MULTIPLE BIOMARKERS FOR THE

PREDICTION OF FIRST MAJOR

CARDIOVASCULAR EVENTS AND DEATH
Wang, Thomas J., et al., Massachusetts General
Hospital.,NEJM.

DR SHAHID HUSSAIN

OVERVIEW

To evaluate the incremental usefulness of

multiple biomarkers from various pathways.

Established risk factors, including smoking,

htn, DM, and dyslipidemia.

Significant interest in new biomarkers for risk

stratification of ambulatory persons.

NOVEL APPROACH

Many individual biomarkers have been

studied

Multimarker Approach

Simultaneous measurement may enhance

risk stratification?

OUTCOMES ANALYSIS

Death from any cause

1st Major cardiovascular event (MI, coronary

insufficiency, heart failure, and stroke.

Reviewed by a committee of three

investigators

STUDY SAMPLE

Large, community based cohort study

Participants from the sixth examination cycle

(1995-1998) of the Framingham Offspring Study

IRB of Boston University Medical Center approval

Written informed consent was obtained

EXCLUSION CRITERIA

Serum creatinine levels greater than 2.0 mg/dL

Missing covariates

Prior event when determining outcome of major

cardiovascular event

Triglycerides > 400

BIOMARKER SELECTION

1. Marker of inflammation- hsCRP

2. Markers of neurohormonal activity- BNP,

aldosterone, renin, N-terminal pro-atrial
natriuretic peptide

3. Marker of thrombosis and inflammation- fibrinogen

4. Marker of fibrinolytic potential and endothelial

function- plasminogen-activator (Inhibitor type 1)

BIOMARKER CONTD

5. Marker of thrombosis- D-dimer

6. Marker of endotheial function and oxidant

stress- homocysteine

7. Marker of glomerular endothelial functionurinary albumin-to-creatinine ratio

LAB PROTOCOL

Fasting blood and urine samples collected in

morning after patient supine for ~10
minutes. Immediately centrifuged and
stored at -70 C

Standardized Assay Methods

STATISTICAL ANALYSIS

Multivariable proportional-hazards model (2

sets of analyses for each outcome due to
urine subgroups)

Logarithmic transformation used to normalize

the distribution of biomarkers

To reduce the number of false positives from

multiple testing:

STATISTICS CONTD

1) Multivariable Cox regression model

2) Backward elimination

3) Construction of multimarker score

4) Quintiles categorized

5) Cumulative probability curves constructed by the KaplanMeier method for low, intermediate and high mulitmarker
scores

RESULTS

Total of 3532 persons- 21 excluded for serum creatinine

and 302 for missing covariates.

10 year follow-up (median 7.4 years) 3209 available for

study.

207 (6%) died, of whom 72 were women

169 (6%, excluding prevalent CV disease at baseline) had

a major cardiovascular event, of whom 68 were women

RESULTS CONTD

Biomarker panel for nine: P<0.001 for death

and P=0.005 for cardiovascular events

Biomarker panel for ten (2750 persons):

P<0.001 for death and P=0.04 for
cardiovascular events

RESULTS CONTD

Backward elimination models: final statistical

model included only the following biomarkers:

BNP, homocysteine, urinary albumin-tocreatinine ratio and renin for death.

BNP and urinary albumin-to-creatinine ratio for
major cardiovascular events.

UTILITY OF MULTIMARKER SCORES

Backward elimination biomarkers selected as

statistically significant were incorporated into
mulitmarker scores.

Restricted to urine sample patients:

1) death from any cause, the number of events and

number at risk were 172 and 2750, respectively;
2) major cardiovascular events, 133 and 2598,
respectively.

UTILITY?

Persons with high multimarker scores had a

risk of death four times as great and a risk of
major cariovascular events almost two times
as great as persons with low mulitmarker
scores.

(P<0.001 and P=0.02, respectively)

DISCUSSION

~10 year study of biomarkers indicating BNP,

hsCRP, homocysteine, renin, and alb/Cr ratio as
most informative for predicting death,

BNP and alb/Cr ration as significant for predicting

cardiovascular outcome.

Although high multimarker scores conferred

greater risk for death and major cardiovascular
events

CONCLUSION

Mulitmarker scores (combination of biomarkers)

add only moderately to conventional risk factors
as evidenced by small changes in C statistic.

Single biomarkers may have correlation with

predicting outcomes

Panel likely will not be useful or cost-effective in

ambulatory setting for further risk stratification

LIMITATIONS

Biomarker selection: omission of lipoproteinassociated phospholipase A2

Each individual marker not independently tested

Not a true cohort study to asses for primary

prevention as nonmajor cardiovascular events
adjusted

Adiposity or insulin resistance not taken into account

SUMMARY

Biomarkers from multiple, biologically distinct

pathways are associated with the risks of
death and major cardiovascular events.

However, only moderately adds to

conventional risk factors currently.