Biomarkers that “guide” therapy

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Presentation transcript:

Biomarkers that “guide” therapy Troponin Hemoglobin Hba1c LDL Urea/creatinine ECG Ejection fraction ACS Anemia Diabetes CV prevention HD, ACE inhibitor Chest pain Heart failure

Biomarker axes

How we should feel about biomarkers Measurement (lab) Precision: closeness of two or more measurements to each other Accuracy: closeness of a measured value to a standard or known value Biologic variation understood Methods (evaluation) Statistics clear and robust Varying across and within patient groups Mechanism Represent pathophysiologic process (static or dynamic) Management Added value Inform decision on diagnosis or treatment Accuracy refers to the closeness of a measured value to a standard or known value. For example, if in lab you obtain a weight measurement of 3.2 kg for a given substance, but the actual or known weight is 10 kg, then your measurement is not accurate. In this case, your measurement is not close to the known value. Precision refers to the closeness of two or more measurements to each other. Using the example above, if you weigh a given substance five times, and get 3.2 kg each time, then your measurement is very precise. Precision is independent of accuracy. You can be very precise but inaccurate, as described above. You can also be accurate but imprecise.

Paris Criteria RCT Ahmed, JACC-HF 2014

Canadian Cardiovascular HF Guidelines We suggest, in ambulatory patients with HF due to systolic dysfunction, measurement of BNP or NT-proBNP to guide management should be considered to decrease HF-related hospitalizations and potentially reduce mortality. The benefit is uncertain in individuals older than 75 years of age (Weak Recommendation, Moderate-Quality Evidence) http://www.ccs.ca/en/heart-failure-program Moe et al, CJC 2015.

Multi-marker panels Added value of looking across multiple pathophysiologic axes: same time Complementary for prognosis E.g. troponin + BNP + mr-proANP Does this aid diagnosis? Does this aid management?

GUIDE-IT Study Design Multicenter, prospective, randomized, parallel control group clinical trial NIH sponsored (PI: Michael Felker, DCRI) 1100 subjects 12-24 months of follow-up

GUIDE-IT Study Design Randomized 1:1 to either: Biomarker Guided Arm: Treatment Titrated to Achieve Target NT-proBNP < 1000 pg/mL OR Usual Care: Treatment titrated based on guidelines