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Heart failure is a complex multifaceted syndrome occurring as a result of impaired cardiac function. Understanding the neurohormonal, inflammatory and molecular pathways involved in the pathophysiology of this syndrome has led to the development of effective and widely used pharmacological treatments. Despite this, mortality and hospitalization rates associated with this condition remain high. The natural course of this illness is usually progressive, often leading inexorably to end stage heart failure, for which orthotopic heart transplant is a treatment option but one with limited resource. In the past decade, mechanical circulatory support has emerged as a potential therapy for certain patients with advanced heart failure. This article reviews the published data regarding biomarkers in the setting of mechanical circulatory support, and highlights areas of ongoing work and potential future areas of interest.

A growing array of biological pathways underpins the syndrome we recognize as heart failure. These include both deleterious pathways promoting its development and progression, as well as compensatory cardioprotective pathways. Components of these pathways can be utilized as biomarkers of this condition to aid diagnosis, prognostication and potentially guide management. As our understanding of the pathophysiology of heart failure deepens further candidate biomarkers are being identified. We provide an overview of the more recently emerging biomarkers displaying potential promise for future clinical use.

Aims: The aim of the study was to examine the ease of use and the reproducibility of a novel point-of-care BNP measurement system when used by patients and healthcare providers (HCP)., Patients & Methods: Patients with symptomatic heart failure were recruited from outpatient clinics at four hospitals. They were provided with brief training and instructional material for the use of the point-of-care BNP measurement system. Finger-prick blood BNP concentration was measured by the HCP and the patient (n = 150). Ease of use and reproducibility of the system were assessed., Results: In total, 80% of the 164 patients who completed a questionnaire on the ease of use of the system found it easy to operate. There was excellent correlation of BNP measurement compared between patients and HCP (r = 0.966; p < 0.001)., Conclusion: Patients find the Alere Heart Check BNP measurement system easy to operate. BNP concentration measurements obtained by patients show excellent correlation with those obtained by healthcare providers.

Cardiac transplantation can be a life-saving treatment for selected patients with heart failure. However, despite advances in immunosuppressive therapy, acute allograft rejection remains a significant cause of morbidity and mortality. The current 'gold standard' for rejection surveillance is endomyocardial biopsy, which aims to identify episodes of rejection prior to development of clinical manifestations. This is an invasive technique with a risk of false-positive and false-negative results. Consequently, a wide variety of noninvasive alternatives have been investigated for their potential role as biomarkers of rejection. This article reviews the evidence behind proposed alternatives such as imaging techniques, electrophysiological parameters and peripheral blood markers, and highlights the potential future role for biomarkers in cardiac transplantation as an adjunct to biopsy.

Aim: Apelin is an endogenous vasodilator and inotrope, plasma concentrations of which are reduced in advanced heart failure (HF). We determined the prognostic significance of plasma concentrations of apelin in advanced HF., Patients & Methods: Plasma concentrations of apelin were measured in 182 patients with advanced HF secondary to left ventricular systolic dysfunction. The predictive value of apelin for the primary end point of all-cause mortality was assessed over a median follow-up period of 544 (IQR: 196-923) days., Results: In total, 30 patients (17%) reached the primary end point. Of those patients with a plasma apelin concentration above the median, 14 (16%) reached the primary end point compared with 16 (17%) of those with plasma apelin levels below the median (p = NS). NT-proBNP was the most powerful prognostic marker in this population (log rank statistic: 10.37; p = 0.001)., Conclusion: Plasma apelin concentrations do not predict medium to long-term prognosis in patients with advanced HF secondary to left ventricular systolic dysfunction.

Aims: Effective cardiac resynchronization therapy may depend upon the distance between left ventricular (LV) and right ventricular (RV) pacing leads. We assessed the influence of lead separation upon circulating NT-proBNP., Materials & Methods: In total, 132 patients underwent assessment, including NT-proBNP assay, before and after cardiac resynchronization therapy. 3D lead separation was calculated from postero-anterior and lateral chest radiography., Results: Lead separation correlated with NT-proBNP reduction (r = 0.25; p = 0.004). Circulating NT-proBNP only fell in those with lead separation in the upper two quartiles. Deteriorating NT-proBNP occurred in 44 patients. Lead separation was less in these patients compared with those with an improvement (corrected 3D lead separation: 148.0 ± 5.38 and 170.5 ± 4.21 mm, respectively; p = 0.0018)., Conclusion: Left ventricular-right ventricular lead separation correlates with postcardiac resynchronization therapy improvements in circulating NT-proBNP, a powerful marker of heart failure status and prognosis. Attention should be paid to achieving maximal lead separation at implantation.

It is inevitable that all patients with implantable cardioverter-defibrillators (ICDs) will die during extended follow-up. End-of-life care planning may become appropriate as a patient's condition deteriorates. There is concern about multiple futile shocks in the final hours of life, although the incidence of this problem has been estimated at only 8-16%. Despite broad consensus that ICD deactivation should be discussed as part of end-of-life care planning, the effect of ICD deactivation, in particular whether life expectancy is altered, is uncertain. Many clinicians are reluctant to discuss ICD deactivation. Many patients have misconceptions regarding ICD function and value longevity above quality of life. As such, ICD deactivation is often discussed late or not at all. The management of ICDs in patients approaching death is likely to become a major problem in the coming years. This article will discuss directions in which clinical practice might develop and areas for future research.

Heart failure is a complex systemic syndrome resulting from significant impairment of cardiac function. A vast array of biological pathways is now known to be involved in heart failure, including deleterious pathways promoting its development and progression, as well as compensatory cardioprotective pathways. Some of the components of these pathways are now recognized as biomarkers of this condition, and can aid diagnosis, prognostication and guide management. As the understanding of the pathophysiology of heart failure progresses, further candidate biomarkers are being identified. This article reviews the literature regarding the more recently identified biomarkers and outlines areas requiring further study.

Many individual variables are predictive of an increased risk of mortality and morbidity in heart failure. These include a range of data from patient demographics, clinical findings, comorbidities and invasive and noninvasive parameters. Some of these markers, for example the B-type natriuretic peptides, have been identified as independently predictive in large, robust, multivariable analyses. However, many markers have had less vigorous scrutiny and were identified in small cohorts after only univariate or limited multivariable analyses. Recently, cardiac troponins have emerged as potential biomarkers for patients with heart failure. In this article, we consider the utility of cardiac troponins in heart failure and propose what role they may play in improving the risk stratification of this disease.

The B-type natriuretic peptides (BNPs) now have a well-established role in the diagnosis of heart failure. There is also a wealth of evidence on their ability as prognostic markers in patients with heart failure. The other potential role of BNPs is in the arena of therapy monitoring, although much less is known regarding this putative application. This review summarizes what evidence there is both for and against using BNPs to monitor heart failure patients.

There is increasing interest in the B-type natriuretic peptides in many clinical settings, with most research centered on patients with heart failure. These peptides have a strong negative predictive value in patients suspected of having this diagnosis, but are also known to be powerfully predictive of an adverse outcome. This latter property is particularly important in patients with advanced heart failure, allowing the selection of at-risk individuals for therapies that are in scarce resource. There is also ongoing research into B-type natriuretic peptide as a treatment for decompensated heart failure, as well as in other clinical contexts. This review aims to summarize the contemporary and established data on the B-type natriuretic peptides, with particular emphasis in the context of advanced heart failure.

The angiotensin receptor-like 1 (APJ) and its novel ligand, apelin, share similarities in structure and anatomical distribution with that of angiotensin II and the angiotensin II type 1 receptor. However, apelin has positive inotropic, vasodilatory and diuretic properties. Differential expression and synthesis of apelin and the APJ receptor in normal and failing hearts suggest that the apelin system may contribute to the pathophysiology of human heart failure and has potential therapeutic use in treatment of heart failure.