Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

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2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European respiratory society (ERS)

New @ESCardio Guidelines for the Diagnosis and Management of Acute #PulmonaryEmbolism developed in collaboration with @EuroRespSoc now available: #cardiotwitter @erspublicationshttp://bit.ly/2HnrJaj

https://erj.ersjournals.com/content/erj/early/2019/08/29/13993003.01647-2019.full.pdf

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) : The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)

Background: Heart failure (HF) remains one of the leading causes of death to date despite extensive research funding. Various studies are conducted every year in an attempt to improve diagnostic accuracy and therapy monitoring. The small cytoplasmic heart-type fatty acid-binding protein (H-FABP) has been studied in a variety of disease entities. Here, we provide a review of the available literature on H-FABP and its possible applications in HF. Methods: Literature research using PubMed Central was conducted. To select possible studies for inclusion, the authors screened all available studies by title and, if suitable, by abstract. Relevant manuscripts were read in full text. Results: In total, 23 studies regarding H-FABP in HF were included in this review. Conclusion: While, algorithms already exist in the area of risk stratification for acute pulmonary embolism, there is still no consensus for the routine use of H-FABP in daily clinical practice in HF. At present, the strongest evidence exists for risk evaluation of adverse cardiac events. Other future applications of H-FABP may include early detection of ischemia, worsening of renal failure, and long-term treatment planning.

https://www.mdpi.com/2077-0383/9/1/164/pdf

Heart-Type Fatty Acid-Binding Protein (H-FABP) and Its Role as a Biomarker in Heart Failure: What Do We Know So Far?

Cardiac troponins (cTn) are currently the standard of care for the diagnosis of acute coronary syndromes (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). However,...

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Heart-type fatty acid-binding protein: an overlooked cardiac biomarker.

The ability to predict death or other unfavorable outcomes after an acute pulmonary embolism (PE) is challenging, with current available risk score models having relatively unsatisfactory prognostic performance in this area. For example, the simplified pulmonary embolism severity index (sPESI), the most frequently used stratification tool, misclassifies a significant percentage of low- and high-risk patients. This gap in care, along with the increasing clinical availability of high-sensitivity cardiac troponin (hs-cTn) laboratory tests and the recent emphasis on detecting myocardial injury, may foster further evaluation of hs-cTn testing in patients with acute PE. Our analysis of the current scientific literature on hs-cTn in patients with acute PE identified that hs-cTn testing may provide valuable information for predicting future adverse outcomes and mortality, independently from baseline clinical risk assessment. Although the risk of an adverse event is indeed higher in patients with higher sPESI scores, cTns retain their prognostic value also in those at low risk, suggesting that a combination of hs-cTn with sPESI may provide an incremental value over assessment of either variable alone. Accordingly, the future development of updated risk stratification models, with the inclusion of laboratory tests such as hs-cTn, may represent an enhanced approach for risk stratification in patients with acute PE. Additional research, however, is needed to verify whether the combination of cTns, specifically as measured with hs-cTn assays, with other biomarkers may further improve the current capacity to efficiently manage patients with acute PE.

Measurement of High-Sensitivity Cardiac Troponin in Pulmonary Embolism: Useful Test or a Clinical Distraction.

Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT

In heart failure (HF), pressure and volume overload results in the release of natriuretic peptides (NP), including B-type natriuretic peptide (BNP), responsible for natriuresis, vasodilation and blockage of the renin–angiotensin–aldosterone system. BNP plays not only a role in diagnostic process, but also has a prognostic value, predicting hospitalization and mortality in chronic HF. Recently, sacubitril/valsartan has been included in the European Society of Cardiology HF therapeutic recommendations for patients with HF with reduced ejection fraction (HFrEF), as it proved to reduce death from cardiovascular causes and the risk of hospitalization for HF. Sacubitril inhibits neprilysin, a protease theoretically responsible for BNP cleavage. Therefore, in this context, the diagnostic and prognostic value of BNP has not been clarified. ProBNP, a 108-amino acid polypeptide, is synthesized and cut into a 76-amino acid non-biologically active peptide [N-terminal proBNP (NT-proBNP)] and a 32-amino acid biologically active peptide (BNP) in cardiomyocytes. Neprilysin was shown to be responsible for NP degradation such as atrial NP and C-type NP,1 but has neither effect on proBNP nor on NT-proBNP.2 As sacubitril acts inhibiting neprilysin activity, it was thought that it would induce an initial rise, followed by a decline, in NP like BNP, while lowering NTproBNP levels, as seen in the PARADIGM-HF3 and PIONEER-HF trials.4 Thus, BNP use as a prognostic biomarker in patients treated with this drug has been discredited, recommending NT-proBNP. Although it was believed that neprilysin degrades also BNP, recent experimental trials failed to demonstrate neprilysinmediated BNP degradation (and, therefore, BNP elevation) in human kidney membranes5 (main BNP target). The aim of this study was to evaluate if BNP is still a reliable biomarker. To describe the variation of BNP, patients with HFrEF who initiated sacubitril/valsartan were prospectively assessed. Clinical characteristics, aetiology, functional class, admission and mortality rates were evaluated. The endpoint was to evaluate if BNP levels after sacubitril/valsartan treatment are related to decompensations and HF admissions, maintaining its role as a diagnostic and prognostic biomarker. Abbott Architect BNP assay was used to analyse BNP plasma level before treatment and after 3, 6 and 12 months of treatment, as well as in every in-hospital admission. Significant BNP change was set as 50 pg/mL. Statistical analysis was performed using Statistical Package for Social Sciences V.22.0, statistical software (SPSS, Chicago, IL, USA). Shapiro–Wilk test was performed, proving the sample was not normally distributed. Friedman test was conducted, followed by post-hoc analysis with Wilcoxon signed-rank test. A total of 86 patients started sacubitril/valsartan from October 2016 to June 2018. Patients lacking BNP level during follow-up and those who discontinued sacubitril/valsartan were excluded. Ten patients stopped treatment (due to renal dysfunction in four, hyperkalaemia in one, hypotension in two, and economic difficulties in three). Two patients died during this period. Finally, a total of 70 patients were included. Baseline characteristics of the study patients are detailed in Table 1. At baseline, median BNP concentration was 576 pg/mL [interquartile range (IQR) 258–1058]. There were no significant differences in BNP levels after adjusting for sex, renal function, or New York Heart Association functional class. After 6 months of treatment, median BNP concentration decreased to 367 pg/mL (IQR 149–955; P = 0.001) (Figure 1). Based on BNP kinetics during followup, patients were classified into three groups: stable (change ≤ 50 pg/mL), rising and descending BNP level. After 6-month follow-up, 19% showed no changes, 21% presented rising levels, and 60% had lower BNP concentration. Comparing prevalence of readmissions between groups, patients with increasing BNP concentration were more frequently admitted because of HF (50%) than patients with lower concentration (21%). Sixteen patients suffered from acute Table 1 Baseline characteristics of the study patients (n = 70)

Jose Manuel del Rey

Papers

Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT

Sacubitril/valsartan and B-type natriuretic peptide value: recalculating route.