Prognostic Utility of ST2 in Patients With Acute Dyspnea and Preserved Left Ventricular Ejection Fraction

Study Questions:

What is the value of soluble ST2 (sST2), in the evaluation of acute dyspnea in patients with normal ejection fraction (EF)?

Methods:

An interleukin-1 receptor family member, sST2, is an emerging risk indicator for patients with cardiovascular disease. The authors evaluated the prognostic role of sST2 in 387 patients (39% female, mean [SD] age 57.6 [14.5] years) presenting to the emergency department with acute dyspnea, who had a left ventricular EF (LVEF) >50%.

Results:

After 1 year, 46 patients (12%) died. In the subpopulation of patients with normal systolic function (n = 200), only sST2 predicted mortality after multivariate adjustment (per log, 2.6; 1.1-6.0, p = 0.03). N-terminal pro-B–type natriuretic peptide (NT-proBNP), but not sST2 concentrations, correlated with multiple echocardiographic indices of LV diastolic function.

Conclusions:

The authors concluded that sST2 is a strong predictor of mortality in patients presenting with acute dyspnea, particularly those with preserved LVEF, and may be useful for triage and risk stratification in this challenging group.

Perspective:

This is an interesting study on what many have started to call death markers, which include ST2, GDF-15, and Pro-ADM. This study focused on those with diastolic abnormalities predominantly. This is fortunate because the marker did not appear useful in those with reduced LV systolic function. In contrast, in those with diastolic abnormalities, ST2 was predictive of mortality and performed as in some other studies, and was better than NT-proBNP in that regard. However, only 29% of a relatively small group had decompensated heart failure, and the mode of death was not defined for the cohort. Thus, despite a relationship between values and some of the echocardiographic measures that might point toward a cardiovascular etiology for long-term events, this concept cannot be considered furthered by this analysis. ST2 is clearly a death marker and may well work better than NT-proBNP because it detects those at risk regardless of the presence of decompensated heart failure. However, how to use it properly will depend on determining how it works and what is its appropriate use.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Prognosis, Biological Markers, Heart Failure, Receptors, Interleukin-1, Stroke Volume, Dyspnea, Systole, Natriuretic Peptide, Brain


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