Classifications

• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
  • G01N33/6893—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids related to diseases not provided for elsewhere
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
  • A61B5/00—Measuring for diagnostic purposes; Identification of persons
  • A61B5/02—Detecting, measuring or recording for evaluating the cardiovascular system, e.g. pulse, heart rate, blood pressure or blood flow
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
  • A61B5/00—Measuring for diagnostic purposes; Identification of persons
  • A61B5/48—Other medical applications
  • A61B5/4836—Diagnosis combined with treatment in closed-loop systems or methods
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
  • A61B5/00—Measuring for diagnostic purposes; Identification of persons
  • A61B5/48—Other medical applications
  • A61B5/4884—Other medical applications inducing physiological or psychological stress, e.g. applications for stress testing
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
  • A61B6/00—Apparatus or devices for radiation diagnosis; Apparatus or devices for radiation diagnosis combined with radiation therapy equipment
  • A61B6/50—Apparatus or devices for radiation diagnosis; Apparatus or devices for radiation diagnosis combined with radiation therapy equipment specially adapted for specific body parts; specially adapted for specific clinical applications
  • A61B6/503—Apparatus or devices for radiation diagnosis; Apparatus or devices for radiation diagnosis combined with radiation therapy equipment specially adapted for specific body parts; specially adapted for specific clinical applications for diagnosis of the heart
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/28—Neurological disorders
  • G01N2800/2871—Cerebrovascular disorders, e.g. stroke, cerebral infarct, cerebral haemorrhage, transient ischemic event
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/32—Cardiovascular disorders
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/32—Cardiovascular disorders
  • G01N2800/324—Coronary artery diseases, e.g. angina pectoris, myocardial infarction
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/52—Predicting or monitoring the response to treatment, e.g. for selection of therapy based on assay results in personalised medicine; Prognosis

Definitions

• the present disclosure relates biomarker panels, assays, and kits and methods for determining the diagnosis and/or prognosis of a cardiovascular disease or outcome in a patient.
• ASCVD Atherosclerotic cardiovascular disease
• cardiovascular events including, for example, obstructive coronary artery disease (CAD), myocardial infarction (MI), stroke, and cardiovascular death (CVD) are predominantly caused by an underlying vascular endothelial process leading to deposition of lipid material and other proteins resulting in atherosclerotic plaque formation in multiple vascular beds in the human body. While this process is associated with identifiable and modifiable risk factors, the disease process and its related events noted above remain the leading cause of death and severe disability worldwide (Yusuf et al., Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the rNTERHEART study): case-control study, Lancet, 364:937-52 (2004)).
• CAD obstructive coronary artery disease
• MI myocardial infarction
• CVD cardiovascular death
• cardiovascular disease typically associated with underlying atherosclerosis
• atherosclerosis is the leading cause of death (Martin- Ventura et al., 2009, Rev. Esp. Cardiol 62(6):677-688, citing Murray and Lopez, 1997, Lancet 349: 1269-1276).
• Risk factors for cardiac disease are well known, and include hypertension, diabetes, smoking, elevated cholesterol, obesity, and family history.
• CAD obstructive coronary artery disease
• the link between the onset of symptoms and a cardiac event requiring intervention remains elusive.
• Symptoms can be non-specific, such as a feeling of heaviness in the chest, and can reflect CAD but could also be explained by gastric distress; pain in the left arm could be of cardiac origin or could be caused by arthritis. Even when pain is highly likely to be cardiac in origin, there can be questions regarding the type and intensity of treatment required; in some scenarios, medication may be sufficient, but in others, an interventional strategy is necessary to avoid CVE.
• a number of technologies have been developed to identify patients at high risk for an adverse cardiac event. These include exercise and pharmacologic stress testing using evaluations of the ECG response, the cardiac wall motion response using ultrasound, and changes in myocardial perfusion using nuclear imaging techniques. Coronary angiography, the most invasive approach, has been considered the "gold standard" diagnostic tool to evaluate coronary artery anatomy, cardiac structure, and function, but it is invasive, costly, has defined complications, and is subject to operator-dependent variability (Sharma et al., 2010, Vase. Health Risk Manag. 3:17-316). Other, newer and less-invasive options are being explored, including coronary computed tomographic angiography (Sharma et al., supra; Cury et al., 2008. J.
• the present disclosure provides methods for determining the diagnosis and/or prognosis of a cardiovascular disease or outcome in a subject, comprising the steps: (i) determining the level of at least one, at least two, at least three, at least four or greater than four biomarkers in a biological sample obtained from the subject, wherein the biomarkers are selected from the group consisting of those set forth in Tables 1 A, IB, 2A, and 2B; (ii) optionally, determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of those set forth in Tables 3 A, 3B, 4A and 4B; (iii) calculating a diagnostic and/or prognostic score for the subject based on the determined level of at least one biomarker and, optionally, the status of the clinical variable(s) determined in step (ii); (iv) classifying the diagnostic or prognostic score as a positive or negative result; and (v) determining a therapeutic or diagnostic intervention regimen based
• the diagnosis or prognosis provided by the methods of the present disclosure are particularly important in defining and determining a therapeutic path forward for a patient receiving a positive diagnosis of coronary artery disease and/or a positive prognosis of cardiovascular death, myocardial infarct (MI), stroke, all cause death, or a composite thereof.
• MI myocardial infarct
• the determined diagnosis and/or prognosis of a cardiovascular disease or outcome in the subject facilitates a determination by a medical practitioner of a need for a therapeutic or diagnostic intervention in the subject.
• the biomarkers used in the methods are selected from the biomarkers listed in Tables 1 A, IB, 2A, and 2B, particularly those that have a p-value of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• the method comprises determining the levels of at least one, at least two, at three, at least four, or greater than four biomarkers selected from the group consisting of adiponectin, apolipoprotein A-II, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule-1, matrix metalloproteinase 9 (MMP-9), midkine, myoglobin, N terminal prohormone of brain natriuretic protein (NT-proBNP), osteopontin, pulmonary surfactant associated protein D, stem cell factor, tissue inhibitor of metalloproteinases-1 (TEVIP-l), troponin, and vascular cell adhesion molecule (VCAM).
• biomarkers selected from the group consisting of adiponectin, apolipoprotein A-II, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule-1, matrix metalloproteinase 9 (MMP-9), midkine, myoglobin,
• the method further comprises determining the status of at least one clinical variable, such as those listed in Tables 3 A, 3B, 4A and 4B, particularly those having a p-value of less than 0.1, less than 0.05, less than 0.01, or less than 0.001.
• the method comprises determining the status of at least one clinical variable selected from the group consisting of age, history of coronary artery bypass graft surgery (CABG), history of diabetes type 2, history of hemodialysis, history of myocardial infarct (MI), history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• CABG coronary artery bypass graft surgery
• MI myocardial infarct
• percutaneous coronary intervention e.g., balloon angioplasty with or without stent placement
• step (i) of the method comprises determining the level of at least one, at least two, at least three, at least four, or greater than four biomarkers selected the groups consisting of adiponectin, apolipoprotein A-II, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule-1, matrix metalloproteinase 9 (MMP-9), midkine, myoglobin, N terminal prohormone of brain natriuretic protein (NT-proB P), osteopontin, pulmonary surfactant associated protein D, stem cell factor, tissue inhibitor of metalloproteinases-1 (TIMP-1), troponin, and vascular cell adhesion molecule (VCAM), and step (ii) comprises determining the status of at least one clinical variables selected from age, history of coronary artery bypass graft surgery (CABG), history of diabetes type 2, history of hemodialysis, history of myocardial infarct (MI), history
• CABG coronary artery bypass graft surgery
• the methods advantageously provide a diagnosis of obstructive coronary artery disease in the subject.
• the diagnosis of obstructive coronary artery disease in the subject comprises a diagnosis of 70% or greater obstruction in a major epicardial vessel.
• step (i) of the method comprises determining the level of at least one, at least two, at least three, at least four, or greater than four biomarkers selected from the group consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule-1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• biomarkers selected from the group consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule-1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• the methods provide a prognosis of the likelihood for a cardiac outcome, such as an outcome selected from cardiovascular death, myocardial infarct (MI), stroke, all cause death, or a composite thereof.
• a cardiac outcome such as an outcome selected from cardiovascular death, myocardial infarct (MI), stroke, all cause death, or a composite thereof.
• MI myocardial infarct
• the present provides methods for diagnosing the presence of obstructive coronary artery disease in a subject, comprising the steps: (i) determining the level of at least one, at least two, at least three, at least four, or greater than four biomarkers in a biological sample obtained from the subject, wherein the biomarkers are selected from the group consisting of the biomarkers listed in Tables 1 A and IB; (ii) optionally determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of the clinical variables listed in Tables 3 A and 3B; (iii) calculating a diagnostic score for the subject based on the determined level of the at least one biomarker and optionally the status of the at least one clinical variable; (iv) classifying the score as a positive or negative diagnosis of obstructive coronary artery disease; and (iv) determining a therapeutic or diagnostic intervention regimen based on the positive or negative diagnosis.
• the biomarkers are selected from those listed in Tables 1A and IB having p-values of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• step (i) of the method comprises determining the levels at least one, at least two, at least three, at least four, or greater than four biomarkers selected from the group consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• biomarkers selected from the group consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• the clinical variable(s) assessed according to the method is selected from those listed in Tables 3A and 3B having p-values of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• step (ii) of the method comprises determining the status of at least one clinical variables selected from the group consisting of age, history of coronary artery bypass graft surgery (CABG), history of diabetes type 2, history of hemodialysis, history of myocardial infarct (MI), history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• CABG coronary artery bypass graft surgery
• MI myocardial infarct
• percutaneous coronary intervention e.g., balloon angioplasty with or without stent placement
• step (i) of the method comprises determining the levels at least one, at least two, at least three, at least four, or greater than four biomarkers selected the groups consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin and step (ii) comprises determining the status of at least one clinical variables selected from age, history of coronary artery bypass graft surgery (CABG), history of diabetes type 2, history of hemodialysis, history of myocardial infarct (MI), history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• CABG coronary artery bypass graft surgery
• MI myocardial infarct
• MI myocardial infarct
• a positive diagnosis for obstructive coronary artery disease in the subject facilitates a determination by a medical practitioner of the need for an intervention or further testing.
• An intervention or further testing may include but are not limited to one or more of a diagnostic cardiac catheterization (also referred to as "cath"), percutaneous coronary intervention (balloon angioplasty with or without stent placement), coronary artery bypass graft (CABG), and administration of pharmacologic agents, such as one selected from one or more of nitrates, beta blockers, ACE inhibitor and lipid-lowering agents.
• a negative diagnosis for obstructive coronary artery disease in the subject facilitates a determination by a medical practitioner of the need for an intervention or further testing.
• An intervention or further testing may include but are not limited to one or more of ongoing monitoring and management of coronary risk factors including hypertension, diabetes, and smoking, and lifestyle modifications selected from diet modification, exercise, and smoking cessation.
• Another aspect of the present disclosure provides methods for the prognosis of a cardiac outcome in a subject, comprising the steps: (i) determining the level of at least one biomarker in a biological sample obtained from the subject, wherein the biomarkers are selected from the group consisting of the biomarkers listed in Tables 2A and 2B; (ii) optionally determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of the clinical variables listed in Tables 4A and 4B; (iii) calculating a prognostic score for the subject based on the determined levels of the at least one biomarker and, optionally, the status of the clinical variable(s) determined in step (ii); (iv) classifying the prognostic score as a positive or negative prognosis; and (v) determining a therapeutic or diagnostic intervention regimen based on the positive or negative prognosis.
• the biomarkers evaluated in the method are selected from those listed in Tables 2A and 2B having p-values of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• the clinical variable(s) assessed according to the method is selected from those listed in Tables 4A and 4B having p-values of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• step (i) of the method comprises determining the levels of at least one, at least two, at least three, at least four, or greater than four biomarkers selected from the group consisting of apolipoprotein A-II, kidney injury molecule- 1, midkine, N terminal prohormone of brain natriuretic protein (NT-proB P), osteopontin, tissue inhibitor of metalloproteinases-1 (TIMP-1), and vascular cell adhesion molecule (VCAM).
• the prognosis of a cardiac outcome is a prognosis of cardiovascular death, myocardial infarct (MI), stroke, all cause death, or a composite thereof.
• a positive prognosis of a cardiac outcome facilitates a determination by a medical practitioner of the need for an intervention or further testing.
• An intervention or further testing may include but are not limited to one or more of stress testing with ECG response or myocardial perfusion imaging, coronary computed tomography angiogram, diagnostic cardiac catheterization, percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), coronary artery bypass graft (CABG), enrollment in a clinical trial, and administration or monitoring of effects of agents selected from, but not limited to, nitrates, beta blockers, ACE inhibitors, antiplatelet agents and lipid-lowering agents.
• a negative prognosis of a cardiac outcome facilitates a determination by a medical practitioner of the need for an intervention or further testing.
• An intervention or further testing may include but are not limited to one or more of ongoing monitoring and management of coronary risk factors including hypertension, diabetes, hyperlipidemia and smoking; and lifestyle modifications selected from diet modification, exercise and smoking cessation.
• the present disclosure provides a diagnostic or prognostic kit comprising a panel of biomarkers and optionally clinical variables as described.
• the panel had a robust area under the curve (AUC) of 0.87.
• Figure 2 shows a distribution of the CAD panel FM139/685 (as described in
• a bimodal distribution is noted, with preponderance of those with significant CAD distributed at higher scores.
• Positive subjects with at least one coronary stenosis > 70%
• negative subjects with no coronary stenoses > 70%.
• Figure 3 shows results from dividing the CAD panel FM139/685 (as described in
• Figure 4 shows Kaplan-Meier survival curves depicting time to incident acute MI as a function of CAD Score in panel FM139/685 (as described in Example 1). Though developed as a diagnostic tool for CAD, the score also presaged incident acute MI during follow- up.
• the panel had a robust area under the curve (AUC) of 0.87.
• the panel had an area under the curve (AUC) of 0.72.
• the panel had an area under the curve (AUC) of 0.69.
• the panel had an area under the curve (AUC) of 0.73.
• the panel had a robust area under the curve (AUC) of 0.84.
• the panel had a robust area under the curve (AUC) of 0.80.
• the panel had a robust area under the curve (AUC) of 0.84.
• the panel had a robust area under the curve (AUC) of 0.86.
• the panel had a robust area under the curve (AUC) of 0.85.
• the panel had a robust area under the curve (AUC) of 0.86.
• the panel had a robust area under the curve (AUC) of 0.86.
• the panel had a robust area under the curve (AUC) of 0.84.
• Figure 19 shows a distribution of the CAD panel FM46/572 (as described in
• a bimodal distribution is noted, with preponderance of those with significant CAD distributed at higher scores.
• Positive subjects with at least one coronary stenosis > 70%
• negative subjects with no coronary stenoses > 70%.
• Figure 20 shows Kaplan-Meier survival curves depicting time to incident acute
• MI as a function of CAD Score panel FM 46/572 (as described in Example 2). Though developed as a diagnostic tool for CAD, the score also presaged incident acute MI during follow- up.
• the panel had a robust area under the curve (AUC) of 0.80.
• the panel had a robust area under the curve (AUC) of 0.84.
• the panel had a robust area under the curve (AUC) of 0.83.
• the panel had a robust area under the curve (AUC) of 0.85.
• the panel had a robust area under the curve (AUC) of 0.85.
• the panel had a robust area under the curve (AUC) of 0.89.
• the panel had a robust area under the curve (AUC) of 0.87.
• the panel had an area under the curve (AUC) of 0.79.
• the panel had an area under the curve (AUC) of 0.77.
• the panel had an area under the curve (AUC) of 0.78.
• the panel had an area under the curve (AUC) of 0.75.
• the panel had an area under the curve (AUC) of 0.79.
• the panel had an area under the curve (AUC) of 0.77.
• the panel had an area under the curve (AUC) of 0.78.
• the panel had an area under the curve (AUC) of 0.75.
• the panel had an area under the curve (AUC) of 0.79.
• the panel had an area under the curve (AUC) of 0.76.
• the panel had an area under the curve (AUC) of 0.76.
• the panel had an area under the curve (AUC) of 0.75.
• the panel had an area under the curve (AUC) of 0.75.
• the panel had an area under the curve (AUC) of 0.73.
• the panel had a robust area under the curve (AUC) of 0.80.
• the panel had a robust area under the curve (AUC) of 0.81.
• the panel had a robust area under the curve (AUC) of 0.81.
• the panel had a robust area under the curve (AUC) of 0.83.
• the panel had a robust area under the curve (AUC) of 0.82.
• invention or "present invention” as used herein is a non-limiting term and is not intended to refer to any single embodiment of the particular invention but
• the term “about” or “approximately” refers to a quantity, level, value, number, frequency, percentage, dimension, size, amount, weight or length that varies by as much as 30, 25, 20, 25, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1% to a reference quantity, level, value, number, frequency, percentage, dimension, size, amount, weight or length.
• the terms “about” or “approximately” when preceding a numerical value indicates the value plus or minus a range of 15%, 10%, 5%, or 1%.
• the present disclosure relates generally to the diagnosis and/or prognosis of cardiovascular disease and/or adverse cardiovascular events.
• diagnosis refers to an identification or likelihood of the presence of a cardiovascular disease or event in a subject.
• prognosis refers to the likelihood or risk of a subject developing a particular outcome or particular event.
• Cardiovascular disease refers to a class of d seases that involve the heart or blood vessels. Cardiovascular disease includes coronary artery
• CAD myocardial infarction
• stroke hypertensive heart disease
• rheumatic heart disease CAD
• cardiomyopathy CAD
• cardiac arrhythmias i.e., atrial fibrillation, ventricular tachycardia, etc.
• cerebrovascular disease CAD
• peripheral arterial disease CAD
• arterial thrombosis CAD
• cardiovascular event denotes a variety of adverse outcomes related to the cardiovascular system. These events include but are not limited to myocardial infarct, cardiovascular death, and stroke.
• CAD coronary artery disease
• obstruction is characterized by atherosclerotic obstruction in the coronary arteries. Such obstruction may be clinically relevant at levels of 50% or greater, 60% or greater, 70% or greater, 80% or greater, 90% or greater, or 100%.
• Atherosclerotic plaque the hallmark of atherosclerosis, progressively narrows the coronary artery lumen and impairs antegrade myocardial blood flow.
• the reduction in coronary artery flow may be symptomatic or asymptomatic.
• Symptoms of coronary obstruction typically occur with exertion, but can occur at rest, and may culminate in a myocardial infarction, stroke, and/or cardiovascular death depending on obstruction severity and the rapidity of development.
• CV death refers to death resulting from an acute myocardial infarction (MI), sudden cardiac death, death due to heart failure (HF), death due to stroke, death due to cardiovascular (CV) procedures, death due to CV thrombosis or hemorrhage, death due to cardiac infection, and death due to other recognized CV causes within a specified period of time after the test sample is obtained.
• MI myocardial infarction
• HF heart failure
• CV cardiovascular
• MI myocardial infarction
• Acute myocardial infarction or acute myocardial infarction
• AMI AMI
• a heart attack occurs when blood flow is limited to a part of the heart, causing damage to the heart muscle.
• the most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Often, it is in the center or left side of the chest and lasts for more than a few minutes. The discomfort may occasionally feel like heartburn. Other symptoms may include shortness of breath, nausea, feeling faint, a cold sweat, or feeling tired. Most Mis occur due to obstructive coronary artery disease.
• Identified risk factors of obstructive coronary artery disease include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, family history of early cardiovascular death or myocardial infarction, and excessive alcohol intake, among others.
• the mechanism of an MI often involves progression or rupture of the atherosclerotic plaque causing complete blockage of a coronary artery. Mis are less commonly caused by coronary artery spasms, which may be due to medications such as cocaine, significant emotional stress, and extreme cold, among others.
• stroke also known as cerebrovascular accident (CVA)
• CVI cerebrovascular insult
• ischemic due to lack of blood flow caused by thrombosis or embolus
• hemorrhagic due to bleeding. They typically result in significant dysfunction in the portions of the brain affected.
• Signs and symptoms of a stroke may include an inability to move or to experience sensations of touch, heat, cold, or pain on one side of the body, problems understanding or speaking, feeling like the world is spinning, or loss of vision to one side among others. Signs and symptoms often appear soon after the stroke has occurred.
• all-cause death or "all-cause mortality” is defined as death from any non-trauma-related cause, including CV death, within a specified period of time after the test sample is obtained.
• biomarkers of the present invention can be advantageously used in the diagnosis and prognosis of cardiovascular diseases and events.
• the terms “marker” and “biomarker” are used interchangeably throughout the disclosure.
• a biomarker refers generally to a protein or polypeptide, the level or concentration of which is associated with a particular biological state, particularly a state associated with a cardiovascular disease, event or outcome.
• Panels, assays, kits and methods of the present invention may comprise antibodies, binding fragments thereof or other types of binding agents, which are specific for the biomarkers described herein.
• polypeptide and protein refer to a polymeric form of amino acids of any length, which can include coded and non-coded amino acids, chemically or biochemically modified or derivatized amino acids, and polypeptides having modified peptide backbones.
• detecting the levels of naturally occurring biomarker proteins in a biological sample is contemplated for use within diagnostic, prognostic, or monitoring methods disclosed herein.
• the term also includes fusion proteins, including, but not limited to, naturally occurring fusion proteins with a heterologous amino acid sequence, fusions with heterologous and homologous leader sequences, with or without N-terminal methionine residues; immunologically tagged proteins; and the like.
• a "substantially isolated” or “isolated” substance is one that is substantially free of its associated surrounding materials in nature. By substantially free is meant at least 50%, preferably at least 70%, more preferably at least 80%, and even more preferably at least 90% free of the materials with which it is associated in nature.
• isolated can refer to polynucleotides, polypeptides, antibodies, cells, samples, and the like.
• Certain illustrative diagnostic biomarkers of the present invention can be found listed in Tables 1 A and IB, while certain illustrative prognostic biomarkers can be found listed in Tables 2A and 2B. Based on the information therein in Tables 1 A, IB, 2A, and 2B, the skilled artisan can readily identify, select and implement a biomarker or biomarker combination in accordance with the present disclosure.
• the biomarkers used in accordance with the present invention include those listed in Tables 1 A, IB, 2A, and 2B, particularly those that are associated with a p-value of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• the biomarkers used in accordance with the present disclosure are selected from the group consisting of adiponectin, apolipoprotein A-II, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, N terminal prohormone of brain natriuretic protein (NT-proB P), osteopontin, pulmonary surfactant associated protein D, stem cell factor, tissue inhibitor of metalloproteinases-1 (TIMP-1), troponin, and vascular cell adhesion molecule (VCAM).
• adiponectin refers to a protein involved in regulating glucose as well as fatty acid breakdown. It is also referred to as GBP-28, apMl, AdipoQ, and Acrp30. Adiponectin is a 244-amino-acid peptide secreted by adipose tissue, whose roles include the regulation of glucose and fatty acid metabolism.
• apolipoprotein ⁇ - ⁇ refers to an apolipoprotein found in high density lipoprotein (HDL) cholesterol in plasma.
• apolipoprotein C-I is a protein component of lipoproteins normally found in the plasma and responsible for the activation of esterified lecithin cholesterol and in removal of cholesterol from tissues.
• decorin also known as PG40 and PGS2
• PG40 and PGS2 is a protein, which belongs to the small leucine-rich proteoglycan family. It regulates assembly of the extracellular collagen matrix.
• interleukin-8 also known as IL8
• neutrophil chemotactic factor chemokine ligand 8
• CXCL8 is a chemokine produced by macrophages and other cell types such as epithelial cells, airway smooth muscle cells, and endothelial cells.
• IL-8 induces chemotaxis in target cells, primarily neutrophils but also other granulocytes, causing them to migrate toward the site of infection.
• IL-8 also induces phagocytosis once they have arrived.
• IL-8 is also known to be a potent promoter of angiogenesis.
• IL-8 induces a series of physiological responses required for migration and phagocytosis, such as increases in intracellular Ca ⁇ , exocytosis (e.g. histamine release), and the respiratory burst.
• kidney injury molecule-1 also known as “KIM-1” is a type I cell membrane glycoprotein that serves as a receptor for oxidized lipoproteins and plays a functional role in the kidney. KIM-1 is a proximal renal tubular marker whose concentrations have been linked to acute kidney injury.
• matrix metalloproteinase 9 also known as MMP-9, 92 kDA type IV collagenase, 92 kDa gelatinase, and gelatinase B or GELB, is a is a matrixin, a class of enzymes that belong to the zinc-metalloproteinases family involved in the degradation of the extracellular matrix. Proteins of the matrix metalloproteinase (MMP) family are involved in the breakdown of extracellular matrix in normal physiological processes, such as embryonic development reproduction, angiogenesis, bone development, wound healing, cell
• midkine also known as “neurite growth-promoting factor 2” or
• EGF2 refers to a basic heparin-binding growth factor of low molecular weight and forms a family with pleiotrophin.
• Midkine is a heparin-binding cytokine/growth factor with a molecular weight of 13 kDa.
• myoglobin is an iron- and oxygen-binding protein found in the muscle tissue of vertebrates in general and in almost ail mammals. Myoglobin is released from damaged muscle tissue (rhabdomyolysis), which has very high concentrations of myoglobin. The released myoglobin is filtered by the kidneys but is toxic to the renal tubular epithelium and so may cause acute kidney injury. It is not the myoglobin itself that is toxic (it is a protoxin) but the ferrihemate portion that is dissociated from myoglobin in acidic environments (e.g., acidic urine, lysosomes). Myoglobin is a sensitive marker for muscle injury, making it a potential marker for heart attack in patients with chest pain.
• N-terminal prohormone of brain natriuretic peptide or "NT-
• PB P is also known as "NT-proB P” or “B PT” and refers to an N-terminal inactive protein that is cleaved from proBNP to release brain natriuretic peptide.
• osteopontin also known as “bone sialoprotein I”, "BSP-1”,
• BNSP headly T-lymphocyte activation
• ETA-1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 secreted phosphoprotein 1
• SPP1 small integrin binding ligand N- linked glycoprotein
• pulmonary surfactant associated protein D also referred to as surfactant, pulmonary-associated protein D, or SP-D or SFTPD, is a protein that contributes to the lung's defense against inhaled microorganisms, organic antigens and toxins.
• stem cell factor also known as SCF, KIT-ligand, KL, and steel factor
• SCF stem cell factor
• KIT-ligand KIT-ligand
• KL KL
• steel factor is a cytokine that binds to the c-KIT receptor (CD117).
• SCF can exist both as a transmembrane protein and a soluble protein. This cytokine plays an important role
• hematopoiesis formation of blood cells
• spermatogenesis formation of blood cells
• melanogenesis formation of melanogenesis
• tissue inhibitor of metalloproteinases-1 also known as "TEVIP-
• TIMP metallopeptidase inhibitor 1 refers to a glycoprotein expressed in several tissues.
• troponin also known as the troponin complex
• troponin C is a complex of three regulatory proteins (troponin C, troponin I, and troponin T) that is integral to muscle contraction in skeletal muscle and cardiac muscle, but not smooth muscle.
• a troponin biomarker may identify each of these proteins individually or in combination.
• An increased level of the cardiac protein isoform of troponin circulating in the blood has been shown to be a biomarker of heart disorders, the most important of which is myocardial
• Raised troponin levels indicate cardiac muscle cell death as the molecule is released into the blood upon injury to the heart.
• vascular cell adhesion molecule also known as VCAM-1, VCAM, cluster of differentiation 106, and CD106, is a cell adhesion molecule.
• VCAM-1 vascular cell adhesion molecule
• the VCAM-1 protein mediates the adhesion of lymphocytes, monocytes, eosinophils, and basophils to vascular endothelium. It also functions in leukocyte-endothelial cell signal transduction, and it may play a role in the development of atherosclerosis and rheumatoid arthritis.
• core refers to a binary, multilevel, or continuous result as it relates diagnostic or prognostic determinations.
• the term “panel” refers to specific combination of biomarkers and clinical markers used to determine a diagnosis or prognosis of a cardiovascular disease or outcome in a subject.
• the term “panel” may also refer to an assay comprising a set of biomarkers used to determine a diagnosis or prognosis of a cardiovascular disease or outcome in a subject.
• the "training set” is the set of patients or patient samples that are used in the process of training (i.e., developing, evaluating and building) the final diagnostic or prognostic model.
• the “validation set” is a set of patients or patient samples that are withheld from the training process, and are only used to validate the performance of the final diagnostic or prognostic model.
• biomarkers of the present invention can optionally be used in combination with certain clinical variables in order to provide for an improved diagnosis and/or prognosis of a cardiovascular disease or event in a subject.
• certain clinical variables useful in the context of the present disclosure can be found listed in Tables 3A, 3B, 4A, and 4B.
• Enzyme (ACE) (ng/mL) 79 (60, 103.2) 78 (59.8, 105) 0.954
• Apolipoprotein A-l (Apo A-l)
• Apolipoprotein A-ll (Apo A-ll)
• Apolipoprotein B (Apo B)
• Apolipoprotein C-l (Apo C-l)
• Apolipoprotein C-lll (Apo C-lll)
• Apolipoprotein H (Apo H)
• Beta-2-Microglobulin (B2M)
• BDNF BDNF
• ng/mL 2.15 (0.9, 4.325) 2.75 (1.1, 4.725) 0.017
• CRP C-Reactive Protein
• CEACAM1 (ng/mL) 24 (20, 27) 23 (21, 28.2) 0.258
• Eotaxin-1 (pg/mL) 104 (42.5, 148) 96 (42.5, 137.2) 0.343
• Fetuin-A (ug/mL) 698.5 (582.5, 828) 675.5 (583.8, 810) 0.627
• Haptoglobin (mg/mL) 1.3 (0.66, 2.1) 0.88 (0.478, 1.7) ⁇ 0.001
• Immunoglobulin A (IgA)
• Immunoglobulin M (IgM)
• Insulin (ulU/mL) 1 (0.11, 2.5) 0.49 (0.11, 1.5) ⁇ 0.001
• IP-10 Protein 10 (pg/mL) 307.5 (232.8, 399.2) 288 (223.2, 402) 0.207 lnterleukin-1 receptor
• IL-6ra IL-6 receptor antagonist (pg/mL) 119 (90, 158) 108.5 (83.8, 140.2) 0.005 lnterleukin-6 receptor (IL-6r)
• M-CSF Stimulating Factor 1
• MCP-1 Protein 1 (pg/mL) 112 (79, 160.2) 103 (77, 152) 0.272
• MCP-2 Protein 2 (MCP-2) (pg/mL) 23 (17, 29) 23 (17.8, 30) 0.804
• MCP-4 Protein 4 (pg/mL) 2300 (1720, 3382) 2300 (1538, 3362) 0.587
• MIG Interferon
• Myoglobin (ng/mL) 33 (24, 52.2) 28 (20, 43.2) ⁇ 0.001
• NT brain natriuretic peptide
• proBNP proBNP (pg/mL) 1520 (552.5, 4270) 1370 (449.8, 3650) 0.144
• Inhibitor 1 (PAI-1) (ng/mL) 43 (26, 69) 46.5 (25, 75) 0.465
• PECAM-1 adhesion molecule
• SP-D Pulmonary surfactant-associated protein D
• Resistin ng/mL
• Resistin 2.4 (1.8, 3.5) 2.3 (1.7, 3.2) 0.149
• SCF Stem Cell Factor
• Glycoprotein (THP) ug/mL 0.029 (0.02, 0.038) 0.034 (0.024, 0.044) ⁇ 0.001
• TM Thrombomodulin
• TRIP-1 Metalloproteinases 1
• TTR Transthyretin
• TNFR2 TNFR2
• TNFR2 ng/mL
• 6.4 4.8, 9.6
• 6 4.5, 7.5
• VCAM-1 (ng/mL) 586 (464.8, 730.2) 528 (442, 669.2) 0.004
• VEGF vascular endothelial growth factor
• VDBP (ug/mL) 249 (191.2, 310.5) 249 (194.5, 306.2) 0.927
• VKDPS VKDPS
• Vitronectin (ug/mL) 465 (352, 593) 444.5 (349.5, 552) 0.148 von Willebrand Factor (vWF)
• Enzyme (ACE) (ng/mL) 79 (60, 106) 77.5 (59.8, 103.2) 0.763
• Apolipoprotein A-l (Apo A-l)
• Apolipoprotein A-ll (Apo A-ll)
• Apolipoprotein B (Apo B)
• Apolipoprotein C-l (Apo C-l)
• Apolipoprotein C-lll (Apo C-lll)
• Apolipoprotein H (Apo H)
• Beta-2-Microglobulin (B2M)
• BDNF BDNF
• ng/mL 2.2 (0.89, 4.3) 2.85 (1.175, 4.7) 0.013
• CRP C-Reactive Protein
• CEACAM1 (ng/mL) 23 (20, 27) 23 (21, 28) 0.271
• Eotaxin-1 (pg/mL) 102 (42.5, 144) 96 (42.5, 137) 0.664
• Fetuin-A (ug/mL) 700 (584, 829) 676.5 (583.8, 813.8) 0.689
• Fibrinogen (mg/mL) 4.4 (3.6, 5.3) 4.1 (3.5, 5.1) 0.133
• Haptoglobin (mg/mL) 1.3 (0.65, 2.1) 0.825 (0.458, 1.6) ⁇ 0.001
• Immunoglobulin A (IgA)
• Immunoglobulin M (IgM)
• Insulin (ulU/mL) 1 (0.22, 2.5) 0.545 (0.11, 1.6) ⁇ 0.001
• IP-10 Protein 10 (pg/mL) 304 (232, 396) 291 (227.8, 406.2) 0.631 lnterleukin-1 receptor
• IL-6ra IL-6 receptor antagonist (IL-lra) (pg/mL) 119 (90, 158) 108.5 (84, 141) 0.018 lnterleukin-6 receptor (IL-6r)
• IL-18bp ng/mL 9.4 (7.3, 13) 8.9 (6.6, 11) 0.002 lnterleukin-23 (IL-23) (ng/mL) 2.6 (2, 3.3) 2.4 (1.9, 3.1) 0.253
• M-CSF Stimulating Factor 1
• Protein 1 (MCP-1) (pg/mL) 110 (77, 158) 103 (78, 150.5) 0.567
• MCP-2 Protein 2 (MCP-2) (pg/mL) 23 (17, 29) 23 (18, 30) 0.297
• Protein 4 (pg/mL) 2260 (1690, 3390) 2305 (1562, 3360) 0.85
• MIG Interferon
• NT brain natriuretic peptide
• proBNP proBNP
• Inhibitor 1 (PAI-1) (ng/mL) 44 (26, 69) 47 (25.8, 75) 0.442
• PECAM-1 adhesion molecule
• SP-D Pulmonary surfactant-associated protein D
• Resistin ng/mL
• Resistin 2.4 (1.8, 3.5) 2.3 (1.7, 3.2) 0.268
• SCF Stem Cell Factor
• THP Glycoprotein
• TM Thrombomodulin
• Thrombospondin-1 (ng/mL) 3940 (2020, 7080) 5360 (2478, 7655) 0.011
• TRIP-1 Metalloproteinases 1
• TTR Transthyretin
• TNFR2 TNFR2 (ng/mL) 6.3 (4.8, 9.6) 6 (4.6, 7.5) 0.015
• VCAM-1 (ng/mL) 588 (465, 733) 533 (448.8, 682.2) 0.022
• VEGF vascular Factor
• VDBP (ug/mL) 248 (188, 313) 250 (192.2, 310.2) 0.984
• VKDPS VKDPS
• Vitronectin (ug/mL) 467 (352, 593) 446 (350, 552) 0.224 von Willebrand Factor (vWF)
• MACE major adverse cardiac events
• Enzyme (ACE) (ng/mL) 75 (59, 106.5) 79 (60, 104.8) 0.629
• Apolipoprotein A-l (Apo A-l)
• Apolipoprotein A-ll (Apo A-ll)
• Apolipoprotein B (Apo B)
• Apolipoprotein C-l (Apo C-l)
• Apolipoprotein C-lll (Apo C-lll)
• Apolipoprotein H (Apo H)
• Beta-2-Microglobulin (B2M)
• BDNF BDNF
• CRP C-Reactive Protein
• CEACAM1 (ng/mL) 24 (21, 29) 23 (20, 27.8) 0.254
• Eotaxin-1 (pg/mL) 118.5 (42.5, 153) 97 (42.5, 143.8) 0.034
• Fetuin-A 644.5 (539.8, 766) 696 (593, 828.5) 0.005
• Immunoglobulin A (IgA)
• Immunoglobulin M (IgM)
• Insulin 0.89 (0.11, 1.8) 0.815 (0.11, 2.175) 0.837
• IP-10 Protein 10 (pg/mL) 335 (242.5, 432.5) 299.5 (228, 398) 0.094 lnterleukin-1 receptor
• IL-6ra IL-6 receptor antagonist (pg/mL) 122 (97.2, 160.5) 114 (88, 148) 0.1 lnterleukin-6 receptor (IL-6r)
• M-CSF Stimulating Factor 1
• MCP-1 Protein 1 (pg/mL) 113.5 (74, 161) 108 (78, 158) 0.811
• MCP-2 Protein 2 (pg/mL) 24 (19, 29.8) 23 (17, 30) 0.268
• Protein 4 (pg/mL) 2295 (1680, 3385) 2300 (1662, 3360) 0.867
• MIG Interferon
• Myoglobin (ng/mL) 47 (29, 78.5) 30 (21, 45.8) ⁇ 0.001
• NT brain natriuretic peptide
• proBNP proBNP (pg/mL) 5610 (2050, 15980) 1310 (460.8, 3235) ⁇ 0.001
• Inhibitor 1 (PAI-1) (ng/mL) 46 (26, 74.2) 44 (26, 71.8) 0.905
• PECAM-1 adhesion molecule
• SP-D Pulmonary surfactant-associated protein D
• Resistin (ng/mL) 2.9 (2.1, 4.575) 2.3 (1.8, 3.3) ⁇ 0.001
• SCF Stem Cell Factor
• THP Glycoprotein
• TM Thrombomodulin
• Thrombospondin-1 (ng/mL) 3670 (2010, 7210) 4305 (2170, 7392) 0.404
• TRIP-1 Metalloproteinases 1
• TRR Transthyretin
• TNFR2 TNFR2 (ng/mL) 9.4 (6.3, 15) 6 (4.7, 8.1) ⁇ 0.001
• VCAM-1 (ng/mL) 705.5 (544, 982.2) 545 (448.2, 681.8) ⁇ 0.001
• VEGF vascular endothelial growth factor
• VKDPS VKDPS
• Vitronectin (ug/mL) 426 (328.2, 534.5) 463.5 (358, 591) 0.043 von Willebrand Factor (vWF)
• the numbers in this table were calculated using the composite endpoint of one-year MACE with CV death, MI, or major stroke; these proteins produce similar results with the composite endpoint of one-year MACE with all- cause death, MI and/or major stroke.
• Enzyme (ACE) (ng/mL) 74 (59, 105) 79 (60, 105) 0.38
• Apolipoprotein A-l (Apo A-l)
• Apolipoprotein A-ll (Apo A-ll)
• Apolipoprotein B (Apo B)
• Apolipoprotein C-l (Apo C-l)
• Apolipoprotein C-lll (Apo C-lll)
• Apolipoprotein H (Apo H)
• Beta-2-Microglobulin (B2M)
• BDNF BDNF
• ng/mL 1.9 (0.745, 4.05) 2.35 (1, 4.6) 0.192
• CRP C-Reactive Protein
• Eotaxin-1 (pg/mL) 118 (42.5, 152) 97 (42.5, 144.2) 0.068
• Fetuin-A (ug/mL) 651 (541.5, 766.5) 692.5 (588.8, 827.2) 0.021
• Immunoglobulin A (IgA)
• Immunoglobulin M (IgM)
• Insulin (ulU/mL) 1 (0.11, 1.9) 0.815 (0.11, 2.1) 0.806
• IP-10 Protein 10 (IP-10) (pg/mL) 336 (246, 437) 300 (228, 398) 0.076 lnterleukin-1 receptor
• IL-6ra IL-6 receptor antagonist (pg/mL) 121 (95.5, 158) 114.5 (88, 148) 0.224 lnterleukin-6 receptor (IL-6r)
• IL-18bp (ng/mL) 14 (9.3, 19) 9 (7, 12) ⁇ 0.001 lnterleukin-23 (IL-23) (ng/mL) 2.6 (1.8, 3.2) 2.5 (2, 3.2) 0.604
• M-CSF Stimulating Factor 1
• Protein 1 (MCP-1) (pg/mL) 113 (73, 161.5) 108 (78, 158) 0.938
• MCP-2 Protein 2 (MCP-2) (pg/mL) 26 (19, 30) 23 (17, 30) 0.135
• MCP-4 Protein 4 (pg/mL) 2370 (1635, 3320) 2295 (1668, 3362) 0.892
• MIG Interferon
• NT brain natriuretic peptide
• proBNP proBNP (pg/mL) 6470 (2220, 15980) 1330 (461.5, 3302) ⁇ 0.001
• Inhibitor 1 (PAI-1) (ng/mL) 46 (26, 66.5) 44 (26, 73) 0.766
• PECAM-1 adhesion molecule
• Prolactin (PRL) (ng/mL) 9.7 (6.3, 15) 8 (5.5, 12) 0.029
• SP-D Pulmonary surfactant-associated protein D
• Resistin ng/mL 3.1 (2.1, 4.65) 2.3 (1.8, 3.3) ⁇ 0.001
• SCF Stem Cell Factor
• Glycoprotein (THP) ug/mL 0.022 (0.013, 0.03) 0.032 (0.022, 0.041) ⁇ 0.001
• TM Thrombomodulin
• Thrombospondin-1 (ng/mL) 3660 (1860, 6960) 4305 (2170, 7445) 0.359
• TRIP-1 Metalloproteinases 1
• TRR Transthyretin
• TNFR2 TNFR2 receptor 2 (TNFR2) (ng/mL) 10 (6.7, 15) 6 (4.7, 8.1) ⁇ 0.001
• VCAM-1 (ng/mL) 792 (582, 1015) 543.5 (448.8, 680.2) ⁇ 0.001
• VEGF vascular endothelial growth factor
• VDBP (ug/mL) 231 (176.5, 309.5) 250 (195.8, 307.8) 0.316
• VKDPS VKDPS
• Vitronectin (ug/mL) 424 (326.5, 542.5) 463.5 (355.8, 591) 0.062 von Willebrand Factor (vWF)
• Diastolic BP (mmHg) 72.6 (11.7) 73 (10.9) 0.658
• Beta blocker 342/427 (80.1%) 133 / 220 (60.5%) ⁇ 0.001
• Glucose (mg/dL) 104 (93, 129.5) 99 (89, 108.5) 0.001
• BP blood pressure
• MI myocardial infarction
• COPD chronic obstructive pulmonary disease
• CVA/TIA cerebrovascular accident/transient ischemic attack
• CKD chronic kidney disease
• CABG coronary artery by-pass graft
• ACE-I/ARB angiotensin converting enzyme inhibitor/ angiotensin receptor blocker
• CCB calcium channel blocker
• LVEF left ventricular ejection fraction
• RVSP right ventricular systolic pressure
• eGFR estimated glomerular filtration rate
• LDL low density lipoprotein
• HGB hemoglobin.
• Beta blocker 289 / 361 (80.1%) 120 / 204 (58.8%) ⁇ 0.001
• Aldosterone antagonist 12/361 (3.3%) 8/204(3.9%) 0.813
• LDL cholesterol (mg/dL) 75.2 (29.4) 93.3 (37.9) ⁇ 0.001
• Glucose (mg/dL) 103 (93, 125.2) 99 (89, 107.8) 0.006
• BP blood pressure
• MI myocardial infarction
• COPD chronic obstructive pulmonary disease
• CVA/TIA cerebrovascular accident/transient ischemic attack
• CKD chronic kidney disease
• CABG coronary artery by-pass graft
• ACE-I/ARB angiotensin converting enzyme inhibitor/ angiotensin receptor blocker
• CCB calcium channel blocker
• LVEF left ventricular ejection fraction
• RVSP right ventricular systolic pressure
• eGFR estimated glomerular filtration rate
• LDL low density lipoprotein
• HGB hemoglobin.
• the numbers in this table were calculated using the composite endpoint of one-year MACE with C V death, MI, or maj or stroke; these proteins produce similar results with the composite endpoint of one-year MACE with all-cause death, MI and/or major stroke.
• RSVP (mmHg) 44.2 (11.3) 40.4 (11.1) 0.067
• Creatinine (mg/dL) 1.3 (1.1, 1.9) 1.1 (0.9, 1.3) ⁇ 0.001 eGFR (median, CKDEPI) 67.7 (45.3, 89.3) 102.3 (79.7, 112.3) ⁇ 0.001
• LDL cholesterol (mg/dL) 77.5 (42.9) 79.4 (31.6) 0.735
• Glucose (mg/dL) 114 (101, 145) 100 (90, 120) ⁇ 0.001
• BP blood pressure
• MI myocardial infarction
• COPD chronic obstructive pulmonary disease
• CVA/TIA cerebrovascular accident/transient ischemic attack
• CKD chronic kidney disease
• CABG coronary artery by-pass graft
• ACE-I/ARB angiotensin converting enzyme inhibitor/ angiotensin receptor blocker
• CCB calcium channel blocker
• LVEF left ventricular ejection fraction
• RVSP right ventricular systolic pressure
• eGFR estimated glomerular filtration rate
• LDL low density lipoprotein
• HGB hemoglobin.
• the numbers in this table were calculated using the composite endpoint of one-year MACE with CV death, MI, or major stroke; these proteins produce similar results with the composite endpoint of one-year MACE with all- cause death, MI and/or major stroke.
• Beta blocker 54/71 (76.1%) 421 / 575 (73.2%) 0.671
• Creatinine (mg/dL) 1.3 (1.1, 1.9) 1.1 (0.9, 1.3) ⁇ 0.001 eGFR (median, CKDEPI) 65.7 (42.9, 86) 102.2 (79.1, 112.4) ⁇ 0.001
• Glucose (mg/dL) 114 (101, 144) 101 (91, 120) ⁇ 0.001
• BP blood pressure
• MI myocardial infarction
• COPD chronic obstructive pulmonary disease
• CVA/TIA cerebrovascular accident/transient ischemic attack
• CKD chronic kidney disease
• CABG coronary artery by-pass graft
• ACE-I/ARB angiotensin converting enzyme inhibitor/ angiotensin receptor blocker
• CCB calcium channel blocker
• LVEF left ventricular ejection fraction
• RVSP right ventricular systolic pressure
• eGFR estimated glomerular filtration rate
• LDL low density lipoprotein
• HGB hemoglobin.
• the methods of the invention relate generally to providing a diagnosis and/or prognosis of a cardiovascular disease or outcome in a subject, comprising the steps of: (i) determining the level of at least one biomarker in a biological sample obtained from the subject, particularly where the biomarkers are selected from the group consisting of those set forth in Tables 1 A, IB, 2A and 2B; (ii) optionally, determining the status of at least one clinical variable for the subject, where the clinical variable is selected from the group consisting of those set forth in Tables 3 A, 3B, 4A and 4B; (iii) calculating a diagnostic or prognostic score based on the levels of the biomarkers determined in step (i) and, optionally optionally, the status of the clinical variable(s) determined in step (ii); (iv) classifying the diagnostic or prognostic score as a positive or negative result; and (v) determining a therapeutic or diagnostic intervention regimen based on the positive or negative result.
• Embodiments of the present invention provide methods for evaluating cardiovascular status in a subject, comprising: (i) obtaining a sample from a subject selected for evaluation; (ii) performing one or more assays configured to detect a biomarker selected from the group consisting of those set forth in Tables 1A, IB, 2A, and 2B by introducing the sample obtained from the subject into an assay instrument which (a) contacts the sample with one or more antibodies which specifically bind for the detection of the biomarker(s) which are assayed, and (b) generates one or more assay results indicative of binding of each biomarker which is assayed to a respective antibody to provide one or more assay results; (iii) optionally, determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of those set forth in Tables 3A, 3B, 4A, and 4B; (iv) correlating the assay result(s) generated by the assay instrument and optionally the clinical variable status
• Embodiments of the present invention provide a method for diagnosing obstructive coronary artery disease in a subject comprising: (i) obtaining a sample from a subject selected for evaluation; (ii) performing one or more assays configured to detect a biomarker selected from the group consisting of those set forth in Tables 1 A and IB by introducing the sample obtained from the subject into an assay instrument which (a) contacts the sample with one or more antibodies which specifically bind for the detection of the biomarker(s) which are assayed, and (b) generates one or more assay results indicative of binding of each biomarker which is assayed to a respective antibody to provide one or more assay results; (iii) optionally, determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of those set forth in Tables 3A and 3B; (iv) correlating the assay result(s) generated by the assay instalment and optionally the clinical variable status to o
• the present disclosure provides methods for the prognosis of a cardiac outcome in a subject within time endpoints, comprising: (i) obtaining a sample from a subject selected for evaluation; (ii) performing one or more assays configured to detect a biomarker selected from the group consisting of those set forth in Tables 2A and 2B by introducing the sample obtained from the subject into an assay instrument which (a) contacts the sample with one or more antibodies which specifically bind for detection of the biomarker(s) which are assayed, and (b) generates one or more assay results indicative of binding of each biomarker which is assayed to a respective antibody to provide one or more assay results; (iii) optionally, determining the status of at least one clinical variable for the subject, wherein the clinical variable is selected from the group consisting of those set forth in Tables 4A and 4B; (iv) correlating the assay result(s) generated by the assay instrument and optionally the clinical variable status to the likelihood
• biomarkers can be used in the methods of the present invention for the diagnosis of obstructive coronary artery disease.
• biomarkers, optionally used in conjunction with clinical variables can be used in the prognosis of cardiovascular outcomes, including but not limited to cardiovascular death, myocardial infarct, and stroke.
• the methods can also be used, for example, to predict the risk of a composite endpoint, which is a combination of various clinical events that might happen, such as cardiovascular death, myocardial infarct, or stroke where any one of those events would count as part of the composite endpoint.
• the composite may include all-cause death, which is inclusive of cardiovascular death.
• biomarkers and/or clinical variables used in accordance with the methods of the present invention include those listed in Tables 1 A, IB, 2A, 2B, 3 A, 3B, 4A and 4B, particularly those which are associated with a p-value of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• At least 1, at least 2, at least 3 or at least 4 biomarkers are used in the methods described herein.
• the number of biomarkers employed can vary, and may include at least 5, 6, 7, 8, 9, 10, or more.
• the number of biomarkers can include at least 15, 20, 25 or 50, or more.
• the biomarkers used in the diagnostic methods of the invention are selected from adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• the biomarkers used in the prognostic methods of the invention are selected from apolipoprotein A-II, kidney injury molecule- 1, midkine, N terminal prohormone of brain natriuretic protein (NT-proB P), osteopontin, tissue inhibitor of metalloproteinases-1 (TIMP-1), and vascular cell adhesion molecule.
• the diagnostic or prognostic model will result in a numeric or categorical score that relates the patient's level of likelihood of CAD, e.g. including but not limited to positive predictive value (PPV), negative predictive value (NPV), sensitivity (Sn), or specificity (Sp) or the risk of a cardiovascular event occurring within the specified period of time.
• the number of levels used by the diagnostic model may be as few as two ("positive” vs. "negative") or as many as deemed clinically relevant, e.g., a diagnostic model for CAD may result a five-level score, where a higher score indicates a higher likelihood of disease.
• a score of 1 indicates a strong degree of confidence in a low likelihood of CAD (determined by the test's NPV)
• a score of 5 indicates a strong degree of confidence in a high likelihood of CAD (determined by the test's PPV)
• a score of 3 indicates a moderate likelihood for CAD.
• a medical practitioner upon making a positive diagnosis for obstructive coronary artery disease in the subject according to the methods disclosed herein, can advantageously use the diagnosis to identify the need for a therapeutic, diagnostic or other intervention in the subject, particularly an intervention selected from one or more of a diagnostic cardiac catheterization, percutaneous coronary intervention (balloon angioplasty with or without stent placement), coronary artery bypass graft (CABG), and administration of pharmacologic agents selected from nitrates, beta blockers, ACE inhibitor and lipid-lowering agents.
• a diagnostic cardiac catheterization percutaneous coronary intervention (balloon angioplasty with or without stent placement), coronary artery bypass graft (CABG), and administration of pharmacologic agents selected from nitrates, beta blockers, ACE inhibitor and lipid-lowering agents.
• pharmacologic agents selected from nitrates, beta blockers, ACE inhibitor and lipid-lowering agents.
• a medical practitioner upon making a negative diagnosis for obstructive coronary artery disease in the subject according to the methods disclosed herein, a medical practitioner can advantageously use the information thereby obtained to identify the need for an intervention in the subject, such as an intervention selected from one or more of ongoing monitoring and management of coronary risk factors including hypertension, diabetes, and smoking, and lifestyle modifications selected from diet modification, exercise and smoking cessation.
• a medical practitioner can advantageously use the prognostic information thereby obtained to identify the need for an intervention in the subject, such as an intervention selected from one or more of stress testing with ECG response or myocardial perfusion imaging, coronary computed tomography angiogram, diagnostic cardiac catheterization, percutaneous coronary (e.g., balloon angioplasty with or without stent placement), coronary artery bypass graft (CABG), enrollment in a clinical trial, and administration or monitoring of effects of agents selected from, but not limited to, of agents selected from nitrates, beta blockers, ACE inhibitors, antiplatelet agents and lipid-lowering agents.
• a medical practitioner upon making a negative prognosis of a cardiac outcome according to the methods described herein, can advantageously use the information thereby obtained to identify the need for an intervention, particularly an intervention selected from one or more of ongoing monitoring and management of coronary risk factors including hypertension, diabetes, hyperlipidemia and smoking; and lifestyle modifications selected from diet modification, exercise and smoking cessation.
• a "biological sample” encompasses essentially any sample type obtained from a subject that can be used in a diagnostic or prognostic method described herein.
• the biological sample may be any bodily fluid, tissue or any other sample from which clinically relevant biomarker levels may be determined.
• the definition encompasses blood and other liquid samples of biological origin, solid tissue samples such as a biopsy specimen or tissue cultures or cells derived therefrom and the progeny thereof.
• the definition also includes samples that have been manipulated in any way after their procurement, such as by treatment with reagents, solubilization, or enrichment for certain components, such as polynucleotides.
• biological sample encompasses a clinical sample, but also, in some instances, includes cells in culture, cell supernatants, cell lysates, blood, serum, plasma, urine, cerebral spinal fluid, biological fluid, and tissue samples.
• the sample may be pretreated as necessary by dilution in an appropriate buffer solution or concentrated, if desired. Any of a number of standard aqueous buffer solutions, employing one of a variety of buffers, such as phosphate, Tris, or the like, preferably at physiological pH can be used.
• Biological samples can be derived from patients using well known techniques such as venipuncture, lumbar puncture, fluid sample such as saliva or urine, or tissue biopsy and the like.
• the biological sample used in the methods of the present disclosure include but are not limited to, whole blood, plasma, serum, or urine.
• the sample is whole blood.
• the sample is plasma.
• the sample is serum or urine.
• Determining biomarker levels in a sample taken from a subject can be accomplished according to standard techniques known and available to the skilled artisan. In many instances, this will involve carrying out protein detection methods, which provide a quantitative measure of protein biomarkers present in a biological sample.
• binding agents that specifically bind to the biomarkers described herein and thereby allow for a determination of the levels of the biomarkers in a biological sample.
• Any of a variety of binding agents may be used including, for example, antibodies, polypeptides, sugars and nucleic acids.
• the binding agent is an antibody or a fragment thereof that specifically binds to a biomarker of the present disclosure, and that is effective to determine the level of the biomarker to which it binds in a biological sample.
• Antibody binding to an epitope on a specific biomarker sequence is preferably stronger than binding of the same antibody to any other epitope, particularly those which may be present in molecules in association with, or in the same sample, as the specific biomarker of interest.
• Antibodies which bind specifically to a biomarker of interest may be capable of binding other polypeptides at a weak, yet detectable, level (e.g., 10% or less, 5% or less, 1% or less of the binding shown to the polypeptide of interest). Such weak binding, or background binding, is readily discernible from the specific antibody binding to the compound or polypeptide of interest, e.g. by use of appropriate controls.
• antibodies used in compositions and methods of the invention which bind to a specific biomarker protein with a binding affinity of 10 7 moles/L or more, preferably 10 8 moles/L or more are said to bind specifically to the specific biomarker protein.
• the affinity of specific binding of an antibody or other binding agent to a biomarker is about 2 times greater than background binding, about 5 times greater than background binding, about 10 times greater than background binding, about 20 times greater than background binding, about 50 times greater than background binding, about 100 times greater than background binding, or about 1000 times greater than background binding, or more.
• the affinity of specific binding of an antibody or other binding agent to a biomarker is between about 2 to about 1000 times greater than background binding, between about 2 to 500 times greater than background binding, between about 2 to about 100 times greater than background binding, between about 2 to about 50 times greater than background binding, between about 2 to about 20 times greater than background binding, between about 2 to about 10 times greater than background binding, or any intervening range of affinity.
• antibody herein is used in the broadest sense and specifically covers, but is not limited to, monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies) formed from at least two intact antibodies, single chain antibodies (e.g., scFv), and antibody fragments or other derivatives, so long as they exhibit the desired biological specificity.
• the term "monoclonal antibody” as used herein refers to an antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical except for possible naturally occurring mutations that can be present in minor amounts.
• the monoclonal antibody is an antibody specific for a biomarker described herein.
• Monoclonal antibodies are highly specific, being directed against a single antigenic site. Furthermore, in contrast to conventional (polyclonal) antibody preparations which typically include different antibodies directed against different determinants (epitopes), each monoclonal antibody is directed against a single determinant on the antigen. In addition to their specificity, the monoclonal antibodies are advantageous in that they are synthesized by the hybridoma culture, uncontaminated by other immunoglobulins.
• the modifier "monoclonal" indicates the character of the antibody as being obtained from a substantially homogeneous population of antibodies, and is not to be construed as requiring production of the antibody by any particular method.
• the monoclonal antibodies to be used in accordance with the present invention may be made by the hybridoma method first described by Kohler et al., Nature, 256: 495 (1975), or may be made by recombinant DNA methods (see, e.g., U.S. Pat. No.
• the "monoclonal antibodies” may also be isolated from phage antibody libraries using the techniques described in Clackson et al., Nature, 352: 624-628 (1991) and Marks et al., J. Mol. Biol., 222: 581-597 (1991), for example.
• the monoclonal antibodies herein specifically include "chimeric" antibodies in which a portion of the heavy and/or light chain is identical with or homologous to corresponding sequences in antibodies derived from a particular species or belonging to a particular antibody class or subclass, while the remainder of the chain (s) is identical with or homologous to corresponding sequences in antibodies derived from another species or belonging to another antibody class or subclass, as well as fragments of such antibodies, so long as they exhibit the desired biological activity and/or specificity (e.g., U.S. Pat. No. 4,816,567; Morrison et al., Proc. Natl. Acad. Sci. USA, 81 : 6851-6855 (1984)). Methods of making chimeric antibodies are known in the art.
• “Functional fragments” of antibodies can also be used and include those fragments that retain sufficient binding affinity and specificity for a biomarker so as to permit a determination of the level of the biomarker in a biological sample. In some cases, a functional fragment will bind to a biomarker with substantially the same affinity and/or specificity as an intact full chain molecule from which it may have been derived.
• An "isolated” antibody is one which has been identified and separated and/or recovered from a component of its natural environment. Contaminant components of its natural environment are materials that would interfere with diagnostic or prognostic uses for the antibody, and may include enzymes, hormones, and other proteinaceous or non-proteinaceous solutes. In specific embodiments, the antibody will be purified to greater than 95% by weight of antibody, e.g., as determined by the Lowry method, and most preferably more than 99% by weight.
• detectably labeled antibody refers to an antibody (or antibody fragment) which retains binding specificity for a biomarker described herein, and which has an attached detectable label.
• the detectable label can be attached by any suitable means, e.g., by chemical conjugation or genetic engineering techniques. Methods for production of detectably labeled proteins are well known in the art.
• Detectable labels may be selected from a variety of such labels known in the art, including, but not limited to, haptens, radioisotopes, fluorophores, paramagnetic labels, enzymes (e.g., horseradish peroxidase), or other moieties or compounds which either emit a detectable signal (e.g., radioactivity, fluorescence, color) or emit a detectable signal after exposure of the label to its substrate.
• haptens e.g., radioisotopes, fluorophores, paramagnetic labels, enzymes (e.g., horseradish peroxidase), or other moieties or compounds which either emit a detectable signal (e.g., radioactivity, fluorescence, color) or emit a detectable signal after exposure of the label to its substrate.
• detectable label/substrate pairs e.g., horseradish peroxidase/diaminobenzidine, avidin/streptavidin, luciferase/luciferin
• methods for labeling antibodies, and methods for using labeled antibodies are well known in the art (see, for example, Harlow and Lane, eds. (Antibodies: A Laboratory Manual (1988) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N. Y.)).
• the level of a protein biomarker of the present disclosure is determined using an assay or format including, but not limited to, e.g., immunoassays, ELISA sandwich assays, lateral flow assays, flow cytometry, mass spectrometric detection, calorimetric assays, binding to a protein array (e.g., antibody array), single molecule detection methods, nanotechnology-based detection methods, or fluorescent activated cell sorting (FACS).
• an assay or format including, but not limited to, e.g., immunoassays, ELISA sandwich assays, lateral flow assays, flow cytometry, mass spectrometric detection, calorimetric assays, binding to a protein array (e.g., antibody array), single molecule detection methods, nanotechnology-based detection methods, or fluorescent activated cell sorting (FACS).
• an assay or format including, but not limited to, e.g., immunoassays, ELISA sandwich assays, lateral flow assays
• an approach involves the use of labeled affinity reagents (e.g., antibodies, small molecules, etc.) that recognize epitopes of one or more biomarker proteins in an ELISA, antibody-labelled fluorescent bead array, antibody array, or FACS screen.
• labeled affinity reagents e.g., antibodies, small molecules, etc.
• an ELISA antibody-labelled fluorescent bead array
• antibody array antibody array
• FACS screen any of a number of illustrative methods for producing, evaluating and/or using antibodies for detecting and quantifying the biomarkers herein are well known and available in the art. It will also be understood that the protein detection and quantification in accordance with the methods described herein can be carried out in single assay format, multiplex format, or other known formats.
• high-throughput multiplex formats exist for evaluating the disclosed biomarkers.
• high-throughput refers to a format that performs a large number of assays per day, such as at least 100 assays, 1000 assays, up to as many as 10,000 assays or more per day.
• assays either the number of samples or the number of markers assayed can be considered.
• the samples are analyzed on an assay instrument.
• the assay instrument may be a multiplex analyzer that simultaneously measures multiple analytes, e.g. proteins, in a single microplate well.
• the assay format may be receptor-ligand assays, immunoassays, and enzymatic assays.
• An example of such an analyzer is the Luminex® 100/200 system which is a combination of three xMAP® Technologies. The first is xMAP microspheres, a family of fluorescently dyed micron-sized polystyrene microspheres that act as both the identifier and the solid surface to build the assay.
• the second is a flow cytometry -based instrument, the Luminex® 100/200 analyzer, which integrates key xMAP® detection components, such as lasers, optics, fluidics, and high-speed digital signal processors.
• the third component is the xPO ENT® software, which is designed for protocol-based data acquisition with robust data regression analysis.
• a dataset may be generated and used (as further described herein) to classify the biological sample to one or more of risk stratification, prognosis, diagnosis, and monitoring of the cardiovascular status of the subject, and further assigning a likelihood of a positive or negative diagnosis, outcome, or one or more future changes in cardiovascular status to the subject to thereby establish a diagnosis and/or prognosis of cardiovascular disease and/or outcome, as described herein.
• the dataset may be obtained via automation or manual methods.
• the methods of the invention are capable of discriminating between different endpoints.
• the endpoints may include, for example, obstructive coronary artery disease (CAD), cardiovascular death (CVD), myocardial infarction (MI), stroke, composites thereof, and composites further of all cause death.
• CAD obstructive coronary artery disease
• CVD cardiovascular death
• MI myocardial infarction
• stroke composites thereof, and composites further of all cause death.
• the identity of the markers and their corresponding features are used in developing and implementing an analytical process, or plurality of analytical processes, that discriminate between clinically relevant classes of patients.
• a biomarker and clinical variable dataset may be used in an analytic process for correlating the assay result(s) generated by the assay instrument and optionally the clinical variable status to the cardiovascular status of the subject, wherein said correlation step comprises correlating the assay result(s) to one or more of risk stratification, prognosis, diagnosis, classifying and monitoring of the cardiovascular status of the subject, wherein said correlating step comprises assigning a likelihood of a positive or negative diagnosis, or one or more future changes in cardiovascular status to the subject based on the assay result(s).
• a biomarker and clinical variable dataset may be used in an analytic process for generating a diagnostic and/or prognostic result or score.
• an illustrative analytic process can comprise a linear model with one term for each component (protein level or clinical factor).
• the result of the model is a number that generates a diagnosis and/or prognosis.
• the result may also provide a multi-level or continuous score with a higher number representing a higher likelihood of disease or risk of event.
• the examples below illustrate how data analysis algorithms can be used to construct a number of such analytical processes.
• Each of the data analysis algorithms described in the examples use features (e.g., quantitative protein levels and/or clinical factors) of a subset of the markers identified herein across a training population.
• Specific data analysis algorithms for building an analytical process or plurality of analytical processes, that discriminate between subjects disclosed herein will be described in the subsections below.
• the analytical process can be used to classify a test subject into one of the two or more phenotypic classes and/or predict survival/mortality or a severe medical event within a specified period of time after the blood test is obtained. This is accomplished by applying one or more analytical processes to one or more marker profile(s) obtained from the test subject.
• Such analytical processes therefore, have enormous value as diagnostic or prognostic indicators.
• the present invention therefore further provides for an algorithm that may be used to transform the levels of a panel of biomarkers, as described above, into a score that may be used to determine whether a patient is diagnosed with obstructive coronary artery disease or has a prognosis of risk for developing an adverse cardiovascular event.
• the data are processed prior to the analytical process.
• the data in each dataset are collected by measuring the values for each marker, usually in duplicate or triplicate or in multiple replicates.
• the data may be manipulated; for example, raw data may be transformed using standard curves, and the average of replicate measurements used to calculate the average and standard deviation for each patient. These values may be transformed before being used in the models, e.g., log-transformed, normalized to a standard scale, Winsorized, etc.
• the data is transformed via computer software. This data can then be input into the analytical process with defined parameters.
• the direct levels of the proteins (after log-transformation and normalization), the presence/absence of clinical factors represented in binary form (e.g. sex), and/or clinical factors in quantitative form (e.g., BMI, age) provide values that are plugged into the diagnostic model provided by the software, and the result is evaluated against one or more cutoffs to determine the diagnosis or prognosis.
• binary form e.g. sex
• quantitative form e.g., BMI, age
• the statistical analysis may be applied for one or both of two tasks. First, these and other statistical methods may be used to identify preferred subsets of markers and other indices that will form a preferred dataset. In addition, these and other statistical methods may be used to generate the analytical process that will be used with the dataset to generate the result.
• Several statistical methods presented herein or otherwise available in the art will perform both of these tasks and yield a model that is suitable for use as an analytical process for the practice of the methods disclosed herein.
• the data Prior to analysis, the data is partitioned into a training set and a validation set.
• the training set is used to train, evaluate and build the final diagnostic or prognostic model.
• the validation set is not used at all during the training process, and is only used to validate final diagnostic or prognostic models. All processes below, except when explicitly mentioned, involve the use of only the training set.
• the balance of various outcomes (e.g., presence of 70% or greater obstruction, the occurrence of MI within one year, etc.) is considered to confirm that the outcomes of interest are properly represented in each data set.
• the features (e.g., proteins and/or clinical factors) of the diagnostic and/or prognostic models are selected for each outcome using a combination of analytic processes, including least angle regression (LARS; a procedure based on stepwise forward selection), shrinkage in statistical learning methods such as least absolute shrinkage and selection operator (LASSO), significance testing, and expert opinion.
• LRS least angle regression
• LASSO least absolute shrinkage and selection operator
• the statistical learning method used to generate a result may be any type of process capable of providing a result useful for classifying a sample (e.g., a linear model, a probabilistic model, a decision tree algorithm, or a comparison of the obtained dataset with a reference dataset).
• the diagnostic or prognostic signal in the features is evaluated with these statistical learning methods using a cross-validation procedure.
• the training set is further split into training and validation sets (hereby called CV-training and CV-validation data sets).
• the diagnostic or prognostic model is built using the CV-training data, and evaluated with the CV-validation data.
• Models during the cross-validation process are evaluated with standard metrics of classification accuracy, e.g. the area under the ROC curve (AUC), sensitivity (Sn), specificity (Sp), positive predictive values (PPV), and negative predictive values (NPV).
• standard metrics of classification accuracy e.g. the area under the ROC curve (AUC), sensitivity (Sn), specificity (Sp), positive predictive values (PPV), and negative predictive values (NPV).
• a final predictive model is built using all of the training data.
• This final model or a model optimized for a particular biomarker platform when used in a clinical setting, may be implemented as a software system, either running directly on the assay hardware platform or an independent system.
• the model may receive protein level or concentration data directly from the assay platform or other means of data transfer, and patient clinical data may be received via electronic, manual, or other query of patient medical records or through interactive input with the operator. This patient data may be processed and run through the final model, which will provide a result to clinicians and medical staff for purposes of decision support.
• the present invention further provides panels, assays, and kits comprising at least
• a diagnostic or prognostic panel or kit comprises one or a plurality of biomarkers set out in Tables 1A, IB, 2A, and 2B and optionally one or a plurality of applicable clinical variables set out in Tables 3 A, 3B, 4A, and 4B.
• the panels, assays, and kits described herein comprise antibodies, binding fragments thereof and/or other types of binding agents which are specific for the biomarkers of Tables 1A, IB, 2A, and 2B, and which are useful for determining the levels of the corresponding biomarker in a biological sample according to the methods describe herein.
• the very same panel, assay, or kit can advantageously comprise, in addition or instead, one or a plurality of antibodies, binding fragments thereof or other types of binding agents, which are specific for the biomarkers of Tables 1A, IB, 2A, and 2B.
• the panels, assays, and kits can further comprise, include or recommend a determination of one or a plurality of applicable clinical variables as set out in Tables 3A, 3B, 4A, and 4B.
• the biomarkers and/or clinical variables used in in conjunction with a panel, assay, or kit include those listed in Tables 1 A, IB, 2A, 2B and Tables 3 A, 3B, 4A and 4B, respectively, particularly those which are associated with a p-value of less than 0.1, less than 0.05, less than 0.01 or less than 0.001.
• panels, assays, and kits may comprise at least 1, at least 2, at least 3 or at least 4 biomarkers as described herein.
• the number of biomarkers employed can include at least 5, 6, 7, 8, 9 or 10 or more.
• the number of biomarkers employed can include at least 15, 20, 25 or 50, or more.
• a panel, assay, or kit may include additional biomarkers (or binding agents thereto) not specifically described herein, particularly where the biomarkers in the panel themselves provide statistically significant information regarding a diagnosis or prognosis of interest, e.g., whether a patient has coronary artery disease or would be at increased risk for cardiovascular disease and/or an adverse cardiovascular event within one year, at one year, or beyond one year.
• panels, assays, and kits of the present disclosure can be used for identifying the presence of cardiovascular disease in a subject, particularly the presence of obstructive coronary artery disease and/or for predicting cardiac events.
• a diagnostic panel, assay, or kit identifies in a subject the presence of 70% or greater obstruction in any major epicardial vessels.
• a prognostic panel, assay, or kit is used to predict the risk of a cardiovascular disease or event within one year, about 1 year, about 2 years, about 3 years, about 4 years, about 5 years, or more from the date on which the sample is drawn.
• Time endpoints are defined as from sample draw and include less than one year, one year, and greater than one year. Less than or within one year may be any time from time of sample draw up to and including 365 days.
• the panel results may predict the risk of a cardiovascular disease or event from time of sample draw to 30 days, to 60 days, to 90 days, to 120 days, to 150 days, to 180 days, to 210 days, to 240 days, to 270 days, to 300 days, to 330 days, to 360 days, to 365 days.
• time endpoints are defined as 3 days post sample draw to 30 days, to 60 days, to 90 days, to 120 days, to 150 days, to 180 days, to 210 days, to 240 days, to 270 days, to 300 days, to 330 days, to 360 days, to 365 days.
• panels, assays, and kits for the diagnosis of obstructive CAD comprise at least 1, at least 2, at least 3, at least 4 or greater than four biomarkers, or antibodies, binding fragments thereof or other types of binding agents, which are specific for the biomarkers, where the biomarkers are selected from the group consisting of adiponectin, apolipoprotein C-I, decorin, interleukin-8, kidney injury molecule- 1, matrix metalloproteinase 9, midkine, myoglobin, pulmonary surfactant associated protein D, stem cell factor, and troponin.
• at least one clinical variable described herein is used in conjunction with the biomarker levels determined.
• the clinical variable is selected from the group consisting of age, history of coronary artery bypass graft surgery (CABG), history of diabetes type 2, history of hemodialysis, history of myocardial infarct (MI), history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• CABG coronary artery bypass graft surgery
• MI myocardial infarct
• percutaneous coronary intervention e.g., balloon angioplasty with or without stent placement
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin, apolipoprotein C-l, kidney injury molecule- 1, and midkine and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• biomarkers for adiponectin, apolipoprotein C-l, kidney injury molecule- 1, and midkine and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), and sex.
• This combination of biomarkers and clinical variables is represented by panel FM139/685 in Table 25, Example 1, and Figures 1-4.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin, apolipoprotein C-l, kidney injury molecule- 1, and midkine and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement), sex, and age.
• This combination of biomarkers and clinical variables is represented by panel FM144/696 in Table 25 and Figure 5.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin, apolipoprotein C-I, kidney injury molecule-1, and midkine and clinical variables of sex and age. This combination of biomarkers and clinical variables is represented by panel FM145/701 in Table 25 and Figure 6.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin, apolipoprotein C-I, kidney injury molecule-1, and midkine. This combination of biomarkers is represented by panel FM146/690 in Table 25 and Figure 7.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin, kidney injury molecule-1, and midkine and clinical variables of history of diabetes mellitus type 2, sex, and age. This combination of biomarkers and clinical variables is represented by panel FM152/757 in Table 25 and Figure 8.
• Embodiments of the present invention comprise a panels, assays, and kits for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprising at least one biomarker and one or more clinical variables.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises a biomarker for midkine and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex.
• This combination of biomarkers and clinical variables is represented by panel FM117a/657 in Table 25 and Figure 9.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises a biomarker for adiponectin and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex.
• a biomarker for adiponectin and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex.
• This combination of biomarkers and clinical variables is represented by panel FM139CLa/658 in Table 25 and Figure 10.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises a biomarker for apolipoprotein C-1 and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex.
• a biomarker for apolipoprotein C-1 and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex.
• This combination of biomarkers and clinical variables is represented by panel FM139CLb/750 in Table 25 and Figure 11.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises a biomarker for kidney injury molecule-1 and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex. This combination of biomarkers and clinical variables is represented by panel FM139CLc/751 in Table 25 and Figure 12.
• a panel, assay, or kit for the diagnosis of 70% or greater obstruction in any major epicardial vessel comprises biomarkers for adiponectin and midkine and clinical variables of history of percutaneous coronary intervention (e.g., balloon angioplasty with or without stent placement) and sex. This combination of biomarkers and clinical variables is represented by panel FM117b/663 in Table 25 and Figure 13.

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