Congestion in heart failure: a circulating biomarker‐based perspective. A review from the Biomarkers Working Group of the Heart Failure Association, European Society of Cardiology

Abstract

Congestion is a cardinal sign of heart failure (HF). In the past, it was seen as a homogeneous epiphenomenon that identified patients with advanced HF. However, current evidence shows that congestion in HF varies in quantity and distribution. This updated view advocates for a congestive-driven classification of HF according to onset (acute vs. chronic), regional distribution (systemic vs. pulmonary), compartment of distribution (intravascular vs. extravascular), and clinical vs. subclinical. Thus, this review will focus on the utility of circulating biomarkers for assessing and managing the different fluid overload phenotypes. This discussion focused on the clinical utility of the natriuretic peptides, carbohydrate antigen 125 (also called mucin 16), bio-adrenomedullin and mid-regional pro-adrenomedullin, ST2 (also known as interleukin-1 receptor-like 1), cluster of differentiation 146, troponin, C-terminal pro-endothelin-1, and parameters of haemoconcentration. The utility of circulation biomarkers on top of clinical evaluation, haemodynamics, and imaging needs to be better determined by dedicated studies. Some multiparametric frameworks in which these tools contribute to management are proposed.

New Insight in Cardiorenal Syndrome: From Biomarkers to Therapy

“…Among specific cardiac biomarkers, cardiac troponins (cTns) (including cTnT and cTnI) raise in CRS and correlate with ventricular remodeling in HF [ 74 ]. In patients with advanced HF on optimal medical therapy, increased cTns levels are associated with clinical congestion, as detected by peripheral edema and pulmonary rales, high pulmonary arterial pressure and high pulmonary capillary wedge pressures [ 75 ]. However, their clinical applicability as a surrogate of congestion is limited by the lack of evidence of the correlation of changes over time of cTns levels with clinical congestion.…”

Biomarkers as Prognostic Predictors and Therapeutic Guide in Critically Ill Patients: Clinical Evidence

“…ADM is released by endothelial and vascular smooth muscle cells in response to intravascular volume overload and plays a key role in maintaining endothelial barrier function, thereby regulating tissue volume and edema [ 74 ]. In fact, the role of biomarkers to evaluate pulmonary and systemic congestion and distinguish phenotypes has recently been highlighted [ 75 ]. Natriuretic peptides in pulmonary congestion and MR-ProADM and BioADM in both vascular and tissue congestion are very useful.…”

“…It cannot be doubted that there have been enormous advances and that in pathologies such as severe infection, severe CAP, VAP, and sepsis, biomarkers have contributed a lot in management, as well as in acute heart failure and other critical pathologies. There are fields such as congestion, relevant in recent years, in which biomarkers can play a key role not only in their phenotypic diagnosis, but also in therapeutic guidance [ 75 ].…”

Natriuretic Peptides in Clinical Practice: A Current Review

“…Accurate and early diagnosis or exclusion of HF is crucial for timely intervention in a dyspneic patient. Conventionally HF was regarded as congestion consequent to fluid accumulation 1 . The current view is that HF is a complex heterogeneous entity encompassing severity (clinical versus sub-clinical), onset (acute versus chronic), fluid distribution (cardiopulmonary versus generalized), and vascular compartment involved (intra-versus extra-vascular) 1 .…”

“…Conventionally HF was regarded as congestion consequent to fluid accumulation 1 . The current view is that HF is a complex heterogeneous entity encompassing severity (clinical versus sub-clinical), onset (acute versus chronic), fluid distribution (cardiopulmonary versus generalized), and vascular compartment involved (intra-versus extra-vascular) 1 . The myriad of biomarkers that reflect different parts of HF pathophysiology exist 2 .…”