference ratio of the amount
of a cardiac troponin to the amount of GDF-15. In some cases, the
reference ratio is derived from a subject for whom the therapy is
appropriate, or from a subject for whom the therapy is not
appropriate.
[0355] According to some embodiments, an increased ratio of the
amount of a cardiac troponin to the amount of GDF-15 in the sample
from the subject to be tested as compared to the reference ratio
indicates that the therapy is appropriate (and thus, that therapy
shall not be changed), whereas a decreased ratio of the amount of a
cardiac troponin to the amount of GDF-15 in the sample from the
subject to be tested as compared to the reference ratio indicates
that the therapy is not appropriate. Exemplary reference ratios are
mentioned herein below.
[0356] According to some embodiments of the present disclosure, the
above mentioned ratio cardiac troponin/GDF 15 is used in connection
with the individual concentrations. In general, a ratio troponin
T/GDF-15 of equal to or higher than about 0.01, for example about
0.017, is indicative that the medication is appropriate. On the
contrary, a ratio troponin T/GDF-15 of < (lower than) about
0.01, for example about 0.005 is indicative that the medication is
not appropriate.
[0357] In a further embodiment of the present disclosure, the ratio
natriuretic peptide/GDF-15 is formed. The natriuretic peptide may
be a BNP type or an ANP type natriuretic peptide, for example
NT-proBNP.
[0358] In a further embodiment of the aforementioned method the
ratio of the amount of a natriuretic peptide to the amount of
GDF-15 is formed, and compared to a reference ratio of the amount
of a natriuretic peptide to the amount of GDF-15. According to some
embodiments, the reference ratio is derived from a subject for whom
the therapy is appropriate, or from a subject for whom the therapy
is not appropriate.
[0359] According to some embodiments, an increased ratio of the
amount of a natriuretic peptide to the amount of GDF-15 in the
sample from the subject to be tested as compared to the reference
ratio indicates that the therapy is appropriate, whereas a
decreased ratio of the amount of a natriuretic peptide to the
amount of GDF-15 in the sample from the subject to be tested as
compared to the reference ratio indicates that the therapy is not
appropriate. Exemplary reference ratios are mentioned herein
below.
[0360] In general, a ratio NT-proBNP/GDF-15 of equal to or higher
than about 0.8, for example about 1.9, is indicative that the
medication is appropriate. On the contrary, a ratio
NT-proBNP/GDF-15 of < (lower than) about 0.7, for example about
0.4 is indicative that the medication is not appropriate.
[0361] It is to be understood that the subjects of the present
disclosure (suffering from either heart failure, such as classified
stage C of the ACC/AHA classification; or having risk factors for
heart failure or suffering from functional and/or structural
abnormalities of the heart preceding heart failure, such as
classified stage A or B of the ACC/AHA classification) already
receive medication for the treatment of the aforementioned states,
in general a medication selected from ACE inhibitors, angiotensin
receptor blockers and aldosterone antagonists. In an embodiment,
the subject does not receive administration of an aldosterone
antagonist.
[0362] In the decision on the adaptation of the medication, an
exemplary embodiment is the decision on the administration of an
aldosterone antagonist, or the decision on the augmentation of the
concentration of the aldosterone antagonist, or the decision on the
administration of a different or a further aldosterone
antagonist.
[0363] Accordingly, the therapy adaptation may be selected from i)
the administration of an aldosterone antagonist, ii) the
augmentation of the concentration (in particular the dosage) of the
aldosterone antagonist, and iii) the administration of a different
or a further aldosterone antagonist. According to some embodiments,
i) is recommended if the subject did not receive aldosterone
antagonists prior to carrying out the method (i.e. before the
sample has been obtained). According to some embodiments, ii) or
iii) is recommended if the subject did receive aldosterone
antagonists prior to carrying out the method (i.e. before the
sample has been obtained).
[0364] In case the concentrations of GDF-15 or a variant thereof in
the individual show that inflammatory processes are predominant, in
particular in consideration of the concentrations of a cardiac
troponin in the individual showing heart failure or stages
preceding heart failure, the medication should be adapted.
According to some embodiments, administration of an aldosterone
antagonist should be initiated.
[0365] In case the concentrations of a cardiac troponin or a
variant thereof in the individual show that the individual suffers
from heart failure and stages preceding heart failure, in
particular in consideration of the concentrations of GDF-15 or a
variant thereof in the individual showing inflammatory processes or
not, the medication should be adapted if the GDF-15 concentration
shows that inflammatory processes are predominant, and the
medication should not be adapted if GDF-15 concentrations are not
increased or only slightly increased in respect to healthy
individuals, indicating that inflammatory processes are not
existent or not predominant.
[0366] Collagen synthesis in the heart is believed to be a reason
for diastolic dysfunction, as the left ventricle becomes stiffer as
a consequence of collagen deposition between the cells. An impaired
filling capacity results. Therefore, aldosterone antagonists appear
to be in particular appropriate for treating individuals who are at
risk of suffering from diastolic dysfunction, or who are about to
develop diastolic dysfunction, or who suffer from diastolic
dysfunction which may worsen.
[0367] In the context of the present embodiment of the present
disclosure, the terms "decreased" and "increased" refer to the
average values in a healthy subject. These values are known to the
person skilled in the art and are as follows: about 2.0 pg/mL, or
about 3 pg/ml for troponin T (or 0.0 pg/mL taking into account the
test's sensitivity of about 2.0); about 680 pg/ml, about 580 pg/mL,
about 500 pg/mL for GDF-15; about 68 pg/ml, about 37 pg/mL, about
18 pg/mL for NT-proBNP.
[0368] As known to the person skilled in the art mean average
values of NT-ProBNP in healthy subjects increase with age (e.g. 37
pg/mL at age 18-44, 72 pg/ml at age 55-64, 107 pg/ml at age 65-74,
211 pg/ml at age above 75). The person skilled in the art considers
this when assessing whether the amount of natriuretic peptide is
increased. Thus, whether an amount of a natriuretic peptide is
increased, e.g. by at least 20% in respect to the amount in a
sample from a healthy individual, can be determined by the skilled
person without further ado.
[0369] The terms "decreased" or "increased" as used in the context
of the present disclosure denote in case of GDF-15 an increase or
decrease of at least 10%, at least 20% in respect to healthy
individuals; in case of troponin T and NT-proBNP, the terms
"decreased" or "increased" as used in the context of the present
disclosure denote an increase or decrease of at least 20%, at least
30%, in respect to healthy individuals. Accordingly, an increase of
at least 20%, at least 30% of a cardiac troponin, of troponin T, in
respect to the amount in a sample from a healthy subject or in
respect to the amount in a sample from a subject bearing risk
factors of heart failure, but not having functional and/or
structural abnormalities preceding heart failure (for example in a
stage A subject) is indicative for the diagnosis of functional
and/or structural abnormalities preceding heart failure and/or
preceding left ventricular hypertrophy. Further embodiments include
an increase of at least 50% of a cardiac troponin, such as of
troponin T, in respect to the aforementioned amounts is indicative
for the diagnosis of functional and/or structural abnormalities
preceding heart failure and/or preceding left ventricular
hypertrophy. According to some embodiments, the risk factors of the
test subject and the reference subject are the same.
[0370] A healthy subject/individual may be a subject not bearing
risk factors of heart failure, in particular a normotensive subject
(see e.g. group 1 in Example 1). According to some embodiments,
said subject is a subject not bearing risk factors of heart failure
and not having functional and structural abnormalities of the heart
preceding heart failure and/or preceding left ventricular
hypertrophy. Is is a further embodiment that the healthy subject
may be a subject bearing risk factors of heart failure, but not
having functional and/or structural abnormalities preceding heart
failure and/or preceding LVH (see e.g. group 2 in Example 1). For
example, the subject bearing risk factors of heart failure, but not
having functional and/or structural abnormalities preceding heart
failure and/or preceding LVH is a stage A subject. If the healthy
subject bears risk factors of heart disease, the subject to be
tested bears the same risk factors.
[0371] According to some embodiments, an amount of a cardiac
troponin in sample from a test subject which is decreased or which
is essentially same as compared to the amount of a cardiac troponin
in a sample from a healthy subject (or from a subject bearing risk
factors of heart failure, but not having functional and/or
structural abnormalities preceding heart failure (in particular in
a stage A subject) indicates that the subject does not suffer from
functional and/or structural abnormalities preceding heart failure
and/or preceding left ventricular hypertrophy.
[0372] Particular reference amounts for troponin T that may serve
as cut-off amount include, for example, 3.3 pg/ml and 3.5 pg/ml. An
exemplary reference amount for troponin I that may serve as cut-off
amount includes 9 pg/ml. An exemplary reference range may be 0.2 up
to 9 pg/ml. An amount of a cardiac troponin in a sample, such as a
serum or plasma sample, from a subject larger than the reference
amount may indicate that the subject suffers from structural or
functional abnormalities of the heart preceding heart failure
and/or preceding left ventricular hypertrophy. An amount of a
cardiac troponin in sample from a subject lower than the reference
amount may indicate that the subject does not suffer from
structural or functional abnormalities of the heart preceding heart
failure and/or preceding left ventricular hypertrophy.
[0373] Particular reference amounts for IGFBP7 that may serve as
cut-off amount include 42.6 pg/ml and 46.2 pg/ml. An exemplary
reference range is 33.3 pg/ml to 46.2 pg/ml.
[0374] The term "natriuretic peptide" comprises Atrial Natriuretic
Peptide (ANP)-type and Brain Natriuretic Peptide (BNP)-type
peptides and variants thereof having the same predictive potential.
Natriuretic peptides according to the present disclosure comprise
ANP-type and BNP-type peptides and variants thereof (see e.g.
Bonow, 1996, Circulation 93: 1946-1950). ANP-type peptides comprise
pre-proANP, proANP, NT-proANP, and ANP. BNP-type peptides comprise
pre-proBNP, proBNP, NT-proBNP, and BNP. The pre-pro peptide (134
amino acids in the case of pre-proBNP) comprises a short signal
peptide, which is enzymatically cleaved off to release the pro
peptide (108 amino acids in the case of proBNP). The pro peptide is
further cleaved into an N-terminal pro peptide (NT-pro peptide, 76
amino acids in case of NT-proBNP) and the active hormone (32 amino
acids in the case of BNP, 28 amino acids in the case of ANP).
Natriuretic peptides according to the present disclosure include
NT-proANP, ANP, and NT-proBNP, BNP, and variants thereof. ANP and
BNP are the active hormones and have a shorter half-life than their
respective inactive counterparts, NT-proANP and NT-proBNP. BNP is
metabolized in the blood, whereas NT-proBNP circulates in the blood
as an intact molecule and as such is eliminated renally. The
in-vivo half-life of NT-proBNP is 120 min longer than that of BNP,
which is 20 min (Smith 2000, J Endocrinol. 167: 239-46.).
Preanalytics are more robust with NT-proBNP allowing easy
transportation of the sample to a central laboratory (Mueller 2004,
Clin Chem Lab Med 42: 942-4.). Blood samples can be stored at room
temperature for several days or may be mailed or shipped without
recovery loss. In contrast, storage of BNP for 48 hours at room
temperature or at 4.degree. Celsius leads to a concentration loss
of at least 20% (Mueller loc. cit.; Wu 2004, Clin Chem 50:
867-73.). Therefore, depending on the time-course or properties of
interest, either measurement of the active or the inactive forms of
the natriuretic peptide can be advantageous. Exemplary natriuretic
peptides according to the present disclosure are NT-proBNP or
variants thereof. As briefly discussed above, the human NT-proBNP,
as referred to in accordance with the present disclosure, is a
polypeptide comprising, for example, 76 amino acids in length
corresponding to the N-terminal portion of the human NT-proBNP
molecule. The structure of the human BNP and NT-proBNP has been
described already in detail in the prior art, e.g., WO 02/089657,
WO 02/083913 or Bonow loc. cit. According to some embodiments,
human NT-proBNP as used herein is human NT-proBNP as disclosed in
EP 0 648 228 B1. These prior art documents are herewith
incorporated by reference with respect to the specific sequences of
NT-proBNP and variants thereof disclosed therein. The NT-proBNP
referred to in accordance with the present disclosure further
encompasses allelic and other variants of said specific sequence
for human NT-proBNP discussed above. Specifically, envisaged are
variant polypeptides which are (on the amino acid level) at least
50%, 60%, 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical
to human NT-proBNP, for example over the entire length of human
NT-proBNP. The degree of identity between two amino acid sequences
can be determined by algorithms well known in the art. According to
some embodiments, the degree of identity is to be determined by
comparing two optimally aligned sequences over a comparison window,
where the fragment of amino acid sequence in the comparison window
may comprise additions or deletions (e.g., gaps or overhangs) as
compared to the reference sequence (which does not comprise
additions or deletions) for optimal alignment. The percentage is
calculated by determining the number of positions at which the
identical amino acid residue occurs in both sequences to yield the
number of matched positions, dividing the number of matched
positions by the total number of positions in the window of
comparison and multiplying the result by 100 to yield the
percentage of sequence identity. Optimal alignment of sequences for
comparison may be conducted by the local homology algorithm of
Smith and Waterman Add. APL. Math. 2:482 (1981), by the homology
alignment algorithm of Needleman and Wunsch J. Mol. Biol. 48:443
(1970), by the search for similarity method of Pearson and Lipman
Proc. Natl. Acad. Sci. (USA) 85: 2444 (1988), by computerized
implementations of these algorithms (GAP, BESTFIT, BLAST, PASTA,
and TFASTA in the Wisconsin Genetics Software Package, Genetics
Computer Group (GCG), 575 Science Dr., Madison, Wis.), or by visual
inspection. Given that two sequences have been identified for
comparison, GAP and BESTFIT may be employed to determine their
optimal alignment and, thus, the degree of identity. According to
some embodiments, the default values of 5.00 for gap weight and
0.30 for gap weight length are used. Variants referred to above may
be allelic variants or any other species specific homologs,
paralogs, or orthologs. Substantially similar and also envisaged
are proteolytic degradation products which are still recognized by
the diagnostic means or by ligands directed against the respective
full-length peptide. Also encompassed are variant polypeptides
having amino acid deletions, substitutions, and/or additions
compared to the amino acid sequence of human NT-proBNP as long as
the said polypeptides have NT-proBNP properties. NT-proBNP
properties as referred to herein are immunological and/or
biological properties. According to some embodiments, NT-proBNP
variants have immunological properties (i.e. epitope composition)
comparable to those of human NT-proBNP. Thus, the variants shall be
recognizable by the aforementioned means or ligands used for
determination of the amount of the natriuretic peptides. Biological
and/or immunological NT-proBNP properties can be detected by the
assay described in Karl et al. (Karl 1999, Scand J Clin Lab Invest
230:177-181), Yeo et al. (Yeo 2003, Clinica Chimica Acta
338:107-115). Variants also include posttranslationally modified
peptides such as glycosylated peptides. Further, a variant in
accordance with the present disclosure is also a peptide or
polypeptide which has been modified after collection of the sample,
for example by covalent or non-covalent attachment of a label,
particularly a radioactive or fluorescent label, to the
peptide.
[0375] It is to be understood that the subjects which are in the
context of the present embodiment of the disclosure (namely methods
of therapy monitoring and therapy adaptation in a subject receiving
administration of a medicament selected from ACE inhibitors,
angiotensin receptor blockers and aldosterone antagonists) should
not suffer from diseases which affect the concentrations of the
markers cited in respect to individuals not suffering from the
cardiac abnormalities or diseases which are the subject-matter of
the present disclosure. Accordingly, the subject should be
clinically healthy except for heart failure/functional and/or
structural abnormalities of the heart preceding heart failure, and
for risk factor of suffering from heart failure. Furthermore, the
subject should not suffer from diabetes mellitus, should not have
liver disease, should not be pregnant and should not suffer from
malignancies.
[0376] The person skilled in the art is aware that the
concentrations cited in the present application for the cardiac
troponins (troponin T or a variant thereof and troponin I or a
variant thereof), NT-proBNP or a variant thereof and--to a lesser
extent--for GDF-15 or a variant thereof may not apply for patients
suffering from impaired renal function, for example some patients
suffering from renal failure such as patients suffering from
chronic and end stage renal failure. In an exemplary embodiment of
the present disclosure, patients suffering from impaired renal
function such as renal failure, including chronic and end stage
renal failure are not comprised in (excluded from) the methods of
the present disclosure. In another embodiment, patients with renal
hypertension are not comprised in (excluded from) the methods of
the present disclosure.
[0377] According to some embodiments, the "subject" as used herein
excludes patients suffering from impaired renal function, for
example patients suffering from renal failure, e.g., from chronic
and end stage renal failure and renal hypertension. In this
context, "renal failure" is regarded as an impaired glomerular
filtration rate (GFR) lying below the usual ranges of 60 to 120
ml/min, preferably below 60 ml/min. Chronic renal failure is a
long-standing, progressive deterioration of renal function which
often results in end stage renal failure. End stage renal failure
is diagnosed when the GFR reaches a rate of up to about 30 ml/min.
GFR is determined by the creatinine clearance, which is known to
the person skilled in the art. Subjects with impaired renal
function show higher levels of troponin I and troponin T than those
cited above, due to an impaired clearance of the peptide. The
levels vary with the severity of the renal impairment.
[0378] The severity of renal impairment is divided into various
grades, as displayed below. [0379] 0: .gtoreq.90 ml/min [0380] 1:
.gtoreq.90 ml/min with microalbuminuria [0381] 2: .gtoreq.60-<90
ml/min [0382] 3: .gtoreq.30-<60 ml/min [0383] 4:
.gtoreq.15-<30 ml/min [0384] 5: <15 ml/min (Source: National
Kidney Foundation, as published in: Am J. Kidney Dis 39 suppl 1,
2002; Clinical Practice Guidelines for chronic kidney disease).
[0385] The subject as set forth herein shall be, preferably, about
to leave stage A and about to enter stage B (or shall have entered
early stage B). Accordingly, the subject, preferably, shall have no
history of myocardial infarction, in particular shall have no
history of known myocardial infarction. Thus, the term "subject" as
used herein, according to some embodiments, excludes a subject
having a history of known myocardial infarction. This applies, for
example, to the methods of diagnosing, methods of differentiating,
methods of monitoring a medication, and methods of predicting as
set forth herein.
[0386] A subject who has no history of known myocardial infarction
(MI) in general will not have suffered from myocardial infarction
(in particular from diagnosed myocardial infarction) in the past,
i.e. before the sample to be tested has been obtained. The term
"myocardial infarction" is well known in the art. As used herein,
the term includes ST-elevation MI (STEM) and non-ST-elevated MI
(NSTEMI).
[0387] Also, the term "subject" as used herein may, exclude a
subject who suffers from coronary artery disease. Thus, the subject
to be tested shall not suffer from coronary artery disease. This
applies, in particular, to the methods of diagnosing, methods of
differentiating, methods of monitoring a medication, and methods of
predicting as set forth herein.
[0388] The term "coronary artery disease" (CAD, frequently also
called coronary heart disease (CHD) is known to the person skilled
in the art. The term refers to a condition in which at least one of
the major coronary arteries is narrowed, whereby stenosis of more
than 50% should occur per vessel, for example. A subject not
suffering from CAD, has less than 50% stenosis (and thus less than
50% occlusion) of the major coronary arteries. How to assess the
degree of occlusion of a coronary artery is well known in the art,
for example the degree may be assessed by coronary angiography.
[0389] Moreover, according to some embodiments the subject to be
tested in the context of the methods of the present disclosure does
not have increased levels of a natriuretic peptide. This applies,
for example, to the methods of diagnosing, methods of
differentiating, methods of monitoring a medication, and methods of
predicting as set forth herein. According to some embodiments, the
subject does not have increased levels of a brain natriuretic
peptide. According to some embodiments, the subject does not have
increased levels of a BNP-type natriuretic peptide. According to
some embodiments, the subject does not have increased levels of
NT-proBNP.
[0390] A subject who does not have increased levels of a
natriuretic peptide, for example NT-proBNP, according to some
embodiments may have less than 20% increase of a natriuretic
peptide, in respect to healthy individuals and, according to some
embodiments in respect to the amount in a sample from a healthy
subject bearing risk factors of heart failure, but not having
functional and/or structural abnormalities preceding LVH and/or
heart failure (in particular in a stage A subject)) in respect to
the amount in a sample from a subject bearing the same risk factors
of heart failure and having functional and/or structural
abnormalities preceding LVH and/or preceding heart failure (for
example in an early stage B subject). According to some
embodiments, the subject has a level of NT-proBNP of less than 10%
as compared to the aforementioned levels. According to the
disclosure, the aforementioned levels apply to serum levels.
[0391] The term "sample" refers to a sample of a body fluid, to a
sample of separated cells or to a sample from a tissue or an organ.
Samples of body fluids can be obtained by well known techniques and
include, samples of blood, plasma, serum, urine, samples of blood,
plasma or serum. It is to be understood that the sample depends on
the marker to be determined. Therefore, it is encompassed that the
polypeptides as referred to herein are determined in different
samples. Cardiac troponins or a variant thereof, NT-proBNP or a
variant thereof, GDF 15 or a variant thereof and IGFBP7 or a
variant thereof are, for example, determined in a blood serum or
blood plasma sample.
[0392] In accordance with the present disclosure, determining the
concentration of a peptide or polypeptide can be achieved by all
known means for determining the concentration of a peptide in a
sample (the terms "concentration", "level" and "amount" are used
interchangeably herein). Said means comprise immunoassay devices
and methods which may utilize labeled molecules in various
sandwich, competition, or other assay formats. Said assays will
develop a signal which is indicative for the presence or absence of
the peptide or polypeptide. Moreover, the signal strength can,
according to some embodiments, be correlated directly or indirectly
(e.g. reverse-proportional) to the concentration of polypeptide
present in a sample. Further suitable methods comprise measuring a
physical or chemical property specific for the peptide or
polypeptide such as its precise molecular mass or NMR spectrum.
Said methods comprise, for example, biosensors, optical devices
coupled to immunoassays, biochips, analytical devices such as
mass-spectrometers, NMR-analyzers, or chromatography devices.
Further, methods include micro-plate ELISA-based methods,
fully-automated or robotic immunoassays (available for example on
Elecsys.TM. analyzers), CBA (an enzymatic Cobalt Binding Assay,
available for example on Roche-Hitachi.TM. analyzers), and latex
agglutination assays (available for example on Roche-Hitachi.TM.
analyzers).
[0393] According to some embodiments, determining the concentration
of a peptide or polypeptide comprises the steps of (a) contacting a
cell capable of eliciting a cellular response the intensity of
which is indicative of the concentration of the peptide or
polypeptide with the said peptide or polypeptide for an adequate
period of time, (b) measuring the cellular response. For measuring
cellular responses, the sample or processed sample is, in some
embodiments, added to a cell culture and an internal or external
cellular response is measured. The cellular response may include
the measurable expression of a reporter gene or the secretion of a
substance, e.g. a peptide, polypeptide, or a small molecule. The
expression or substance shall generate an intensity signal which
correlates to the concentration of the peptide or polypeptide.
[0394] Also according to some embodiments, determining the
concentration of a peptide or polypeptide comprises the step of
measuring a specific intensity signal obtainable from the peptide
or polypeptide in the sample. As described above, such a signal may
be the signal intensity observed at an m/z variable specific for
the peptide or polypeptide observed in mass spectra or a NMR
spectrum specific for the peptide or polypeptide.
[0395] Determining the concentration of a peptide or polypeptide
may comprise the steps of (a) contacting the peptide with a
specific ligand, (b) (optionally) removing non-bound ligand, (c)
measuring the concentration of bound ligand. The bound ligand will
generate an intensity signal. Binding according to the present
disclosure includes both covalent and non-covalent binding. A
ligand according to the present disclosure can be any compound,
e.g., a peptide, polypeptide, nucleic acid, or small molecule,
binding to the peptide or polypeptide described herein. Exemplary
ligands include antibodies, nucleic acids, peptides or polypeptides
such as receptors or binding partners for the peptide or
polypeptide and fragments thereof comprising the binding domains
for the peptides, and aptamers, e.g. nucleic acid or peptide
aptamers. Methods to prepare such ligands are well-known in the
art. For example, identification and production of suitable
antibodies or aptamers is also offered by commercial suppliers. The
person skilled in the art is familiar with methods to develop
derivatives of such ligands with higher affinity or specificity.
For example, random mutations can be introduced into the nucleic
acids, peptides or polypeptides. These derivatives can then be
tested for binding according to screening procedures known in the
art, e.g. phage display. Antibodies as referred to herein include
both polyclonal and monoclonal antibodies, as well as fragments
thereof, such as Fv, Fab and F(ab).sub.2 fragments that are capable
of binding antigen or hapten. The present disclosure also includes
single chain antibodies and humanized hybrid antibodies wherein
amino acid sequences of a non-human donor antibody exhibiting a
desired antigen-specificity are combined with sequences of a human
acceptor antibody. The donor sequences will usually include at
least the antigen-binding amino acid residues of the donor but may
comprise other structurally and/or functionally relevant amino acid
residues of the donor antibody as well. Such hybrids can be
prepared by several methods well known in the art. According to
some embodiments, the ligand or agent binds specifically to the
peptide or polypeptide. Specific binding according to the present
disclosure means that the ligand or agent should not bind
substantially to ("cross-react" with) another peptide, polypeptide
or substance present in the sample to be analyzed. According to
some embodiments, the specifically bound peptide or polypeptide
should be bound with at least 3 times higher, at least 10 times
higher and in some cases even at least 50 times higher affinity
than any other relevant peptide or polypeptide. Non-specific
binding may be tolerable, if it can still be distinguished and
measured unequivocally, e.g. according to its size on a Western
Blot, or by its relatively higher abundance in the sample. Binding
of the ligand can be measured by any method known in the art.
According to some embodiments, said method is semi-quantitative or
quantitative. Suitable methods are described in the following.
[0396] First, binding of a ligand may be measured directly, e.g. by
NMR or surface plasmon resonance.
[0397] Second, if the ligand also serves as a substrate of an
enzymatic activity of the peptide or polypeptide of interest, an
enzymatic reaction product may be measured (e.g. the concentration
of a protease can be measured by measuring the concentration of
cleaved substrate, e.g. on a Western Blot). Alternatively, the
ligand may exhibit enzymatic properties itself and the
"ligand/peptide or polypeptide" complex or the ligand which was
bound by the peptide or polypeptide, respectively, may be contacted
with a suitable substrate allowing detection by the generation of
an intensity signal. For measurement of enzymatic reaction
products, preferably the concentration of substrate is saturating.
The substrate may also be labeled with a detectable label prior to
the reaction. Preferably, the sample is contacted with the
substrate for an adequate period of time. An adequate period of
time refers to the time necessary for a detectable, preferably
measurable, concentration of product to be produced. Instead of
measuring the concentration of product, the time necessary for
appearance of a given (e.g. detectable) concentration of product
can be measured.
[0398] Third, the ligand may be coupled covalently or
non-covalently to a label allowing detection and measurement of the
ligand. Labeling may be done by direct or indirect methods. Direct
labeling involves coupling of the label directly (covalently or
non-covalently) to the ligand. Indirect labeling involves binding
(covalently or non-covalently) of a secondary ligand to the first
ligand. The secondary ligand should specifically bind to the first
ligand. Said secondary ligand may be coupled with a suitable label
and/or be the target (receptor) of tertiary ligand binding to the
secondary ligand. The use of secondary, tertiary or even higher
order ligands is often used to increase the signal. Suitable
secondary and higher order ligands may include antibodies,
secondary antibodies, and the well-known streptavidin-biotin system
(Vector Laboratories, Inc.). The ligand or substrate may also be
"tagged" with one or more tags as known in the art. Such tags may
then be targets for higher order ligands. Suitable tags include
biotin, digoxygenin, His-Tag, Glutathion-S-Transferase, FLAG, GFP,
myc-tag, influenza A virus haemagglutinin (HA), maltose binding
protein, and the like. In the case of a peptide or polypeptide, the
tag may be at the N-terminus and/or C-terminus. Suitable labels are
any labels detectable by an appropriate detection method. Typical
labels include gold particles, latex beads, acridan ester, luminol,
ruthenium, enzymatically active labels, radioactive labels,
magnetic labels ("e.g. magnetic beads", including paramagnetic and
superparamagnetic labels), and fluorescent labels. Enzymatically
active labels include e.g. horseradish peroxidase, alkaline
phosphatase, beta-Galactosidase, Luciferase, and derivatives
thereof. Suitable substrates for detection include
di-amino-benzidine (DAB), 3,3'-5,5'-tetramethylbenzidine, NBT-BCIP
(4-nitro blue tetrazolium chloride and
5-bromo-4-chloro-3-indolyl-phosphate, available as ready-made stock
solution from Roche Diagnostics), CDP-Star.TM. (Amersham
Biosciences), ECF.TM. (Amersham Biosciences). A suitable
enzyme-substrate combination may result in a colored reaction
product, fluorescence or chemoluminescence, which can be measured
according to methods known in the art (e.g. using a light-sensitive
film or a suitable camera system). As for measuring the enzymatic
reaction, the criteria given above apply analogously. Typical
fluorescent labels include fluorescent proteins (such as GFP and
its derivatives), Cy3, Cy5, Texas Red, Fluorescein, and the Alexa
dyes (e.g. Alexa 568). Further fluorescent labels are available
e.g. from Molecular Probes (Oregon). Also the use of quantum dots
as fluorescent labels is contemplated. Typical radioactive labels
include .sup.35S, .sup.125I, .sup.32P, .sup.33P and the like. A
radioactive label can be detected by any method known and
appropriate, e.g. a light-sensitive film or a phosphor imager.
Suitable measurement methods according the present disclosure also
include precipitation (particularly immunoprecipitation),
electrochemiluminescence (electro-generated chemiluminescence), RIA
(radioimmunoassay), ELISA (enzyme-linked immunosorbent assay),
sandwich enzyme immune tests, electrochemiluminescence sandwich
immunoassays (ECLIA), dissociation-enhanced lanthanide fluoro
immuno assay (DELFIA), scintillation proximity assay (SPA),
turbidimetry, nephelometry, latex-enhanced turbidimetry or
nephelometry, or solid phase immune tests. Further methods known in
the art (such as gel electrophoresis, 2D gel electrophoresis, SDS
polyacrylamid gel electrophoresis (SDS-PAGE), Western Blotting, and
mass spectrometry), can be used alone or in combination with
labeling or other detection methods as described above.
[0399] The concentration of a peptide or polypeptide may be
determined as follows: (a) contacting a solid support comprising a
ligand for the peptide or polypeptide as specified above with a
sample comprising the peptide or polypeptide and (b) measuring the
concentration peptide or polypeptide which is bound to the support.
The ligand, may be chosen from the group consisting of nucleic
acids, peptides, polypeptides, antibodies and aptamers, and may be
present on a solid support in immobilized form. Materials for
manufacturing solid supports are well known in the art and include,
inter alia, commercially available column materials, polystyrene
beads, latex beads, magnetic beads, colloid metal particles, glass
and/or silicon chips and surfaces, nitrocellulose strips,
membranes, sheets, duracytes, wells and walls of reaction trays,
plastic tubes etc. The ligand or agent may be bound to many
different carriers. Examples of well-known carriers include glass,
polystyrene, polyvinyl chloride, polypropylene, polyethylene,
polycarbonate, dextran, nylon, amyloses, natural and modified
celluloses, polyacrylamides, agaroses, and magnetite. The nature of
the carrier can be either soluble or insoluble for the purposes of
the disclosure. Suitable methods for fixing/immobilizing said
ligand are well known and include, but are not limited to ionic,
hydrophobic, covalent interactions and the like. It is also
contemplated to use "suspension arrays" as arrays according to the
present disclosure (Nolan 2002, Trends Biotechnol. 20(1):9-12). In
such suspension arrays, the carrier, e.g. a microbead or
microsphere, is present in suspension. The array consists of
different microbeads or microspheres, possibly labeled, carrying
different ligands. Methods of producing such arrays, for example
based on solid-phase chemistry and photo-labile protective groups,
are generally known (U.S. Pat. No. 5,744,305).
[0400] The term "concentration" as used herein encompasses the
absolute concentration of a polypeptide or peptide, the relative
concentration or concentration of the said polypeptide or peptide
as well as any value or parameter which correlates thereto or can
be derived therefrom. Such values or parameters comprise intensity
signal values from all specific physical or chemical properties
obtained from the said peptides by direct measurements, e.g.,
intensity values in mass spectra or NMR spectra. Moreover,
encompassed are all values or parameters which are obtained by
indirect measurements specified elsewhere in this description,
e.g., response levels determined from biological read out systems
in response to the peptides or intensity signals obtained from
specifically bound ligands. It is to be understood that values
correlating to the aforementioned concentrations or parameters can
also be obtained by all standard mathematical operations.
[0401] The present disclosure further encompasses a device adapted
for carrying out the methods of the present disclosure, comprising:
[0402] a) means for determining the concentrations of the following
peptides: a cardiac troponin or a variant thereof, for example
troponin T or troponin I or variants thereof; and optionally one or
more of the following means: means for determining the
concentrations of an inflammatory marker, for example GDF-15 or a
variant thereof; and/or means for determining the concentration of
IGFBP7 or a variant thereof; [0403] b) means for comparing the
concentrations determined in step a) with respective concentrations
of said markers in control samples, whereby the methods of the
present disclosure are carried out.
[0404] The device is adapted for carrying out the methods of the
present disclosure. The methods of the present disclosure include
the following: [0405] diagnosing functional and/or structural
abnormalities of the heart preceding heart failure, in a subject
bearing risk factors of developing heart failure and/or respective
stroke and/or respective chronic kidney disease; and/or [0406]
differentiating, in a subject bearing risk factors of developing
heart failure, if the subject only bears risk factors or if the
subject already suffers from functional and/or structural
abnormalities of the heart preceding heart failure; and/or [0407]
predicting the risk of a subject bearing risk factors of developing
heart failure, to suffer from heart failure.
[0408] In general, the subject (i.e. the individual bearing risk
factors and/or suffering from functional and/or structural
abnormalities of the heart preceding heart failure) does not suffer
from heart failure, i.e. the patient has not experienced permanent
structural or functional damages to his myocardium, and he will be
able to fully restore his health, and he is not classified into
stage C or D of the ACC/AHA classification. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also, the subject may not show overt
signs and/or symptoms of heart failure.
[0409] Depending on the results obtainable by the device according
to the disclosure, a decision on the therapy or therapy adaptation
may be taken. The therapy may be adapted by e.g. augmenting or
diminishing the concentrations of the medicaments which are
administrated. Accordingly, the device is also adapted for
monitoring the said therapy.
[0410] The present disclosure also relates to the use of a device
or devices as cited beforehand, for: diagnosing functional and/or
structural abnormalities of the heart preceding heart failure, in a
subject bearing risk factors of developing heart failure; and/or
stroke and/or chronic kidney disease, [0411] differentiating, in a
subject bearing risk factors of developing heart failure, if the
subject only bears risk factors or if the subject already suffers
from functional and/or structural abnormalities of the heart
preceding heart failure; and/or [0412] predicting the risk of a
subject bearing risk factors of developing heart failure, to suffer
from heart failure.
[0413] In general, the subject (i.e. the individual bearing risk
factors and/or suffering from functional and/or structural
abnormalities of the heart preceding heart failure) does not suffer
from heart failure, i.e. the patient has not experienced permanent
structural or functional damages to his myocardium, and he will be
able to fully restore his health, and he is not classified into
stage C or D of the ACC/AHA classification. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also according to some embodiments, the
subject does not show overt signs and/or symptoms of heart
failure.
[0414] Depending on the results obtainable by the use of the device
according to the disclosure, a decision on the therapy or therapy
adaptation may be taken. The therapy may be adapted by e.g.
augmenting or diminishing the concentrations of the medicaments
which are administrated. Accordingly, the device can also be used
for monitoring the said therapy.
[0415] The term "device" as used herein relates to a system of
means comprising at least the aforementioned means operatively
linked to each other as to allow the prediction. Exemplary means
for determining the concentration of a one of the aforementioned
polypeptides as well as means for carrying out the comparison are
disclosed above in connection with the method of the disclosure.
How to link the means in an operating manner will depend on the
type of means included into the device. For example, where means
for automatically determining the concentration of the peptides are
applied, the data obtained by said automatically operating means
can be processed by, e.g., a computer program in order to obtain
the desired results. According to some embodiments, the means are
comprised by a single device in such a case. Said device may
accordingly include an analyzing unit for the measurement of the
concentration of the peptides or polypeptides in an applied sample
and a computer unit for processing the resulting data for the
evaluation. The computer unit, for example, may comprise a database
including the stored reference concentrations or values thereof
recited elsewhere in this specification as well as a
computer-implemented algorithm for carrying out a comparison of the
determined concentrations for the polypeptides with the stored
reference concentrations of the database. Computer-implemented as
used herein refers to a computer-readable program code tangibly
included into the computer unit. Alternatively, where means such as
test stripes are used for determining the concentration of the
peptides or polypeptides, the means for comparison may comprise
control stripes or tables allocating the determined concentration
to a reference concentration. The test strips are, for example,
coupled to a ligand which specifically binds to the peptides or
polypeptides referred to herein. The strip or device, according to
some embodiments, comprises means for detection of the binding of
said peptides or polypeptides to the said ligand. Exemplary means
for detection are disclosed in connection with embodiments relating
to the method of the disclosure above. In such a case, the means
are operatively linked in that the user of the system brings
together the result of the determination of the concentration and
the diagnostic or prognostic value thereof due to the instructions
and interpretations given in a manual. The means may appear as
separate devices in such an embodiment and are, for example,
packaged together as a kit. The person skilled in the art will
realize how to link the means without further ado. Exemplary
devices are those which can be applied without the particular
knowledge of a specialized clinician, e.g., test strips or
electronic devices which merely require loading with a sample. The
results may be given as output of raw data which need
interpretation by the clinician. According to some embodiments, the
output of the device is, however, processed, i.e. evaluated, raw
data the interpretation of which does not require a clinician.
Further, some devices comprise the analyzing units/devices (e.g.,
biosensors, arrays, solid supports coupled to ligands specifically
recognizing the cardiac troponin, IGFBP7 or GDF 15, Plasmon surface
resonance devices, NMR spectrometers, mass-spectrometers etc.)
and/or evaluation units/devices referred to above in accordance
with the method of the disclosure.
[0416] The present disclosure also relates to the use of a device
as cited beforehand, for monitoring the therapy in a subject
diagnosing functional and/or structural abnormalities of the heart
preceding heart failure, in a subject bearing risk factors of
developing heart failure.
[0417] Moreover, the present disclosure relates to a kit adapted
for carrying out the methods of the present disclosure referred to
above comprising: [0418] a) means for determining the
concentrations of the following peptides: a cardiac troponin or a
variant thereof, preferably troponin T or a variant thereof; an
inflammatory marker, preferably GDF-15 or a variant thereof; IGFBP7
or a variant thereof, and [0419] b) means for comparing the
concentrations determined in step a) with respective concentrations
of said markers in control samples, whereby the methods of the
present disclosure are carried out.
[0420] The kit is adapted for carrying out the method of the
present disclosure referred to above. According to some
embodiments, the kit comprises instructions for carrying out the
said method of the present disclosure.
[0421] The methods of the present disclosure include the following:
[0422] diagnosing functional and/or structural abnormalities of the
heart preceding heart failure, in a subject bearing risk factors of
developing heart failure; and/or [0423] differentiating, in a
subject bearing risk factors of developing heart failure, if the
subject only bears risk factors or if the subject already suffers
from functional and/or structural abnormalities of the heart
preceding heart failure; and/or [0424] predicting the risk of a
subject bearing risk factors of developing heart failure, to suffer
from heart failure.
[0425] In general, the subject (i.e. the individual bearing risk
factors and/or suffering from functional and/or structural
abnormalities of the heart preceding heart failure) does not suffer
from heart failure, i.e. the patient has not experienced permanent
structural or functional damages to his myocardium, and he will be
able to fully restore his health, and he is not classified into
stage C or D of the ACC/AHA classification. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also according to some embodiments, the
subject does not show overt signs and/or symptoms of heart
failure.
[0426] Depending on the results obtainable by the kit according to
the disclosure, a decision on the therapy or therapy adaptation may
be taken. The therapy may be adapted by e.g. augmenting or
diminishing the concentrations of the medicaments which are
administrated. Accordingly, the kit is also adapted for monitoring
the said therapy.
[0427] The present disclosure also relates to the use of a kit or
kits as cited beforehand, for: diagnosing functional and/or
structural abnormalities of the heart preceding heart failure, in a
subject bearing risk factors of developing heart failure; and/or
respective of developing stroke, and/or respective of developing
chronic kidney disease, [0428] differentiating, in a subject
bearing risk factors of developing heart failure, if the subject
only bears risk factors or if the subject already suffers from
functional and/or structural abnormalities of the heart preceding
heart failure; and/or [0429] predicting the risk of a subject
bearing risk factors of developing heart failure, to suffer from
heart failure.
[0430] In general, the subject (i.e. the individual bearing risk
factors and/or suffering from functional and/or structural
abnormalities of the heart preceding heart failure) does not suffer
from heart failure, i.e. the patient has not experienced permanent
structural or functional damages to his myocardium, and he will be
able to fully restore his health, and he is not classified into
stage C or D of the ACC/AHA classification. According to some
embodiments, the subject bears risk factors for heart failure.
These are known to the person skilled in the art and include e.g.
hypertension and diabetes. Also according to some embodiments, the
subject does not show overt signs and/or symptoms of heart
failure.
[0431] Depending on the results obtainable by the use of the kit
according to the disclosure, a decision on the therapy or therapy
adaptation may be taken. The therapy may be adapted by e.g.
augmenting or diminishing the concentrations of the medicaments
which are administrated. Accordingly, in some embodiments, the kit
can also be used for monitoring the said therapy.
[0432] The term "kit" as used herein refers to a collection of the
aforementioned means, for example, provided in separately or within
a single container. The container may comprise instructions for
carrying out the method of the present disclosure.
[0433] The present disclosure also relates to uses of the kits,
devices and means, for example, as indicated below:
[0434] Use of a kit or device for determining the concentration of:
a cardiac troponin or a variant thereof, for example Troponin T or
a variant thereof and/or Troponin I or a variant thereof; and, as
the case may be, GDF-15 or a variant thereof; and/or IGFBP7 or a
variant thereof in a sample of a subject; and the use of a means
for determining the concentration of: a cardiac troponin or a
variant thereof, Troponin T or a variant thereof and/or Troponin I
or a variant thereof; and, as the case may be, GDF-15 or a variant
thereof; and/or IGFBP7 or a variant thereof; and the use of a means
for comparing the concentration of a cardiac troponin or a variant
thereof, Troponin T or a variant thereof and/or Troponin I or a
variant thereof; and, as the case may be, GDF-15 or a variant
thereof; and/or IGFBP7 or a variant thereof, to the concentration
of at least one of said markers in a control sample for: [0435]
diagnosing functional and/or structural abnormalities of the heart
preceding heart failure, in a subject bearing risk factors of
developing heart failure; and/or [0436] differentiating, in a
subject bearing risk factors of developing heart failure but not
showing overt signs of heart failure, if the subject only bears
risk factors or if the subject already suffers from functional
and/or structural abnormalities of the heart preceding heart
failure; and/or [0437] predicting the risk of a subject bearing
risk factors of developing heart failure to suffer from heart
failure, [0438] and wherein all uses are based on diagnosing
functional and/or structural abnormalities of the heart preceding
heart failure in a subject bearing risk factors of developing heart
failure.
[0439] The present disclosure also relates to the use of the
following antibodies and means, for example, as indicated
below:
[0440] Use of an antibody to a cardiac troponin or a variant
thereof, for example Troponin T or a variant thereof and/or
Troponin I or a variant thereof; and, as the case may be, an
antibody to GDF-15 or a variant thereof and/or an antibody to
IGFBP7 or a variant thereof, and/or of means for determining the
concentration of a cardiac troponin or a variant thereof, for
example Troponin T or a variant thereof and/or Troponin I or a
variant thereof; and, as the case may be, means for determining the
concentration of GDF-15 or a variant thereof and/or of means for
determining the concentration of IGFBP7 or a variant thereof,
and/or of means for comparing the concentration of a cardiac
troponin or a variant thereof, for example Troponin T or a variant
thereof and/or Troponin I or a variant thereof; and, as the case
may be, the concentrations of GDF-15 or a variant thereof and/or
IGFBP7 or a variant thereof, to the concentration at least one of
the said markers in a control sample for the manufacture of a
diagnostic composition for: [0441] diagnosing functional and/or
structural abnormalities of the heart preceding heart failure, in a
subject bearing risk factors of developing heart failure; and/or
[0442] differentiating, in a subject bearing risk factors of
developing heart failure, if the subject only bears risk factors or
if the subject already suffers from functional and/or structural
abnormalities of the heart preceding heart failure; and/or [0443]
predicting the risk of a subject bearing risk factors of developing
heart failure, to suffer from heart failure; [0444] and wherein all
uses are based on diagnosing functional and/or structural
abnormalities of the heart preceding heart failure in a subject
bearing risk factors of developing heart failure.
[0445] The present disclosure also relates to the use of the
following antibodies and means, for example, as indicated
below:
[0446] Use of an antibody to a cardiac troponin or a variant
thereof, for example Troponin T or a variant thereof and/or
Troponin I or a variant thereof; and, as the case may be, an
antibody to GDF-15 or a variant thereof and/or an antibody to
IGFBP7 or a variant thereof, and/or of means for determining the
concentration of a cardiac troponin or a variant thereof, for
example Troponin T or a variant thereof and/or Troponin I or a
variant thereof; and, as the case may be, means for determining the
concentration of GDF-15 or a variant thereof and/or of means for
determining the concentration of IGFBP7 or a variant thereof,
and/or of means for comparing the concentration of a cardiac
troponin or a variant thereof, for example Troponin T or a variant
thereof and/or Troponin I or a variant thereof; and, as the case
may be, the concentrations of GDF-15 or a variant thereof and/or
IGFBP7 or a variant thereof, to the concentration of at least one
of the said markers in a control sample for: [0447] diagnosing
functional and/or structural abnormalities of the heart preceding
heart failure, in a subject bearing risk factors of developing
heart failure; and/or [0448] differentiating, in a subject bearing
risk factors of developing heart failure, if the subject only bears
risk factors or if the subject already suffers from myocardial
dysfunction and/or structural functional and/or structural
abnormalities of the heart preceding heart failure; and/or [0449]
predicting the risk of a subject bearing risk factors of developing
heart failure, to suffer from heart failure, [0450] and wherein all
uses are based on diagnosing functional and/or structural
abnormalities of the heart preceding heart failure in a subject
bearing risk factors of developing heart failure.
[0451] Moreover, the present disclosure relates to the use of an
antibody that specifically binds to a cardiac troponin or a variant
thereof, for example Troponin T or a variant thereof and/or
Troponin I or a variant thereof; and, as the case may be, an
antibody that specifically binds to GDF-15 or a variant thereof
and/or an antibody that specifically binds to IGFBP7 or a variant
thereof, in a sample of a female subject, for predicting the risk
of a female subject bearing risk factors of developing heart
failure to suffer from LVH.
[0452] In general, the subject referred to above in connection with
the uses of the disclosure as specified above (i.e. the individual
bearing risk factors and/or suffering from functional and/or
structural abnormalities of the heart preceding heart failure) does
not suffer from heart failure, i.e. the patient has not experienced
permanent structural or functional damages to his myocardium, and
he will be able to fully restore his health, and he is not
classified into stage C or D of the ACC/AHA classification.
According to some embodiments, the subject bears risk factors for
heart failure. These are known to the person skilled in the art and
include e.g. hypertension and diabetes. Also according to some
embodiments, the subject does not show overt signs and/or symptoms
of heart failure.
[0453] The uses of the present disclosure, as specified beforehand,
according to some embodiments, are in vitro methods.
[0454] The following examples, illustrative embodiments, and
figures are provided for the purpose of demonstrating various
embodiments of the instant disclosure and aiding in an
understanding of the present disclosure, the true scope of which is
set forth in the appended claims. These examples are not intended
to, and should not be understood as, limiting the scope or spirit
of the instant disclosure in any way. It should also be understood
that modifications can be made in the procedures set forth without
departing from the spirit of the disclosure.
ILLUSTRATIVE EMBODIMENTS
[0455] The following comprises a list of illustrative embodiments
according to the instant disclosure which represent various
embodiments of the instant disclosure. These illustrative
embodiments are not intended to be exhaustive or limit the
disclosure to the precise forms disclosed, but rather, these
illustrative embodiments are provided to aide in further describing
the instant disclosure so that others skilled in the art may
utilize their teachings.
1. A method of diagnosing functional and/or structural
abnormalities of the heart preceding heart failure in a subject
suffering from hypertension, diabetes, obesity, metabolic syndrome
and/or having a history of smoking, the method comprising the steps
of:
[0456] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0457] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0458] c) diagnosing said functional and/or structural
abnormalities by comparing the concentration determined in step (a)
and optionally the concentration(s) determined in step (b) with a
reference amount
wherein the subject does not show left ventricular hypertrophy, and
wherein the structural and/or functional abnormalities of the heart
preceding heart failure comprise an abnormality selected from a
left ventricular structural change, an increased septum diameter,
an increased posterial wall diameter, and diastolic dysfunction. 2.
The method according to 1, wherein the subject does not suffer from
heart failure or does not display symptoms of heart failure. 3. The
method according to any of 1 to 2, wherein the cardiac troponin is
troponin I or T or a variant thereof. 4. The method according to
any of 1 to 3, wherein the subject suffers from hypertension, in
particular arterial hypertension, and/or diabetes, in particular
type 2 diabetes. 5. The method of any of 1 to 4, wherein the
functional and/or structural abnormalities of the heart preceding
heart failure are structural and/or functional abnormalities of the
heart preceding heart failure and/or left ventricular hypertrophy.
6. The method of any of 1 to 5, wherein the functional and/or
structural abnormality is an increased septum diameter. 7. The
method of any of 1 to 6, wherein the functional and/or structural
abnormality is a diastolic dysfunction, in particular diastolic
dysfunction assymptomatic diastolic left ventricular dysfunction
with preserved left ventricular ejection fraction (LVEF). 8. The
method of any of 1 to 7, wherein the subject does not have
increased NT-proBNP levels, in particular, wherein the subject has
no increase of NT-ProBNP compared to a reference amount of at least
20% or of at least 30%, in particular to the amount of NT-proBNP in
healthy individuals. 9. The method of any of 1 to 8, wherein an
increase of at least 20%, in particular, of at least 30% of a
cardiac Troponin, in particular of Troponin T, in respect to the
amount in healthy individuals is indicative for the diagnosis of
functional and/or structural abnormalities of the heart preceding
heart failure. 10. The method according to any of 1 to 9, wherein
the one or more other marker(s) of heart failure is selected from
GDF-15 or a variant thereof, and/or IGFBP7 or a variant thereof.
11. A method of differentiating between a subject only bearing risk
factors of developing heart failure and a subject not only bearing
risk factors but already suffering from functional and/or
structural abnormalities of the heart preceding heart failure, the
method comprising the steps of:
[0459] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0460] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0461] c) differentiating between said subjects by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) with a reference
amount,
wherein the subject does not show left ventricular hypertrophy, and
wherein the structural and/or functional abnormalities of the heart
preceding heart failure comprise an abnormality selected from a
left ventricular structural change, an increased septum diameter,
an increased posterial wall diameter, and diastolic dysfunction.
12. The method of 11, wherein the subject suffers from
hypertension. 13. A method of predicting the risk of a female
subject to suffer from left ventricular hypertrophy, the method
comprising the steps of:
[0462] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0463] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0464] c) predicting the risk of the subjects to suffer from left
ventricular hypertrophy by comparing the concentration determined
in step (a) and optionally the concentration(s) determined in step
(b) with a reference amount.
14. The method of 13, wherein the subject bears at least one risk
factor of heart failure. 15. The method of 14, wherein the subject
bearing at least one risk factor suffers from hypertension. 16. The
method of any of 13 to 15, wherein the reference amount is derived
from a healthy female subject or a group thereof, and wherein an
increase of a cardiac troponin, such as of troponin T of at least
30%, in particular of at least 50% as compared to the reference
amount is indicative for a risk of the subject to suffer from left
ventricular hypertrophy. 17. A method of monitoring a medication in
a subject subjected to said medication, said medication being
selected from ACE inhibitors, angiotension receptor blockers and
aldosterone antagonists, said subject suffering from heart failure
or stages preceding heart failure including risk factors for heart
failure, the method comprising the steps of:
[0465] a) measuring in a sample obtained from the subject the
concentrations of at least one cardiac troponin or a variant
thereof and/or a natriuretic peptide or a variant thereof,
[0466] b) measuring in a sample the concentration of GDF-15 or a
variant thereof, and
[0467] c) monitoring the medication by comparing the thus
determined concentrations with a reference amount.
18. A method of deciding on the adaptation of a medication selected
from ACE inhibitors, angiotension receptor blockers and aldosterone
antagonists in a subject subjected to said medication and suffering
from heart failure or stages preceding heart failure including risk
factors for heart failure, the method comprising the steps of:
[0468] a) measuring in a sample obtained from the subject the
concentrations of at least one cardiac troponin or a variant
thereof and/or a natriuretic peptide or a variant thereof,
[0469] b) measuring in a sample the concentration of GDF-15 or a
variant thereof, and
[0470] c) deciding on the adaptation of the medication by comparing
the thus determined concentrations with a reference amount.
19. The method according to 17 or 18, wherein the medication is an
ACE inhibitor. 20. The method according any of 17 to 19, wherein
the concentrations of a cardiac troponin, in particular troponin T,
and GDF-15 are measured, and wherein a ratio of the cardiac
troponin and GDF-15 (cardiac Troponin/GDF-15) is formed. 21. The
method according to 20, wherein a ratio of troponin T/GDF-15 of
equal to or higher than about 0.01, in some cases equal to higher
than about 0.017, is indicative that the medication is appropriate
and should not be changed, and/or wherein a ratio troponin T/GDF-15
of lower than about 0.01, and ins some cases lower than about 0.005
is indicative that the medication is not appropriate and should be
adapted. 22. The method according any of 17 to 19, wherein the
concentrations of a natriuretic peptide, in particular NT-proBNP,
and GDF-15 are measured, and wherein a ratio of the natriuretic
peptide and GDF-15 (natriuretic peptide/GDF-15) is formed. 23. The
method according to 22, wherein a ratio of NT-proBNP/GDF-15 of
equal to or higher than about 0.8, in some cases equal to or higher
than about 1.9, is indicative that the medication is appropriate
and should not be changed, and/or wherein a ratio NT-proBNP/GDF-15
of lower than about 0.7, and in some cases lower than about 0.4 is
indicative that the medication is not appropriate and should be
adapted. 24. The method according to any of 18 to 23, wherein the
adaptation is selected from i) the administration of an aldosterone
antagonist, ii) the augmentation of the concentration of the
aldosterone antagonist, and iii) the administration of a different
or a further aldosterone antagonist. 25. In vitro use of a cardiac
Troponin, or of an antibody which specifically binds to a cardiac
Troponin for diagnosing functional and/or structural abnormalities
of the heart preceding heart failure as defined in 1 (above) in a
subject suffering from hypertension, diabetes, obesity, metabolic
syndrome and/or having a history of smoking, wherein the subject
does not show left ventricular hypertrophy. 26. In vitro use of a
cardiac Troponin, or of an antibody which specifically binds to a
cardiac Troponin for differentiating between a subject suffering
from stage A heart failure and a subject suffering from early stage
B heart failure. 27. In vitro use of a cardiac Troponin, or of an
antibody which specifically binds to a cardiac Troponin for
differentiating between a subject only bearing risk factors of
developing heart failure and a subject not only bearing risk
factors but already suffering from functional and/or structural
abnormalities of the heart preceding heart failure as defined in 1
(above), wherein the subject does not show LVH. 28. In vitro use of
a cardiac Troponin, or of an antibody which specifically binds to a
cardiac Troponin for predicting the risk of a female subject to
suffer from left ventricular hypertrophy. 29. The in vitro use of
25 to 28, further comprising the use of one or more other marker(s)
of heart failure, in particular of GDF-15 and/or IGFBP7, or of an
antibody (antibodies) which specifically binds to said one or
marker(s) of heart failure. 30. A method of diagnosing in a subject
functional and/or structural abnormalities of the heart preceding
heart failure, the method comprising the steps of:
[0471] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0472] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0473] c) diagnosing said functional and/or structural
abnormalities by comparing the concentration determined in step (a)
and optionally the concentration(s) determined in step (b) with a
reference amount.
31. The method according to 30, wherein the subject does not suffer
from heart failure or does not display symptoms of heart failure.
32. The method according to any of 30 to 31, wherein the cardiac
troponin is troponin I or T or a variant thereof. 33. The method
according to any of 30 to 32, wherein the subject suffers from left
ventricular dysfunction. 34. The method according to any of 30 to
33, wherein the one or more other marker(s) of heart failure is
selected from GDF-15 or a variant thereof, and/or IGFBP7 or a
variant thereof. 35. A method of differentiating between a subject
only bearing risk factors of developing heart failure and a subject
not only bearing risk factors but already suffering from functional
and/or structural abnormalities of the heart preceding heart
failure, the method comprising the steps of:
[0474] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0475] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0476] c) differentiating between said subjects by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) with a reference
amount.
36. A method of predicting the risk of a subject to suffer from
heart failure, or respective cardiovascular and renal events
preceding heart failure, the method comprising the steps of
[0477] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0478] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0479] c) predicting the risk of the subjects to suffer from heart
failure by comparing the concentration determined in step (a) and
optionally the concentration(s) determined in step (b) with a
reference amount.
37. The method according to 36, wherein the subject suffers from a
left ventricular dysfunction such as a diastolic dysfunction. 38. A
method of deciding on the treatment of functional and/or structural
abnormalities of the heart preceding heart failure in a subject,
the method comprising the steps of
[0480] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0481] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure,
[0482] c) deciding on treatment of the subject by comparing the
thus determined concentration with a reference amount.
39. The method according to 8, wherein the treatment is
administration of at least one of the following medicaments:
Diuretics, calcium antagonists, adrenergic agonists, positive
inotropic agents, statines, hydazaline and isosorbide dinitrate,
beta blockers, aldosterone antagonists, ACE inhibitors, angiotensin
receptor antagonists. 40. A method of monitoring treatment of
functional and/or structural abnormalities of the heart preceding
heart failure in a subject, the method comprising the steps of
[0483] a) determining the concentration of at least one cardiac
troponin or a variant thereof,
[0484] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0485] c) assessing whether the subject has undergone a change in
its pathophysiological state by comparing the thus determined
concentration of the said markers as determined in step a) to its
concentration in a control sample.
41. A method of diagnosing heart failure in a subject, the method
comprising the steps of
[0486] a) measuring in a sample obtained from the subject the
concentration of at least one cardiac troponin or a variant
thereof,
[0487] b) optionally measuring in the sample the concentration of
one or more other marker(s) of heart failure, and
[0488] c) assessing the heart failure by comparing the
concentration determined in step (a) and optionally the
concentration(s) determined in step (b) with a reference
amount.
42. A method of monitoring a medication in a subject subjected to
said medication and suffering from heart failure or stages
preceding heart failure including risk factors for heart failure,
the method comprising the steps of
[0489] a) measuring in a sample obtained from the subject the
concentrations of at least one cardiac troponin or a variant
thereof and/or a natriuretic peptide or a variant thereof,
[0490] b) measuring in a sample the concentration of GDF-15 or a
variant thereof, and
[0491] c) monitoring the medication by comparing the thus
determined concentrations with a reference amount.
43. A method of deciding on the adaptation of a medication in a
subject subjected to said medication and suffering from heart
failure or stages preceding heart failure including risk factors
for heart failure, the method comprising the steps of
[0492] a) measuring in a sample obtained from the subject the
concentrations of at least one cardiac troponin or a variant
thereof and/or a natriuretic peptide or a variant thereof,
[0493] b) measuring in a sample the concentration of GDF-15 or a
variant thereof,
[0494] c) deciding on the adaptation of the medication by comparing
the thus determined concentrations with a reference amount.
44. The method according to 42 or 43, wherein the medication is
selected from ACE inhibitors, angiotension receptor blockers and
aldosterone antagonists.
EXAMPLES
[0495] Methods and Materials.
[0496] Troponin T was determined using Roche's
electrochemiluminescence ELISA sandwich test Elecsys.TM. Troponin T
hs (high sensitive) STAT (Short Turn Around Time) assay. The test
employs two monoclonal antibodies specifically directed against
human cardiac troponin T. The antibodies recognize two epitopes
(amino acid position 125-131 and 136-147) located in the central
part of the cardiac troponin T protein, which consists of 288 amino
acids. The hs-TnT assay allows a measurement of troponin T levels
in the range of 3 to 10000 pg/mL.
[0497] NT-proBNP was determined using Roche's
electrochemiluminescence ELISA sandwich test Elecsys.TM. proBNP II
STAT (Short Turn Around Time) assay. The test employs two
monoclonal antibodies which recognize epitopes located in the
N-terminal part (1-76) of proBNP (1-108).
[0498] To determine the concentration of GDF-15 in serum and plasma
samples, an Elecsys.TM. prototype test was employed, using a
polyclonal, GDF-15 affinity chromatography-purified, goat
anti-human GDF-15 IgG antibody from R&D Systems (AF957). In
each experiment, a standard curve was generated with recombinant
human GDF-15 from R&D Systems (957-GD/CF). The results with new
batches or recombinant GDF-15 protein were tested in standard
plasma samples and any deviation above 10% was corrected by
introducing an adjustment factor for this assay. GDF-15
measurements in serum and plasma samples from the same patient
yielded virtually identical results after correction for eventual
dilution factors. The detection limit of the assay was 200
pg/ml.
[0499] For detection of IGFBP7 in human serum or plasma, a sandwich
ELISA was used. For capture and detection of the antigen, aliquots
of an anti-IGFBP7 polyclonal antibody from R&D Systems
(Catalogue number: AF 1334) was conjugated with biotin and
digoxigenin, respectively.
[0500] Streptavidin-coated 96-well microtiter plates were incubated
with 100 pi biotinylated anti-IGFBP7 polyclonal antibody for 60 min
at 1 pg/ml in lx PBS solution. After incubation, plates were washed
three times with 1.times.PBS+0.02% Tween-20, blocked with PBS+1%
BSA (bovine serum albumen) and then washed again three times with
lx PBS+0.02% Tween-20. Wells were then incubated for 1.5 h with
either a serial dilution of the recombinant IGFBP7 as standard
antigen or with diluted serum or plasma samples (1:50) from
patients or control individuals, respectively. After binding of
IGFBP7, plates were washed three times with lx PBS+0.02% Tween-20.
For specific detection of bound IGFBP7, wells were incubated with
100 .mu.l of digoxigenylated anti-IGFBP7 polyclonal antibody for 60
min at 1 .mu.g/ml in lx PBS+1% BSA. Thereafter, plates were washed
three times to remove unbound antibody. In a next step, wells were
incubated with 75 mU/ml anti-digoxigenin-POD conjugates (Roche
Diagnostics GmbH, Mannheim, Germany, Catalog No. 1633716) for 60
min in lx PBS+1% BSA. Plates were subsequently washed six times
with the same buffer. For detection of antigen-antibody complexes,
wells were incubated with 100 .mu.l ABTS solution (Roche
Diagnostics GmbH, Mannheim, Germany, Catalog No. 11685767) and the
optical density (OD) was measured after 15 min at 405 and 492 nm
with an ELISA reader
Example 1
[0501] Troponin T, NT-proBNP, GDF 15 and IGFBP7 were determined in
the following collectives of individuals. An informed consent of
the patients has been obtained.
[0502] Group 1: normotensive subjects, n=32.
[0503] Group 2: hypertensive subjects bearing risk factors of
suffering from heart failure (stage A), n=47.
[0504] Group 3: hypertensive subjects with functional and/or
structural abnormalities of the heart preceding heart failure,
(early stage B); the subjects did not have elevated NT-proBNP
levels the subjects showed structural changes to the left ventricle
(increased septum wall thickness (>11 mm), increased posterial
wall thickness (>12 mm), or first signs of either hypertrophy or
concentric hypertrophy) and/or the subjects showed a systolic
dysfunction (LVEF<50%) and/or diastolic dysfunction with
preserved ejection fraction LVEF of at least 50%, n=37. The
subjects did not suffer from left ventricular hypertrophy.
[0505] Group 4: subjects with dilated cardiomyopathy (DCM),
n=29.
[0506] For group 1-3, the subjects did not show impaired renal
function. Moreover, patients with a history of known myocardial
infarction and coronary artery disease were excluded from group
1-3.
[0507] Geometrical changes to the left ventricle were determined by
echocardiography (septum wall thickness ST, posterial wall
thickness PWT, LVEF, LVEDD); functional changes (LVEDD) were
determined by echocardiography.
[0508] The data show that the levels of Troponin T are higher in
subjects of group 3 (hypertensive subjects with functional and/or
structural abnormalities of the heart preceding heart failure) than
in group 1 (normotensive subjects) and in group 2 (only bearing
risk factors of suffering from heart failure). Troponin T levels
keep on augmenting when individuals proceed to heart failure (DCM,
group 4).
[0509] The data show that the levels of GDF 15 are higher in
subjects of group 3 (hypertensive subjects with functional and/or
structural abnormalities of the heart preceding heart failure) than
in group 1 (normotensive subjects) and in group 2 (only bearing
risk factors of suffering from heart failure). GDF 15 levels keep
on augmenting when individuals proceed to heart failure (DCM, group
4).
[0510] The data show that the levels of IGFBP7 are higher in
subjects of group 3 (hypertensive subjects with functional and/or
structural abnormalities of the heart preceding heart failure) than
in group 1 (normotensive subjects) and in group 2 (only bearing
risk factors of suffering from heart failure). Insulin growth
factor binding protein 7 levels keep on augmenting when individuals
proceed to heart failure dilated cardiomyopathy (DCM, group 4).
[0511] The data show, that the levels of NT-proBNP are only
enhanced in subjects of group 4 (subjects with dilated
cardiomyopathy), but no difference can be observed between
NT-proBNP levels in group 1 (normotensive subjects), group 2
(hypertensive subjects bearing risk factors of suffering from heart
failure) and group 3 (hypertensive subjects with functional and/or
structural abnormalities of the heart preceding heart failure).
[0512] It was surprisingly found that troponin levels can identify
subjects at early stage B even before hypertrophy becomes apparent,
i.e. the subjects have risk factors of suffering from heart failure
and show first structural changes to the left ventricle, but do not
suffer from hypertrophy. Similar diagnostic information is provided
by GDF-15 and IGFBP7.
[0513] Data are shown in the following tables 1, 2, 3 and 4. FIGS.
1, 2, 3 and 4 are graphical displays of the data in tables 1, 2, 3
and 4, respectively.
TABLE-US-00001 TABLE 1 Troponin T concentrations in patient groups.
hs-TnT Conc [pg/mL] Group 1 Group 2 Group 3 Group 4 Quartil 1 0.99
0.44 4.37 3.96 min 0.00 0.00 1.02 0.00 med 2.77 2.38 6.64 8.79 max
17.20 38.20 56.40 45.35 Quartil 3 5.44 7.49 8.79 21.83 n 32 47 37
29 MW 3.69 5.14 8.26 13.27
TABLE-US-00002 TABLE 2 GDF-15 concentrations in patient group.
GDF-15 Conc [ng/mL] Group 1 Group 2 Group 3 Group 4 Quartil 1 0.554
0.569 0.584 0.625 min 0.400 0.372 0.442 0.402 med 0.621 0.684 0.728
0.893 max 1.559 1.484 1.445 9.337 Quartil 3 0.758 0.885 0.913 1.331
n 32 47 37 29 MW 0.689 0.741 0.794 1.269
TABLE-US-00003 TABLE 3 IGFBP7 concentrations in patient group. Conc
[ng/mL] Group 1 Group 2 Group 3 Group 4 Quartil 1 33.31 36.70 42.45
39.05 min 22.35 18.85 27.50 20.25 med 38.75 43.05 49.70 47.25 max
66.25 68.50 105.20 131.95 Quartil 3 46.23 51.25 58.90 64.15 n 32 47
37 29 MW 40.47 43.88 51.02 53.16
TABLE-US-00004 TABLE 4 NT-proBNP concentrations in patient group.
Conc [pg/mL] Group 1 Group 2 Group 3 Group 4 Quartil 1 49.5 41.4
43.4 264.2 min 24.8 7.8 0.9 37.0 med 75.8 106.8 74.5 383.7 max
814.8 626.2 1555.8 4438.7 Quartil 3 154.1 240.7 209.7 922.1 n 32 47
37 29 MW 134.3 159.2 229.5 899.9
[0514] As it can be seen from table 1, the troponin T levels in
patients belonging to group 3 were more than 30% increased as
compared to patients belonging to group 1 and 2. Thus, an increase
of at least 30% is indicative for the presence of functional and/or
structural abnormalities preceding LVH and/or preceding heart
failure in patients without LVH.
[0515] In contrast and as it can be seen from table 4, the
Nt-ProBNP levels in patients belonging to group 3 remain unchanged
as compared to patients belonging to group 1 and 2. Thus, patients
with no LVH and with functional and/or functional abnormalities
preceding LVH and/or preceding heart failure do not have increased
levels of Nt-ProBNP of at least 20% as compared with reference
amounts in healthy individuals (group 1).
[0516] Levels of both, IGFBP7 and GDF15 are at least 10% increased
in patients belonging to group 3 as compared to levels in patients
belonging to group 1 and group 2. as demonstrated in tables 2 and
3.
[0517] As can be seen from table 3, IGFBP7 levels are increased at
least 20% in stage 3 patients in respect to reference amounts in
healthy subjects belonging to group 1.
[0518] Table 5 shows the distribution of septum and posterial wall
thickness in subject belonging to groups 1, 2 and 3.
TABLE-US-00005 TABLE 5 Distribution of septum and posterial wall
thickness. Group 3 Hypertensive subjects with Group 1 Group 2
structural Normotensive Hypertensive abnormalities subjects
subjects of the heart (n = 32) (n = 47) (n = 37) Mean value septum
wall 9.5 9.7 13.3 thickness (mm) (8-11) (7-11) (12-16) Mean value
posterial 10.2 9.5 13.4 wall thickness (mm) (9-12) (5-10)
(11-18)
[0519] As can be seen from table 5, subjects from group 3 had an
increased septum wall thickness above 11 mm (mean value of 13.3 mm,
between 12 and 16 mm) as well as an increased posterial wall
thickness (mean value 13.4 mm). Patients belonging to group 1 and 2
had no structural changes preceding LVH and/or preceding heart
failure with mean values of septum and posterial wall thickness
ranging from 9.5-10.2.
[0520] Thus patients belonging to group 3 (Early stage B) exhibited
structural changes preceding LVH and/or heart failure as an
increased septum wall thickness above 11 mm (mean value 13.3 mm,
range 12-16 mm). Patients belonging to group 2 (stage A) and group
1 (healthy) had no structural changes, e.g. no increased septum
wall thickness above 11 mm.
TABLE-US-00006 TABLE 6 Characteristics of patient groups 1, 2 and
3: Distribution of gender, age and various risk factors for
developing LVH/HF. Group 2 Group 3 Group 1 Hypertensive subjects
Hypertensive subjects Normotensive without structural with
structural subjects abnormalities abnormalities (n = 32) (n = 47)
(n = 37) Age (yrs) .sup. 59 (36-75) .sup. 61 (36-85) .sup. 64
(48-80) Male Gender 28% (9/32) 57% (27/47) 54% (20/37) History of
smoking 27% (8/30) 36% (16/45) 44% (15/34) Diabetes mellitus type2
6% (2/31) 13% (6/45) 18% (6/33) Diabetes mellitus type 2 and/ 13%
(4/31) 21% (22/47) 22% (16/35) or fasting glucose >110 mg/dl
Lipids 53% (16/30) 80% (37/46) 61% (22/36) Adipositas 25% (7/28)
45% (20/44) 57% (20/35)
[0521] As can be seen from table 6, all patients belonging to the
groups 2 and 3, as well as the apparently healthy subjects of group
1 had a comparable mean age of 60 years.
[0522] Half of the patients at HF stage A or early stage B (groups
2 and 3) were female and all of them had arterial hypertension. As
visible in table 6, 20% of them had Diabetes type 2 and/or fasting
glucose levels below 110 mg/dL.
TABLE-US-00007 TABLE 7 validity of cut-offs for various risk
factors for developing LVH/HF. Group 2 Group 3 % increase in
Hypertensive Hypertensive % increase in respect to Group 1 subjects
w/o subjects with respect to hypertensive Normotensive struct.
structural normotensive subjects w/o subjects Abnorm. abnormalities
subjects struct. abnorm. Cohort of example 1 2.77 2.38 6.64 >30%
>50% Ecluding subjects w 3.12 2.38 6.73 >30% >50% history
of smoking Excluding subjects w 2.66 2.06 6.41 >30% >50%
diabetes mellitus type2 Excluding subjects w 2.63 2.06 6.64 >30%
>50% diabetes type2 a/o glucose >110 mg/dl Excluding subjects
w 2.89 2.06 6.93 >30% >50% lipids Excluding subjects w 2.66
2.41 6.64 >30% >50% adipositas
[0523] As it can be seen from table 1 beforehand, the troponin T
levels in patients belonging to group 3 were more than at least 20%
(>3.3 pg/ml), 30% (>3.5 pg/ml) and even more than 50%
(>4.2 pg/ml) increased as compared to patients belonging to
group 1 and 2. By stepwise exclusion of single risk factors it can
be seen from table 7, that Troponin T levels were increased at
least 30% (>3.5 pg/ml) in early stage B patients compared to
stage A patients with respective risk factors or normotensive
apparently healthy subjects.
[0524] The validity of a cut-off of TnT levels above 3.3, and in
some cases above 3.5 pg/ml or even above 4.2 pg/ml to diagnose
early structural and/or functional changes preceding LVH and/or
heart failure in subjects with arterial hypertension was shown by
step-wise exclusion of different risk factor groups.
[0525] Thus, an increase of at least 30%, and in some cases of at
least 50% is indicative for the presence of functional and/or
structural abnormalities preceding LVH and/or preceding heart
failure in patients with arterial hypertension with or without
further risk factors, e.g. diabetes type 2.
TABLE-US-00008 TABLE 8 Validation of increased Troponin T levels in
early stage B patients with different risk factors for developing
LVH/HF. Group 3 % increase Hypertensive % increase in in respect to
Group 1 Group 2 subjects with respect to hypertensive Normotensive
Hypertensive structural normotensive subjects w/o subjects subjects
abnormalities subjects struct. Abnorm. Cohort of example 1 2.77
2.38 6.64 >30% >30% Females only 2.63 1.80 6.73 >30%
>50% Males only 3.11 4.35 6.42 >30% >20% Only subjects w
1.99 3.21 6.64 >20% >30% history of smoking Only subjects w
3.38 3.61 5.75 >30% >30% diabetes type 2 a/o glucose >110
mg/dl Only subjects w 1.84 3.09 6.68 >30% >30% lipids Only
subjects w 1.02 1.98 6.41 >30% >30% adipositas
[0526] The validity of increased TnT levels of at least 20% in
hypertensive individuals with structural abnormalities in respect
to hypertensives w/o structural abnormalities (and normotensive
individuals) is shown for different risk factor subgroups
(adipositas, history of smoking, . . . ).
[0527] As can be seen from table 8 increased TnT levels
discriminate female patients with arterial hypertension with and
without structural changes better than male patients (increase of
at least 50% versus at least 20%).
[0528] Thus elevated TnT levels indicate early structural and/or
functional changes preceding LVH and/or heart failure, in
particular in hypertensive women.
TABLE-US-00009 TABLE 9 validity of cut-offs for various risk
factors for developing LVH/HF. Group 2 Group 3 % increase in Group
1 Hypertensive Hypertensive subjects respect to Normotensive
subjects w/o with structural normotensive subjects struct. Abnorm.
abnormalities subjects Cohort of example 1 38.7 43.0 49.70 >20%
Ecluding subjects 40.8 42.4 48.6 >10% w history of smoking
Excluding subjects 38.8 42.4 47.3 >20% w diabetes mellitus type2
Excluding subjects 37.6 43.4 48.0 >20% w lipids Excluding
subjects 39.1 43.1 46.9 >10% w adipositas
[0529] As it can be seen from table 1 beforehand, the IGFBP7 levels
in patients belonging to group 3 were more than at least 10% and
even more than 20% (>46.5 pg/ml) increased as compared to
patients belonging to group 1 and 2. By stepwise exclusion of
single risk factors it can be seen from table 9, that IGFBP7 levels
were increased at least 10% in early stage B patients compared to
stage A patients with respective risk factors or normotensive
apparently healthy subjects.
[0530] Thus, an increase of at least 10%, and ins some cases at
least 20% is indicative for the presence of functional and/or
structural abnormalities preceding LVH and/or preceding heart
failure in patients with arterial hypertension with or without
further risk factors, e.g. adipositas.
[0531] The validity of a cut-off of IGFBP7 levels above 46.5 pg/ml
to diagnose early structural and/or functional changes preceding
LVH and/or heart failure in subjects with arterial hypertension was
shown by step-wise exclusion of different risk factor groups.
TABLE-US-00010 TABLE 10 validation of increased IGFBP7 levels in
early stage B patients with different risk factors.The validity of
increased TnT levels of at least 10% in hypertensive individuals
with structural abnormalities in respect to hypertensives w/o
structural abnormalities (and normotensive individuals) is shown
for different risk factor subgroups (lipids, history of smoking, .
. .). Group 3 % increase in Group 1 Group 2 Hypertensive subjects
respect to Normotensive Hypertensive with structural normotensive
subjects subjects abnormalities subjects Cohort of example 1 38.7
43.05 49.70 >20% Only females 40.8 42.2 49.2 >20% Only males
34.0 44.7 47.65 >20% Only subjects w lipids 40.8 42.5 47.1
>10% Only subjects w adipositas 39.6 42.0 47.3 >10%
[0532] Thus elevated IGFBP7 levels indicated early structural
and/or functional changes preceding LVH and/or heart failure, in
particular in hypertensive women.
Example 2
[0533] Troponin T, NT-proBNP and GDF-15 were determined in the
below-described collective of individuals. A total of 97 patients
with overt heart failure were included into the study, mean age
60.9 years, 52 males, 45 females, LVEF below 50%, who had a normal
kidney function as documented by normal creatinine levels. All
patients were on beta blocker as well as on ACE inhibitor therapy,
59 patients were on aldosterone antagonists, 38 did not receive
aldosterone antagonists. Patients were treated in the study
according to guidelines (see above). None of the patients suffered
from diabetes mellitus or metabolic syndrome, in addition none of
the patients suffered from liver disease or malignancies.
[0534] 38 patients receiving no aldosterone (all Class C) had the
following characteristics:
TABLE-US-00011 TABLE 11 Marker concentrations in 38 patients
receiving no aldosterone. ratio NT-pro NT-pro ratio BNP Troponin T
GDF-15 LVEF NYHA BNP/GDF Troponin Percentile (pg/mL) (pg/mL)
(pg/mL) (%) class 15 T/GDF 15 25 157 1.7 663 57 1.0 0.196 0.002 50
464 6.6 1161 45 1.5 0.401 0.005 75 1195 18.1 2228 28.5 2.5 0.682
0.011
[0535] Patients receiving aldosterone antagonists (all class C) has
the following characteristics:
TABLE-US-00012 TABLE 12 Marker concentrations in patients receiving
aldosterone antagonists. ratio NT-pro NT-pro ratio BNP Troponin T
GDF-15 LVEF NYHA BNP/GDF Troponin Percentile (pg/mL) (pg/mL)
(pg/mL) (%) class 15 T/GDF 15 25 475 7.3 915 35 1.0 0.254 0.004 50
1194 15.3 1535 28 2.0 0.800 0.009 75 2072 24.0 2493 20 3.0 1.898
0.017
[0536] Patients who received aldosterone antagonists had more
severe heart failure than those who did not receive aldosterone
antagonists. When ratios were formed it became however clear that
GDF 15 was lower relative to NT-pro BNP and GDF 15 in the
aldosterone antagonist group indicating that GDF 15 was a valuable
marker for the use and monitoring of aldosterone antagonists.
[0537] As described above the recommendation of ACE inhibitors in
stages A and B suggest the need for anti inflammatory treatment,
however because of polymorphisms this appears not to be effective
in all cases, thus low dose aldosterone antagonists are likely to
be useful also in stages A and B heart failure. The ratios of
NT-pro BNP/GDF 15 and Troponin T/GDF 15 give guidance as to the use
of this drug. In all cases, in other words while ACE inhibitors and
angiotension receptor blockers (ARBs) have been shown to be
effective in large randomized trials there is currently no method
available to diagnose the effectiveness of these drugs in the
individual patient. This is in contrast to the application of these
drugs in patients with kidney disease where the decrease of urinary
albumin can be used to verify treatment success. Thus the method
described offers for the first time a method for the diagnosis of
treatment failure and provides guidance for improved treatment
using aldosterone inhibitors or in the future drugs that inhibit
synthesis of aldosterone.
[0538] Case Studies:
[0539] A 62 year old patient with stable established class C heart
failure is currently on a combination of beta blockers and ACE
inhibitors. GDF-15, NT-proBNP and Troponin T are determined in
serum sample obtained from the patient. The NT-pro BNP/GDF 15 ratio
is 0.39, and the Troponin T/GDF 15 ratio is 0.003. Because of
inappropriate therapy he is started with spironolactone 25 mg/day.
Three months later, the NT-pro BNP/GDF 15 ratio is 0.62 and
Troponin T/GDF 15 ratio is 0.006. Because of the still
inappropriate therapy, spironolactone is increased to 50 mg/day.
Again 3 months later therapy is found appropriate with a NT-pro
BNP/GDF 15 ratio of 0.9 and a troponin T/GDF 15 ratio of 0.012.
[0540] A 48 year old female patient with stable class C heart
failure is on standard therapy with beta blockers and ACE
inhibitors. GDF-15, NT-proBNP and Troponin T are determined in
plasma sample obtained from the patient. The NT pro BNP/GDF 15
ratio is 0.95 and the Troponin T/GDF 15 ratio 0.011. The results
indicate that the patient does not require therapy with an
aldosterone antagonist. As the therapy has only been started 9
months ago, she is informed of the possibility of ACE inhibitor
resistance and is advised to have a follow up visit in 12 months or
when symptoms of heart failure develop.
[0541] A 68 year old male patient with stable heart failure class C
is currently on a combination of beta blocker, ACE inhibitors and
low dose aldosterone antagonists. The NT-pro BNP/GDF 15 ratio is
0.95 and the troponin T/GDF 15 ratio is 0.012. The patient is
informed that therapy is adequate and to stay on current treatment
schedule and to return to a follow up visit in 12 months or if
symptoms worsen.
[0542] A 56 year old patient with stable type C heart failure is on
a therapy with beta blockers, ACE inhibitors and 25 mg/day
spironolactone, the NT-pro BNP/GDF 14 ratio is 1.7, the Troponin
T/GDF 15 ratio is 0.02. The patient is advised that an attempt can
be made to discontinue spironolactone for three months, as the
effect of discontinuation is only recognised with significant
delay, and then to decide on the necessity of spironolactone. Three
months after discontinuation of spironolactone the NT-pro BNP/GDF
15 ratio is 0.9 and the troponin T/GDF 14 ratio is 0.013. The
patient is informed that spironolactone can be discontinued.
[0543] All references cited in this specification are herewith
incorporated by reference with respect to their entire disclosure
content and the disclosure content specifically mentioned in this
specification.
[0544] While this disclosure has been described as having an
exemplary design, the present disclosure may be further modified
within the spirit and scope of this disclosure. This application is
therefore intended to cover any variations, uses, or adaptations of
the disclosure using its general principles. Further, this
application is intended to cover such departures from the present
disclosure as come within the known or customary practice in the
art to which this disclosure pertains.
* * * * *