Baylor University Medical Center Proceedings April 2017 - 142

stable range despite having several cases of decompensation that
were not signaled by a meaningful change in the score.
1.

Figure 3. Myocardial Injury Summary Score and corresponding changes in the
therapeutic intensity index from baseline to final visit for each patient in the
biomarker-guided management (B) arm and usual clinical management (UC) arm.

the ability to predict adverse outcomes in ambulatory patients with
chronic HF (8). A post hoc analysis including 151 patients with
chronic HF showed that baseline measurement of 3 biomarkers
(ST2, growth/diﬀerentiation factor 15, and highly sensitive assay
for troponin T) increased the overall prognostic ability, while serial ST2 measurement helped predict change in left ventricular
function (9). In older patients with stable HF, soluble isoform
of ST2 was found to be an independent predictor of worsening
HF, suggesting an association between increasing values of soluble
isoform of ST2 and progressive myocardial failure (10). Titrating
therapy based on the serial values of natriuretic peptides was proven
to be associated with a signiﬁcant reduction in mortality in a metaanalysis, including 6 randomized clinical trials with HF patients
(11), and targeting these biomarkers has been shown to beneﬁt HF
patients. In our case series, we assimilated the 4 biomarkers into
a composite score to guide the prognosis of these patients while
managing the therapeutics based on the biomarkers, providing us
an option to practice precision medicine. The recent GUIDE-IT
(Guiding Evidence-Based Therapy Using Biomarker Intensiﬁed
Treatment in Heart Failure) trial, a comparison of biomarkerguided therapy and usual care for high-risk HF patients based on
a single biomarker (BNP), was terminated early, as no diﬀerence
was noted in the primary outcome between the 2 groups in the
interim analysis (12). However, given the heterogeneity of HF,
our composite score incorporates 4 biomarkers that assess diﬀerent pathologies of HF. Along with the biomarkers, use of clinical
characteristics and echocardiographic ﬁndings have been suggested
to enhance the concept of personalized management in the HF
domain of cardiovascular disease (13, 14).
Our study has all the limitations of small pilot studies testing the feasibility of a new randomized approach with novel
assessments of both exposures and endpoints. As we did not
order renal function tests during each study visit, we were unable to make inferences regarding kidney function over time.
We recognize that these measures will be positioned with clinical
judgment and cannot predict many individual scenarios. For
example, we observed several integrated MISS scores in the

142

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11.

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Baylor University Medical Center Proceedings

Volume 30, Number 2

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings April 2017