The Increasing Burden of Heart Failure
Despite significant advances in the management of heart failure, this disease remains a main cause of mortality and disability. Heart failure affects 1%-2% of the adult population in developed countries and this prevalence rises to more than 10% after 70 years of age.
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Owing to the ageing of the population, the prevalence of heart failure is expected to continue to increase. The health care costs of heart failure also show a continuing rise and represent a significant burden for society.2
Overall, heart failure is a serious public health issue which requires efforts from the research community to develop new drugs and biomarkers to allow movement toward personalized health care.- Heidenreich P.A.
- Trogdon J.G.
- Khavjou O.A.
- et al.
American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
Circulation. 2011; 123: 933-944
Heart Failure Biomarkers
Biomarkers have greatly contributed to improving the diagnosis of heart failure. Natriuretic peptides, particularly N-terminal pro–B-type natriuretic peptide (NT-proBNP), are used for the diagnosis of heart failure. However, like virtually all biomarkers, NT-proBNP fails to reach 100% accuracy, owing notably to elevations of plasma levels from noncardiovascular causes.
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In addition to peptides and proteins, RNAs have been addressed for their potential to aid in heart failure diagnosis and risk stratification.4
After extensive research on microRNAs during the past decade, more recent investigations point out the potential of long noncoding RNAs and circular RNAs as novel heart failure biomarkers.5
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In this issue of the Canadian Journal of Cardiology, Yokokawa et al. focus on cell-free DNA as an alternate reservoir of biomarkers of heart failure.8
Cell-Free DNA as a Heart Failure Biomarker
Circulating cell-free DNA (cfDNA) represents the pool of double-stranded DNA molecules released into the circulation by necrotic cells. Low in normal conditions, plasma levels of cfDNA increase after tissue injury. Therefore, cfDNA might possess value as a cardiovascular biomarker because it could mirror the extent of myocardial or vascular injury. However, this possibility has been poorly investigated thus far. In a study comparing serum cfDNA levels in 55 patients with myocardial infarction and 274 healthy individuals, myocardial infarction patients had 10-fold higher levels of cfDNA compared with control subjects.
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In another study enrolling 19 male heart failure patients (New York Heart Association functional class III) and 20 healthy male control subjects, plasma cfDNA levels—which were similar between heart failure patients and control subjects at baseline—decreased after administration of the calcium sensitizer levosimendan, in parallel to an increase in myocardial performance.10
Although these studies support an association between myocardial dysfunction and circulating cfDNA levels, they failed to show significant correlations between cfDNA levels, cardiac-injury markers, and myocardial performance indices. The absence of such an association might have been caused by either low sample size or by the use of total cfDNA or beta-globin cfDNA, which are not cardiac specific. To overcome this last limitation, Yokokawa et al. used a bisulfite-digital droplet polymerase chain reaction (PCR) system to specifically assess cardiomyocyte-specific cfDNA.8
Assessment of Cardiomyocyte-Specific cfDNA
Total cfDNA was extracted from plasma samples of 32 patients with decompensated heart failure and 28 control subjects without signs of cardiovascular disease.
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Total levels of cfDNA were assessed with the use of LINE-1 primers and real-time quantitative PCR. In parallel, cfDNA was subjected to bisulfite conversion and the levels of unmethylated FAM101A locus were measured with the use of digital droplet PCR. Measurement of unmethylated FAM101A locus allows for the quantification of cardiomyocyte-specific cfDNA, because this locus is known to be unmethylated in a cardiac-specific manner.11
Although total levels of cfDNA were similar between them, levels of cardiomyocyte-specific cfDNA were elevated in heart failure patients compared with control subjects. The cardiomyocyte-specific cfDNA levels were able to discriminate patients from control subjects with an area under the curve of 0.716, and they were positively correlated with troponin I levels (r = 0.438; P = 0.003) but not with BNP.8
Although these observations are limited by low sample size, they suggest that measurement of cardiomyocyte-specific cfDNA might reflect the extent of myocardial injury and might help in the diagnosis of heart failure.Although Yokokawa et al. have provided the first proof-of-concept of the potential of cardiomyocyte cfDNA to aid in heart failure diagnosis,
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Zemmour et al. must also be recognized for the identification of the cluster of cytosines adjacent to the FAM101A locus specifically unmethylated in cardiac tissues (compared with 23 other human tissues) and for the development of the digital-droplet PCR technology to measure unmethylated levels of FAM101A locus.11
In addition, those authors were able to show elevations of unmethylated FAM101A cfDNA levels at admission in 31 acute myocardial infarction patients compared with 83 healthy control subjects, as well as a positive correlation with high-sensitivity cardiac troponin levels.11
Perspectives
Although circulating levels of cardiomyocyte-specific cfDNA have the potential to aid in cardiovascular disease management, much remains to be done before considering translation of these research findings to clinical application. First, the issue of the rapid clearance of cfDNA by the liver has to be considered. Although current studies support the biomarker value of cfDNA in ischemic cardiomyopathy, it would be interesting to determine whether circulating profiles of cfDNA differ according to heart failure etiology. Other cardiomyocyte-specific cfDNAs might possess incremental biomarker value, and panels of cfDNA should be tested in large patient cohorts. The prognostic value of cfDNA would be worth investigating prospectively. For example, the current criterion-standard biomarker of heart failure, NT-proBNP, fails to accurately predict left ventricular remodelling leading to heart failure after acute myocardial infarction—which occurs in one fifth of patients—and cfDNA may provide incremental predictive value in this clinical setting, as shown previously for circulating noncoding RNAs.
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Finally, sex differences should be an integral part of further adequately sized studies.In conclusion, the study by Yokokawa et al.
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applies a novel and powerful technology to show the potential power of cfDNA as a heart failure biomarker and paves the way for future research in this promising and important area.Funding Sources
Y.D. is Chair of the EU-CardioRNA COST ACTION CA17129, supported by COST (European Cooperation in Science and Technology). He is supported by the National Research Fund of Luxembourg (grants C14/BM/8225223 and C17/BM/11613033), the Ministry of Higher Education and Research of Luxembourg, and the Heart Foundation—Daniel Wagner.
Disclosures
The author has no conflicts of interest to disclose.
References
- 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.Eur J Heart Fail. 2016; 18: 891-975
- American Heart Association Advocacy Coordinating Committee; Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Arteriosclerosis; Thrombosis and Vascular Biology; Council on Cardiopulmonary; Critical Care; Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular Surgery and Anesthesia, and Interdisciplinary Council on Quality of Care and Outcomes Research. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.Circulation. 2011; 123: 933-944
- State of the art: using natriuretic peptide levels in clinical practice.Eur J Heart Fail. 2008; 10: 824-839
- Ensembling electrical and proteogenomics biomarkers for improved prediction of cardiac-related 3-month hospitalizations: a pilot study.Can J Cardiol. 2019; 35: 471-479
- Long noncoding RNAs in cardiac development and ageing.Nat Rev Cardiol. 2015; 12: 415-425
- Cardiolinc network. Circular RNAs in heart failure.Eur J Heart Fail. 2017; 19: 701-709
- Circulating microRNAs to predict heart failure after acute myocardial infarction in women.Clin Biochem. 2019; 70: 1-7
- Clinical significance of circulating cardiomyocyte-specific cell-free DNA in patients with heart failure: a proof-of-concept study.Can J Cardiol. 2020; 36: 931-935
- Elevated cell-free serum DNA detected in patients with myocardial infarction.Clin Chim Acta. 2003; 327: 95-101
- Levosimendan reduces plasma cell-free DNA levels in patients with ischemic cardiomyopathy.J Thromb Thrombolysis. 2011; 31: 180-187
- Non-invasive detection of human cardiomyocyte death using methylation patterns of circulating DNA.Nat Commun. 2018; 9: 1443
- MicroRNA-150: A novel marker of left ventricular remodeling after acute myocardial infarction.Circ Cardiovasc Genet. 2013; 6: 290-298
- Cyclin dependent kinase inhibitor 1 C is a female-specific marker of left ventricular function after acute myocardial infarction.Int J Cardiol. 2019; 274: 319-325
- Myocardial infarction-associated circular RNA predicting left ventricular dysfunction.J Am Coll Cardiol. 2016; 68: 1247-1248
- Long noncoding RNAs in patients with acute myocardial infarction.Circ Res. 2014; 115: 668-677
Article info
Publication history
Published online: October 31, 2019
Accepted:
October 25,
2019
Received:
October 24,
2019
Footnotes
See article by Yokokawa et al., pages 931-935 of this issue.
See page 808 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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- Clinical Significance of Circulating Cardiomyocyte-Specific Cell-Free DNA in Patients With Heart Failure: A Proof-of-Concept StudyCanadian Journal of CardiologyVol. 36Issue 6
- PreviewWe investigated clinical significance of cell-free DNA (cfDNA) in heart failure. This study enrolled 32 heart failure patients and 28 control subjects. Total cfDNA levels were not different between groups (P = 0.343). Bisulfite-digital polymerase chain reaction using the unmethylated FAM101A locus demonstrated that cardiomyocyte-specific cfDNA was significantly elevated in heart failure patients compared with control subjects (median 0.99 [interquartile range 0.77-1.98] vs 0 [0-0.91] copies/mL; P = 0.003).
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