Baylor University Medical Center Proceedings April 2017 - 141

Table 4. Therapeutic management and Myocardial Injury Summary Score
Biomarker-blinded management
(usual clinical management, UC)

Biomarker-guided management (B)
Time
Baseline

Visit 1

Visit 2

Visit 3

Variable

B1

B2

B3

B4

UC1

UC2

UC3

UC4

MISS

0.02

-0.24

0.117

-0.307

-0.34

0.338

0.017

0.129

Weight (lbs)

123

179

246.8

196

171

211

164

305

Medications

+ F, BB↑

No change

No change

F↑

+BB

No change

F d/c

BB↑

0.065

0.053

0.013

MISS

-0.09

0.223

-0.062

Weight (lbs)

121

195

171

Medications

BB↑

F↑

No change

No change

No change

MISS

0.033

0.015

0.013

0.06

0.079

Weight (lbs)

125

191

162

Medications

BB↑

BB↑, F↑

No change

MISS

0.21

Weight (lbs)

194

Medications

No change

310
L d/c

175.5
No change

+L

MISS indicates Myocardial Injury Summary Score; BB, beta-blocker; F, furosemide; L, lisinopril; d/c, discontinued.

regimen was adjusted based on the values of the biomarkers,
leading to improved MISS. For patients in the biomarkerblinded category, the therapeutic intensity index, as reflected
by the intensity and frequency of drugs prescribed, in general
remained unchanged compared to those guided by biomarkers. A lower aggregated MISS score suggested that the values of
the individual biomarkers were lower than the values obtained
at the previous clinical visit, signaling a better prognosis in a
patient with HF.
DISCUSSION
We found in this case series that it was feasible to randomize
patients to either a biomarker-informed or -blinded approach
for ambulatory management of HF patients. Additionally, we
found that it was feasible to calculate and monitor a novel
multimarker score reflecting HF disease severity. Lastly, we were

Figure 1. Baseline Myocardial Injury Summary Score by median age.
April 2017

able to calculate an integrated measure of therapeutic intensity,
which changed modestly in the patients with biomarker-guided
management. The results showed that biomarker-guided therapy
led to timely therapeutic adjustment that might be beneficial to
the patient with HF and might help with systematic therapeutic
management.
Several randomized controlled trials have shown that targeting
the biomarkers resulted in better prognostics and diagnostics for HF
patients. The Barcelona Bio-Heart Failure Risk Calculator incorporating ST2, N-terminal pro BNP, and troponin T biomarkers allowed better prediction of death among HF patients (7). Compared
to the Seattle Heart Failure Model, the Penn Heart Failure Study
found that a multimarker score incorporating biomarkers increased

Figure 2. The pharmacologic regimen reflected by the therapeutic intensity index
at different visits for each patient in the biomarker-guided management (B) arm
and usual clinical management (UC) arm.

Personalized treatment of heart failure with biomarker guidance using a novel disease severity score

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