Novel Biomarkers for Heart Disease Printed Edition of the Special Issue Published in Journal of Clinical Medicine www.mdpi.com/journal/jcm Michael Lichtenauer Edited by Novel Biomarkers for Heart Disease Novel Biomarkers for Heart Disease Editor Michael Lichtenauer MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin Editor Michael Lichtenauer Paracelsus Medical University Salzburg Austria; Department of Internal Medicine II, University Clinic Salzburg Austria Editorial Office MDPI St. Alban-Anlage 66 4052 Basel, Switzerland This is a reprint of articles from the Special Issue published online in the open access journal Journal of Clinical Medicine (ISSN 2077-0383) (available at: https://www.mdpi.com/journal/jcm/ special issues/Biomarker Heart Disease). For citation purposes, cite each article independently as indicated on the article page online and as indicated below: LastName, A.A.; LastName, B.B.; LastName, C.C. Article Title. Journal Name Year , Volume Number , Page Range. ISBN 978-3-03943-883-9 (Hbk) ISBN 978-3-03943-884-6 (PDF) Cover image courtesy of Michael Lichtenauer. c © 2020 by the authors. Articles in this book are Open Access and distributed under the Creative Commons Attribution (CC BY) license, which allows users to download, copy and build upon published articles, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. The book as a whole is distributed by MDPI under the terms and conditions of the Creative Commons license CC BY-NC-ND. Contents About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Peter Jirak, Moritz Mirna, Bernhard Wernly, Vera Paar, Uta C. Hoppe and Michael Lichtenauer Assessment of Cardiac Remodeling—A Chance for Novel Cardiac Biomarkers? Reprinted from: J. Clin. Med. 2020 , 9 , 2087, doi:10.3390/jcm9072087 . . . . . . . . . . . . . . . . . 1 Peter Jirak, Rudin Pistulli, Michael Lichtenauer, Bernhard Wernly, Vera Paar, Lukas J. Motloch, Richard Rezar, Christian Jung, Uta C. Hoppe, P. Christian Schulze, Daniel Kretzschmar, R ̈ udiger C. Braun-Dullaeus and Tarek Bekfani Expression of the Novel Cardiac Biomarkers sST2, GDF-15, suPAR, and H-FABP in HFpEF Patients Compared to ICM, DCM, and Controls Reprinted from: J. Clin. Med. 2020 , 9 , 1130, doi:10.3390/jcm9041130 . . . . . . . . . . . . . . . . . 5 David Niederseer, Sarah Wernly, Sebastian Bachmayer, Bernhard Wernly, Adam Bakula, Ursula Huber-Sch ̈ onauer, Georg Semmler, Christian Schmied, Elmar Aigner and Christian Datz Diagnosis of Non-Alcoholic Fatty Liver Disease (NAFLD) Is Independently Associated with Cardiovascular Risk in a Large Austrian Screening Cohort Reprinted from: J. Clin. Med. 2020 , 9 , 1065, doi:10.3390/jcm9041065 . . . . . . . . . . . . . . . . . 17 Isabel Galeano-Otero, Raquel Del Toro, Agust ́ ın Guisado, Ignacio D ́ ıaz, Isabel Mayoral-Gonz ́ alez, Francisco Guerrero-M ́ arquez, Encarnaci ́ on Guti ́ errez-Carretero, Sara Casquero-Dom ́ ınguez, Luis D ́ ıaz-de la Llera, Gonzalo Bar ́ on-Esquivias, Manuel Jim ́ enez-Navarro, Tarik Smani and Antonio Ord ́ o ̃ nez-Fern ́ andez Circulating miR-320a as a Predictive Biomarker for Left Ventricular Remodelling in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention Reprinted from: J. Clin. Med. 2020 , 9 , 1051, doi:10.3390/jcm9041051 . . . . . . . . . . . . . . . . . 27 Moritz Mirna, Albert Topf, Bernhard Wernly, Richard Rezar, Vera Paar, Christian Jung, Hermann Salmhofer, Kristen Kopp, Uta C. Hoppe, P. Christian Schulze, Daniel Kretzschmar, Markus P. Schneider, Ulla T. Schultheiss, Claudia Sommerer, Katharina Paul, Gunter Wolf, Michael Lichtenauer and Martin Busch Novel Biomarkers in Patients with Chronic Kidney Disease: An Analysis of Patients Enrolled in the GCKD-Study Reprinted from: J. Clin. Med. 2020 , 9 , 886, doi:10.3390/jcm9030886 . . . . . . . . . . . . . . . . . . 47 Anna Klimiuk, Anna Zalewska, Robert Sawicki, Małgorzata Knapp and Mateusz Maciejczyk Salivary Oxidative Stress Increases with the Progression of Chronic Heart Failure Reprinted from: J. Clin. Med. 2020 , 9 , 769, doi:10.3390/jcm9030769 . . . . . . . . . . . . . . . . . . 65 Naufal Zagidullin, Lukas J. Motloch, Diana Gareeva, Aysilu Hamitova, Irina Lakman, Ilja Krioni, Denis Popov, Rustem Zulkarneev, Vera Paar, Kristen Kopp, Peter Jirak, Vladimir Ishmetov, Uta C. Hoppe, Eduard Tulbaev and Valentin Pavlov Combining Novel Biomarkers for Risk Stratification of Two-Year Cardiovascular Mortality in Patients with ST-Elevation Myocardial Infarction Reprinted from: J. Clin. Med. 2020 , 9 , 550, doi:10.3390/jcm9020550 . . . . . . . . . . . . . . . . . . 87 v Hiroyuki Naruse, Junnichi Ishii, Hiroshi Takahashi, Fumihiko Kitagawa, Hideto Nishimura, Hideki Kawai, Takashi Muramatsu, Masahide Harada, Akira Yamada, Wakaya Fujiwara, Mutsuharu Hayashi, Sadako Motoyama, Masayoshi Sarai, Eiichi Watanabe, Hideo Izawa and Yukio Ozaki Urinary Liver-Type Fatty-Acid-Binding Protein Predicts Long-Term Adverse Outcomes in Medical Cardiac Intensive Care Units Reprinted from: J. Clin. Med. 2020 , 9 , 482, doi:10.3390/jcm9020482 . . . . . . . . . . . . . . . . . . 103 Erik Nilsson, Jens Kastrup, Ahmad Sajadieh, Gorm Boje Jensen, Erik Kjøller, Hans Jørn Kolmos, Jonas Wuopio, Christoph Nowak, Anders Larsson, Janus Christian Jakobsen, Per Winkel, Christian Gluud, Kasper K Iversen, Johan ̈ Arnl ̈ ov and Axel C. Carlsson Pregnancy Associated Plasma Protein-A as a Cardiovascular Risk Marker in Patients with Stable Coronary Heart Disease During 10 Years Follow-Up—A CLARICOR Trial Sub-Study Reprinted from: J. Clin. Med. 2020 , 9 , 265, doi:10.3390/jcm9010265 . . . . . . . . . . . . . . . . . . 115 Elke Bouwens, Victor J. van den Berg, K. Martijn Akkerhuis, Sara J. Baart, Kadir Caliskan, Jasper J. Brugts, Henk Mouthaan, Jan van Ramshorst, Tjeerd Germans, Victor A. W. M. Umans, Eric Boersma and Isabella Kardys Circulating Biomarkers of Cell Adhesion Predict Clinical Outcome in Patients with Chronic Heart Failure Reprinted from: J. Clin. Med. 2020 , 9 , 195, doi:10.3390/jcm9010195 . . . . . . . . . . . . . . . . . . 127 Kuang-Fu Chang, Gigin Lin, Pei-Ching Huang, Yu-Hsiang Juan, Chao-Hung Wang, Shang-Yueh Tsai, Yu-Ching Lin, Ming-Ting Wu, Pen-An Liao, Lan-Yan Yang, Min-Hui Liu, Yu-Chun Lin, Jiun-Jie Wang, Koon-Kwan Ng and Shu-Hang Ng Left Ventricular Function and Myocardial Triglyceride Content on 3T Cardiac MR Predict Major Cardiovascular Adverse Events and Readmission in Patients Hospitalized with Acute Heart Failure Reprinted from: J. Clin. Med. 2020 , 9 , 169, doi:10.3390/jcm9010169 . . . . . . . . . . . . . . . . . . 143 Ewa Romuk, Wojciech Jache ́ c, Ewa Zbrojkiewicz, Alina Mroczek, Jacek Niedziela, Mariusz G ą sio r, Piotr Rozentryt and Celina Wojciechowska Ceruloplasmin, NT-proBNP, and Clinical Data as Risk Factors of Death or Heart Transplantation in a 1-Year Follow-Up of Heart Failure Patients Reprinted from: J. Clin. Med. 2020 , 9 , 137, doi:10.3390/jcm9010137 . . . . . . . . . . . . . . . . . . 159 Alexandre Meloux, Luc Rochette, Maud Maza, Florence Bichat, Laura Tribouillard, Yves Cottin, Marianne Zeller and Catherine Vergely Growth Differentiation Factor-8 (GDF8)/Myostatin Is a Predictor of Troponin I Peak and a Marker of Clinical Severity after Acute Myocardial Infarction Reprinted from: J. Clin. Med. 2020 , 9 , 116, doi:10.3390/jcm9010116 . . . . . . . . . . . . . . . . . . 175 Radka Koˇ ckov ́ a, Hana L ́ ınkov ́ a, Zuzana Hlubock ́ a, Alena Praveˇ ckov ́ a, Andrea Polednov ́ a, Lucie S ́ ukupov ́ a, Martin Bl ́ aha, Jiˇ r ́ ı Mal ́ y, Eva Honsov ́ a, David Sedmera and Martin Pˇ eniˇ cka New Imaging Markers of Clinical Outcome in Asymptomatic Patients with Severe Aortic Regurgitation Reprinted from: J. Clin. Med. 2019 , 8 , 1654, doi:10.3390/jcm8101654 . . . . . . . . . . . . . . . . . 185 Stas ̇ e Gasiul ̇ e, Vaidotas Stankeviˇ cius, Vaiva Patamsyt ̇ e, Raimundas Raˇ zanskas, Giedrius ˇ Zukovas, ˇ Zana Kapustina, Diana ˇ Zaliaduonyt ̇ e, Rimantas Benetis, Vaiva Lesauskait ̇ e and Giedrius Vilkaitis Tissue-Specific miRNAs Regulate the Development of Thoracic Aortic Aneurysm: The Emerging Role of KLF4 Network Reprinted from: J. Clin. Med. 2019 , 8 , 1609, doi:10.3390/jcm8101609 . . . . . . . . . . . . . . . . . 199 vi Toshiaki Nakajima, Ikuko Shibasaki, Tatsuya Sawaguchi, Akiko Haruyama, Hiroyuki Kaneda, Takafumi Nakajima, Takaaki Hasegawa, Takuo Arikawa, Syotaro Obi, Masashi Sakuma, Hironaga Ogawa, Shigeru Toyoda, Fumitaka Nakamura, Shichiro Abe, Hirotsugu Fukuda and Teruo Inoue Growth Differentiation Factor-15 (GDF-15) Is a Biomarker of Muscle Wasting and Renal Dysfunction in Preoperative Cardiovascular Surgery Patients Reprinted from: J. Clin. Med. 2019 , 8 , 1576, doi:10.3390/jcm8101576 . . . . . . . . . . . . . . . . . 215 Josip A. Borovac, Duska Glavas, Zora Susilovic Grabovac, Daniela Supe Domic, Domenico D’Amario and Josko Bozic Catestatin in Acutely Decompensated Heart Failure Patients: Insights from the CATSTAT-HF Study Reprinted from: J. Clin. Med. 2019 , 8 , 1132, doi:10.3390/jcm8081132 . . . . . . . . . . . . . . . . . 231 Daniel Dalos, Georg Spinka, Matthias Schneider, Bernhard Wernly, Vera Paar, Uta Hoppe, Brigitte Litschauer, Jeanette Strametz-Juranek and Michael Sponder New Cardiovascular Biomarkers in Ischemic Heart Disease—GDF-15, A Probable Predictor for Ejection Fraction Reprinted from: J. Clin. Med. 2019 , 8 , 924, doi:10.3390/jcm8070924 . . . . . . . . . . . . . . . . . . 249 Yi-Lin Shiou, Hsin-Ting Lin, Liang-Yin Ke, Bin-Nan Wu, Shyi-Jang Shin, Chu-Huang Chen, Wei-Chung Tsai, Chih-Sheng Chu and Hsiang-Chun Lee Very Low-Density Lipoproteins of Metabolic Syndrome Modulates STIM1, Suppresses Store-Operated Calcium Entry, and Deranges Myofilament Proteins in Atrial Myocytes Reprinted from: J. Clin. Med. 2019 , 8 , 881, doi:10.3390/jcm8060881 . . . . . . . . . . . . . . . . . . 261 Yi-Cheng Chang, Shih-Che Hua, Chia-Hsuin Chang, Wei-Yi Kao, Hsiao-Lin Lee, Lee-Ming Chuang, Yen-Tsung Huang and Mei-Shu Lai High TSH Level within Normal Range Is Associated with Obesity, Dyslipidemia, Hypertension, Inflammation, Hypercoagulability, and the Metabolic Syndrome: A Novel Cardiometabolic Marker Reprinted from: J. Clin. Med. 2019 , 8 , 817, doi:10.3390/jcm8060817 . . . . . . . . . . . . . . . . . . 277 David de Gonzalo-Calvo, David Vilades, Pablo Mart ́ ınez-Camblor, ` Angela Vea, Andreu Ferrero-Gregori, Laura Nasarre, Olga Bornachea, Jesus Sanchez Vega, Rub ́ en Leta, N ́ uria Puig, Sonia Ben ́ ıtez, Jose Luis Sanchez-Quesada, Francesc Carreras and Vicenta Llorente-Cort ́ es Plasma microRNA Profiling Reveals Novel Biomarkers of Epicardial Adipose Tissue: A Multidetector Computed Tomography Study Reprinted from: J. Clin. Med. 2019 , 8 , 780, doi:10.3390/jcm8060780 . . . . . . . . . . . . . . . . . . 293 Weronika Bulska- B ę dk owska, El ̇ zbieta Chełmecka, Aleksander J. Owczarek, Katarzyna Mizia-Stec, Andrzej Witek, Aleksandra Szybalska, Tomasz Grodzicki, Magdalena Olszanecka-Glinianowicz and Jerzy Chudek CA125 as a Marker of Heart Failure in the Older Women: A Population-Based Analysis Reprinted from: J. Clin. Med. 2019 , 8 , 607, doi:10.3390/jcm8050607 . . . . . . . . . . . . . . . . . . 313 Margaret A. Drazba, Ida Hol ́ askov ́ a, Nadine R. Sahyoun and Melissa Ventura Marra Associations of Adiposity and Diet Quality with Serum Ceramides in Middle-Aged Adults with Cardiovascular Risk Factors Reprinted from: J. Clin. Med. 2019 , 8 , 527, doi:10.3390/jcm8040527 . . . . . . . . . . . . . . . . . . 325 vii Zornitsa Shomanova, Bernhard Ohnewein, Christiane Schernthaner, Killian H ̈ ofer, Christian A. Pogoda, Gerrit Frommeyer, Bernhard Wernly, Mathias C. Brandt, Anna-Maria Dieplinger, Holger Reinecke, Uta C. Hoppe, Bernhard Strohmer, Rudin Pistulli and Lukas J. Motloch Classic and Novel Biomarkers as Potential Predictors of Ventricular Arrhythmias and Sudden Cardiac Death Reprinted from: J. Clin. Med. 2020 , 9 , 578, doi:10.3390/jcm9020578 . . . . . . . . . . . . . . . . . . 339 Abrar Alfatni, Marianne Riou, Anne-Laure Charles, Alain Meyer, Cindy Barnig, Emmanuel Andres, Anne Lejay, Samy Talha and Bernard Geny Peripheral Blood Mononuclear Cells and Platelets Mitochondrial Dysfunction, Oxidative Stress, and Circulating mtDNA in Cardiovascular Diseases Reprinted from: J. Clin. Med. 2020 , 9 , 311, doi:10.3390/jcm9020311 . . . . . . . . . . . . . . . . . . 371 Richard Rezar, Peter Jirak, Martha Gschwandtner, Rupert Derler, Thomas K. Felder, Michael Haslinger, Kristen Kopp, Clemens Seelmaier, Christina Granitz, Uta C. Hoppe and Michael Lichtenauer Heart-Type Fatty Acid-Binding Protein (H-FABP) and Its Role as a Biomarker in Heart Failure: What Do We Know So Far? Reprinted from: J. Clin. Med. 2020 , 9 , 164, doi:10.3390/jcm9010164 . . . . . . . . . . . . . . . . . . 395 viii About the Editor Michael Lichtenauer was born in Vienna, Austria. He attended primary and secondary school in Vienna’s 19th district and finished his Matura exams in 2003 with distinction. After serving his civilian service in the years 2003 and 2004, he registered himself as a student in human medicine at the Medical University Vienna in autumn 2004. He started his career in biomedical sciences in 2006 when he joined a research group at the Department of Cardio-Thoracic Surgery at the Medical University Vienna. Shortly after, he was assigned a research project focusing on regenerative medicine that investigated the positive influence of apoptotic cells in an animal model of acute myocardial infarction. In a follow-up project, he analyzed the effects of apoptotic cells on cellular protective signaling mechanism leading to a reduction in the damage caused by myocardial infarction in a small and large animal model. In his PhD thesis, he described these protective effects which were primarily attributed to soluble (“paracrine”) mediators release by apoptotic cell. After earning his degree in human medicine in 2010, he started his residency in Internal Medicine and Cardiology at the Friedrich Schiller University Jena, Germany (Head: Prof. Figulla). In 2010, he was awarded the First Prize in Basic Science for his research on cell protective mechanisms at the annual meeting of the Austrian Society of Cardiology in Salzburg. In 2012, he finished his PhD thesis and was nominated researcher of the month at the Medical University of Vienna. At the University of Jena, he joined the research group of Prof. Christian Jung and focused on biomarker research in cardiovascular diseases and prevention. In 2014, he returned to Austria and continued his residency in Internal Medicine and Cardiology at the University Hospital Salzburg (Head. Prof. Hoppe). A year later, he filed his application for the venia docendi (Habilitation) at the Paracelsus Medical University. In 2017, he finished his residency and is has been employed as consultant physician since then. In 2019, Dr. Lichtenauer was summoned as Associate Professor in Internal Medicine at the Paracelsus Medical University. He has been awarded national and internal prizes of the scientific community, is acting as a reviewer for international peer-reviewed journals, and is involved in the organization the curriculum of Human Medicine at the Paracelsus Medical University. Furthermore, he holds multiple memberships of national and international medical associations and societies. ix Journal of Clinical Medicine Editorial Assessment of Cardiac Remodeling—A Chance for Novel Cardiac Biomarkers? Peter Jirak, Moritz Mirna, Bernhard Wernly, Vera Paar, Uta C. Hoppe and Michael Lichtenauer * Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; p.jirak@salk.at (P.J.); m.mirna@salk.at (M.M.); b.wernly@salk.at (B.W.); v.paar@salk.at (V.P.); u.hoppe@salk.at (U.C.H.) * Correspondence: m.lichtenauer@salk.at; Tel.: + 43-57855-57130 Received: 21 June 2020; Accepted: 29 June 2020; Published: 3 July 2020 1. Background Biomarkers are defined as “cellular, biochemical or molecular alterations that are measurable in biological media such as human tissues, cells, or fluids”, providing “biological characteristics that can be objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention “according to Hulka et al. as well as Naylor et al. [ 1 , 2 ]. Depending on their respective role in physiologic and pathophysiologic processes, biomarkers can be used for di ff erent purposes such as disease diagnosis, risk stratification, screening, as well as prognosis [ 2 ]. In recent decades, biomarkers have gained major clinical significance, especially in the cardiovascular field. Above all, the introduction of natriuretic peptides and highly sensitive troponin assays have led to significant facilitation and improvement in clinical practice. However, while these markers represent indispensable diagnostic tools in clinical routines, their prognostic impact remains limited. Accordingly, the evaluation of prognosis remains a clinical challenge, even to date. In contrast to the aforementioned markers, novel biomarkers targeting the critical factors for prognosis and outcomes in cardiovascular disease, cardiac fibrosis, and remodeling could be of additional value on this account [ 3 , 4 ]. Cardiac remodeling: The term cardiac remodeling describes changes in the size; mass; geometry; and, consequently, function of the heart in response to acute and chronic myocardial damage [ 5 ]. While acute myocardial damage is usually induced by ischemic processes such as myocardial infarction, chronic damage comprises inflammatory processes, dysregulated metabolic pathways, toxic damage, as well as a chronic increase in cardiac strain [6–8]. Interestingly, in contrast to natriuretic peptides as well as troponin, most novel heart failure biomarkers do not provide a comparable amount of organ specificity [ 9 , 10 ]. However, due to their involvement in multiple pathophysiologic processes, novel cardiac biomarkers represent promising tools to refine the assessment of cardiac remodeling and fibrosis and thus also of prognosis [4,11]. 2. sST2 The most promising marker on this regard represents soluble suppression of tumorigenicity 2 (sST2), which has also found entrance into current guidelines to some extent. sST2 represents a versatile marker, predominantly used in heart failure patients [ 12 ]. sST2 was shown to be elevated in acute and chronic heart failure as well as in acute coronary syndrome [ 13 , 14 ]. Besides, elevated levels have also been reported in pulmonary hypertension and peripheral artery disease, emphasizing its involvement in di ff erent disease entities [15,16]. Regarding its molecular background, two di ff erent isoforms have been identified, a soluble form (sST2) and a membrane-bound form (ST2L) [ 17 ]. Interleukin-33 (IL-33) represents the only known ligand for ST2 and is responsible for the induction of cardioprotective e ff ects by binding to the ST2L receptor [ 17 ]. Besides, IL-33 is also involved in immunomodulation through the secretion and the J. Clin. Med. 2020 , 9 , 2087; doi:10.3390 / jcm9072087 www.mdpi.com / journal / jcm 1 J. Clin. Med. 2020 , 9 , 2087 interaction of T helper 2 (TH2) cells, mast cells, group 2 innate lymphoid cells, (ILC2s) regulatory T (Treg) cells, TH1 cells, CD8 + T cells, and natural killer (NK) cells, among others, further elucidating the involvement of sST2 and ST2L in inflammatory processes [ 18 ]. On the other hand, sST2 can counteract the cardioprotective e ff ects by acting as a decoy receptor for IL-33 [ 17]. Hence, an increase in sST2 results in a decrease of cardioprotective IL-33, consequently leading to cardiac damage and increased cardiac strain [17]. In short, sST2 incorporates di ff erent pathophysiological processes involved in cardiac remodeling and fibrosis such as inflammation and increased cardiac strain. Accordingly, sST2 represents a promising new marker in the assessment of prognosis of heart failure patients. sST2 was shown to predict all-cause mortality as well as cardiovascular mortality in chronic heart failure patients [ 19 ]. Additionally, sST2 was reported to predict mortality in acute heart failure [ 11 ]. With regards to therapy monitoring, an sST2 cut-o ff below 35-ng / mL was proposed to significantly improve outcomes in heart failure patients (Pres-ageassay, Critical Diagnostics, SanDiego, California, USA) [19]. 3. microRNAs While sST2 has already found entrance into current guidelines, the field of microRNAs (miRNAs) is currently limited to investigative research, although previous trials have reported promising results regarding their diagnostic and therapeutic applicability in cardiovascular disease entities. MiRNAs comprise a group of small (19–24 nucleotides) ribonucleic acids (RNAs), which play a pivotal role in posttranslational gene silencing (PTGS) and hence regulation of protein synthesis [ 20 , 21 ]. In recent studies, several miRNAs were found to be involved in cardiac remodeling by promoting myocardial inflammation, as well as pro-fibrotic and -apoptotic pathways. Consequently, patients with acute and chronic heart failure show dysregulated plasma concentrations of various pathological miRNAs, which gives rise to novel diagnostic approaches in these patients. For example, Ovchinnikova et al. recently identified several significantly dysregulated miRNAs (miR-18a-5p, miR-26b-5p, miR-27a-3p, miR-30e-5p, miR-106a-5p, miR-199a-3p, and miR-652-3p) in acute heart failure (AHF), which were also associated with adverse outcomes in these patients [ 22 ]. Furthermore, another trial reported that a combination of miR-30c, miR-221, miR-328, and miR-375 could adequately discriminate heart failure with preserved ejection fraction (HFpEF) from heart failure with reduced ejection fraction (HFrEF) [ 23 ], which is to this extent not possible using conventional cardiovascular biomarkers [ 24 ]. Consequently, analysis of the miRNA expression pattern (“miRNome”) could provide substantial additional information in the clinical management of patients with HF in the future. Besides their application in diagnostics, miRNAs also constitute interesting targets for novel therapeutic approaches. Since myocardial inflammation and cardiac fibrosis are considered potentially reversible processes in the course of cardiac remodeling, miRNAs interacting with these pathways represent promising targets in the management of patients with HF. For example, miR-21 was found to enhance myocardial fibrosis by targeting the extracellular signal-regulated kinase (ERK)–mitogen-activated protein (MAP) kinase pathway, and silencing of miR-21 by synthetic antagonist significantly attenuated myocardial fibrosis in an animal model [ 25 ]. Since miR-21 was also found to be involved in myocardial inflammation by targeting T-cell development, it constitutes an interesting drug target in the management of HF and certainly warrants further investigation in future studies. 4. Conclusions Despite the long time period since the establishment of natriuretic peptides and troponin in clinical practice, the evaluation of prognosis in cardiovascular disease remains challenging. The assessment of cardiac remodeling and fibrosis with the help of novel biomarkers represents a promising approach for a more sophisticated evaluation of prognosis and consequently also therapy guiding. In this regard, their versatility regarding their involvement in numerous di ff erent organ systems might be a considerable benefit over natriuretic peptides and troponin with regards to their prognostic value. As cardiac 2 J. Clin. 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Braun-Dullaeus 5 and Tarek Bekfani 5 1 Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; m.lichtenauer@salk.at (M.L.); b.wernly@salk.at (B.W.); v.paar@salk.at (V.P.); l.motloch@salk.at (L.J.M.); r.rezar@salk.at (R.R.); u.hoppe@salk.at (U.C.H.) 2 Division of Vascular Medicine, Department of Cardiology and Angiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Munster, North Rhine-Westphalia, 48149 Münster, Germany; Rudin.Pistulli@ukmuenster.de 3 Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, 40225 Duesseldorf, Germany; Christian.Jung@med.uni-duesseldorf.de 4 Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, University Hospital Jena, Friedrich Schiller University Jena, 07740 Jena, Germany; Christian.Schulze@med.uni-jena.de (P.C.S.); daniel.kretzschmar@med.uni-jena.de (D.K.) 5 Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Magdeburg, Otto von Gericke University, Magdeburg, 39120 Magdeburg, Germany; r.braun-dullaeus@med.ovgu.de (R.C.B.-D.); tarek.bekfani@med.ovgu.de (T.B.) * Correspondence: p.jirak@salk.at † These authors contributed equally to the paper. Received: 27 February 2020; Accepted: 8 April 2020; Published: 15 April 2020 Abstract: Background: Heart failure with preserved ejection fraction (HFpEF) remains an ongoing therapeutic and diagnostic challenge to date. In this study we aimed for an analysis of the diagnostic potential of four novel cardiovascular biomarkers, GDF-15, H-FABP, sST2, and suPAR in HFpEF patients compared to controls as well as ICM, and DCM. Methods: In total, we included 252 stable outpatients and controls (77 DCM, 62 ICM, 18 HFpEF, and 95 controls) in the present study. All patients were in a non-decompensated state and on a stable treatment regimen. Serum samples were obtained and analyzed for GDF-15 (inflammation, remodeling), H-FABP (ischemia and subclinical ischemia), sST2 (inflammation, remodeling) and suPAR (inflammation, remodeling) by means of ELISA. Results: A significant elevation of GDF-15 was found for all heart failure entities compared to controls ( p < 0.005). Similarly, H-FABP evidenced a significant elevation in all heart failure entities compared to the control group ( p < 0.0001). Levels of sST2 were significantly elevated in ICM and DCM patients compared to the control group and HFpEF patients ( p < 0.0001). Regarding suPAR, a significant elevation in ICM and DCM patients compared to the control group ( p < 0.0001) and HFpEF patients ( p < 0.01) was observed. An AUC analysis identified H-FABP (0.792, 95% CI 0.713–0.870) and GDF-15 (0.787, 95% CI 0.696–0.878) as paramount diagnostic biomarkers for HFpEF patients. Conclusion: Based on their di ff erences in secretion patterns, novel cardiovascular biomarkers might represent a promising diagnostic tool for HFpEF in the future. Keywords: HFpEF; heart failure; HFrEF; biomarker; sST2; suPAR; H-FABP; sST2 J. Clin. Med. 2020 , 9 , 1130; doi:10.3390 / jcm9041130 www.mdpi.com / journal / jcm 5 J. Clin. Med. 2020 , 9 , 1130 1. Introduction With an overall prevalence of 2%, heart failure (HF) represents one of the leading causes of morbidity and mortality in the western world and thus also an important economic factor [ 1 ]. About 50% of all heart failure patients su ff er from heart failure with preserved ejection fraction (HFpEF). HFpEF is characterized by a deterioration of cardiac relaxation resulting in an impaired diastolic filling of the left ventricle, mainly triggered by arterial hypertension along with obesity and metabolic disorders [ 2 , 3 ]. In contrast to heart failure with reduced ejection fraction (HFrEF), the left ventricular ejection fraction in HFpEF remains preserved [2,3]. The cellular processes involved in the development of HFpEF are heterogeneous. One of the most generally accepted hypotheses is that cellular hypertrophy combined with a reduction in cellular relaxation and an increase in tissue fibrosis could contribute strongly to the development of ventricular sti ff ening [ 4 , 5 ]. Furthermore, obesity, which is a very frequent co-morbidity of HF, leads to adipose tissue dysfunction along with elevated leptin levels and can trigger an upregulation of aldosterone, leading to sodium retention [ 6 ]. In consequence, higher levels of aldosterone trigger a volume expansion leading to increased filling pressures, thereby promoting cardiac remodeling, myocardial hypertrophy and fibrosis [6]. While numerous advancements have been made in the pharmacologic treatment of heart failure with reduced ejection fraction over the last decades (e.g., ARNIs), no evidence-based therapy for HFpEF patients exists to date [ 3 , 7 ]. Despite huge e ff orts, studies failed to show a significant prognostic benefit of pharmaceutical therapies in HFpEF, with the “PARAGON-Trial” as most prominent example [ 8 ]. Accordingly, the prognosis in HFpEF remains poor [9]. In addition to the lack of an evidence-based therapy, the actual diagnosis of HFpEF remains challenging and the precise diagnostic criteria are still matter of ongoing debates [ 9 ]. According to the current ESC guidelines, HFpEF is defined as a combination of: (I) Typical signs and symptoms of heart failure, (II) elevated levels of natriuretic peptides, (III) LVEF > 50%, (IV) evidence of diastolic dysfunction and / or structural heart disease (left ventricular hypertrophy or left atrial enlargement) [ 3 ]. Given the vague diagnostic criteria, the need for novel and additional diagnostic markers for HFpEF is evident. In the last years, novel cardiac biomarkers have emerged as promising diagnostic tools for the assessment of di ff erent cardiovascular disease entities [ 10 , 11 ]. As a result to the complex pathophysiological background of most cardiovascular diseases, a multi-marker approach was reported as most e ff ective for diagnosis, therapy monitoring and risk prediction due to the incorporation of di ff erent pathophysiologic processes covered by each respective marker [10,12]. Among the tested markers in previous studies, H-FABP (myocardial ischemia), sST-2 (myocardial strain and inflammation), GDF-15 (inflammation, remodeling), and suPAR (inflammation, remodeling) proved to be promising tools in achieving an improvement in the diagnosis and prognosis of cardiovascular diseases [ 13 – 16 ]. Accordingly, some of the listed markers are already included in the current guidelines and used in clinical routine [17]. Given the evident need for novel diagnostic tools in HFpEF we aimed for a head-to-head analysis of these four novel cardiovascular biomarkers in patients with heart failure with preserved ejection fraction compared to controls. Additionally, as the aforementioned markers are well studied in HFrEF patients, we aimed for a head-to-head analysis of HFpEF and HFrEF patients to put our findings into reference. 2. Experimental Section The present study was conducted in accordance with the Universal Declaration of Helsinki and was approved by the local ethics committee at the University Hospital Jena, Germany. In total, we included 252 patients in this retrospective single-center study. Seventy-seven patients diagnosed with DCM, 62 patients with ICM, and 18 patients diagnosed with HFpEF were enrolled. Additionally, a control group of 95 patients was included. In these patients, coronary artery disease was excluded 6 J. Clin. Med. 2020 , 9 , 1130 by coronary angiography. During visits in the outpatient ward, serum samples of all patients were obtained and analyzed for GDF-15, H-FABP, sST2, and suPAR. The diagnosis of ICM, DCM and HFpEF was made according to the current guidelines of the European Society of Cardiology [ 3 ]. Clinical examination, assessment of medical history, laboratory analysis as well as transthoracic echocardiography was performed in all patients in the outpatient ward. Additionally, ICM and DCM patients underwent coronary angiography for diagnosis / exclusion of coronary artery disease. Controls also underwent coronary angiography because of suspected coronary artery disease and a relevant risk profile (hypertension, smoking etc.) and evidenced a rule out. All patients were in a stable, non-decompensated state at the timepoint of inclusion and clinical examination and were on a stable treatment regimen. Decompensated HF patients were not enrolled in this study. All examinations were performed by an experienced heart failure specialist. Laboratory analysis was conducted in all patients after informed consent. Serum samples were analyzed by means of ELISA and were stored at − 80 ◦ C until measurements were conducted. Exclusion criteria were defined as: (I) Age under 18 years, (II) acute or chronic infections, (III) malignancies, (IV) advanced stages of renal failure (as indicated by a glomerular filtration rate less than 30 mL / min), (V) decompensated heart failure, (VI) hyperthyroidism, (VII) medication with immunosuppressive agents, and (VIII) recent acute coronary syndrome. For HFpEF patients a glomerular filtration rate under 60 ml / min was an exclusion criterion to rule out a potential cardiorenal confounder in this cohort. 2.1. Laboratory Analysis Routine analysis of blood samples was performed at the Department of Clinical Chemistry (University Hospital Jena). The analyses comprised high-density lipoprotein (HDL; mmol / L), low density, lipoprotein (LDL; mmol / L), triglycerides (mmol / L), and C-reactive protein (CRP, mg / L) and hematological parameters. The glomerular filtration rate was calculated ac