Galectin-3 in Heart Failure with Preserved Ejection Fraction and Persistent Atrial Fibrillation Versus Sinus Rhythm. Correlation with Left Atrial Volume and N-Terminal Pro B-Type Natriuretic Peptide

Research Article

J Cardiovasc Disord. 2021; 7(1): 1043.

Galectin-3 in Heart Failure with Preserved Ejection Fraction and Persistent Atrial Fibrillation Versus Sinus Rhythm. Correlation with Left Atrial Volume and N-Terminal Pro B-Type Natriuretic Peptide

Bertoni M¹*, Traini AM², Celli A³, Bini C¹, Bracciali A¹, Foretic M¹ and Di Natale ME¹

¹2ndDepartment of Internal Medicine, Santo Stefano Hospital, Prato, Italy

²Department of Cardiology, Santo Stefano Hospital, Prato, Italy

³Department of Biochemical Chemistry, Santo Stefano Hospital, Prato, Italy

*Corresponding author: Bertoni M, 2nd Department of Internal Medicine, Santo Stefano Hospital, Via Ugo Foscolo 5, 59100-Prato, Italy

Received: May 21, 2021; Accepted:July 02, 2021; Published: July 09, 2021

Abstract

Background: Galectin-3 (Gal-3) is considered both a profibrotic biomarker in Heart Failure with preserved Ejection Fraction (HFpEF) and a biomarker of atrial remodeling in Atrial Fibrillation (AF). The Left Atrial Volume Index (LAVI) is an echocardiographic parameter considered an index of left atrial remodeling. Aim of this study was to analyse the relation of Gal-3 levels with both LAVI and N-Terminal Pro B-Type Natriuretic Peptide (NT-proBNP) in patients with HFpEF and Persistent AF (HFpEF-PAF).

Methods: Serum Gal-3 and NT-proBNP, along with LAVI were measured. A comparison of such parameters between 49 patients with HFpEF-PAF and 53 patients with HFpEF and sinus rhythm (HEpEF-SR) was made.

Results: Galectin-3, NT-proBNP and LAVI were significantly higher in patients with HFpEF-PAF compared to HFpEF-SR (23±7 ng/mL vs 19.5±8.5 ng/mL, p=0.027; 3,406.8±2,321.9 pg/mL vs 1,459.6±1,372 pg/mL, p<0.001; 40.1±11mL/m² vs 28.4±7.7 mL/m², p<0.001, respectively). In HFpEF-PAF, Gal- 3 showed a significant correlation with both NT-proBNP (r=0.40, p=0.0038) and LAVI (r=0.28, p=0.044). We found a significant association between patients with higher levels of Gal-3 >17.8 ng/mL and HFpEF-PAF (p=0.002). Finally, a multivariate logistic regression analysis adjusted for age, sex and traditional clinical AF risk factors showed that Gal-3 >17,8 ng/mL (OR 3.862, 95% CI 1.416 to 10.532, p=0.008) was an independent predictor of PAF.

Conclusions: In patients with HFpEF-PAF Gal-3 was higher and related with both NT-proBNP and LAVI. The latter correlation may be relevant because LAVI is considered an index of left atrial remodeling. Moreover, higher levels of Gal-3>17,8 ng/mL were an independent predictor of PAF.

Keywords: Galectin-3; Left atrial volume index; Heart Failure with preserved Ejection Fraction; Persistent Atrial Fibrillation

Introduction

Atrial Fibrillation (AF) is a key co-morbidity that is not only highly prevalent, but is associated with worse outcomes in Heart Failure with Preserved Ejection Fraction (HFpEF) [1,2]. In recent years, a growing number of studies have focused on the role of Galectin-3 (Gal-3) as a biomarker of both HFpEF and AF. The level of Gal-3 purportedly reflects an ongoing cardiac fibrotic process and has been associated with ventricular remodeling, which is instrumental in the development of HFpEF syndrome [3]. In this regard, it has been suggested that patients with HFpEF have a much stronger correlation with Gal-3 than those with reduced ejection fraction [4]. Moreover, in the sub-study of PARAMOUNT trial on the role of profibrotic biomarkers in HFpEF, Gal-3 levels correlated with severity of disease as indicated by N-Terminal Pro B-Type Natriuretic Peptide (NTproBNP) and Left Atrial Volume (LAV) [5]. Finally, a recent study showed that increasing levels of Gal-3 possibly reflect the progressive course of HFpEF, as classified by the echocardiographic grades of diastolic dysfunction [3].

The profibrotic role of Gal-3 and its implications in the mechanisms of left atrial remodeling and maintenance of AF have recently been studied. With reference to Persistent AF (PAF), two recent studies recently suggested a role of Gal-3 in the maintenance of this arrhythmia. The first one evidenced that Gal-3 levels were significantly higher in PAF patients than in controls with Sinus Rhythm (SR) and were significantly correlated with LAV Index (LAVI), an accepted echocardiographic marker of left atrial remodelling [6]. In the second study, performed in patients with AF and preserved left ventricular function, Gal-3 levels were significantly greater than in controls with SR, significantly higher in patients with PAF than those with paroxysmal AF and, finally, significantly correlated with LAVI [7].

This study primarily aimed at searching a possible increase of Gal-3 levels in patients with HFpEF and PAF (HFpEF-PAF) compared to patients with HFpEF and SR (HFpEF-SR). Secondly, the possible correlation between Gal-3 levels and indices of severity of HFpEF such as LAVI and NT-proBNP was sought in both the aforementioned groups of patients.

Methods

Study design and population characteristics

With regard to the sample size, we considered three main aspects: a) in Europe and the United States the prevalence of heart failure (HF) in over 65-year-olds is about 4% in males and about 3% in females [8]; b) according to the 2014 Italian Institute of Statistics data, the over-65 inhabitants of the province of Prato were about 23,340 males and 30,682 females; c) the Santo Stefano Hospital in Prato is the only hospital of the province. It is therefore conceivable that the expected prevalence values of HF in the Prato population over the age of 65 are about 933 cases in males and about 920 cases in females. Finally, data from a large epidemiological study have shown that the prevalence of HFpEF is about 50% of all cases of HF [9]. Therefore, we planned to include approximately 10% of the target population in the study, i.e. a sample of approximately 100 patients, representative of the reference population and stratified by age and sex.

This study was a mono-centric study conducted at the 2nd Department of Internal Medicine of the Santo Stefano Hospital, Prato, Italy. The research adhered to the principles outlined in the Declaration of Helsinki and was approved by the Medical Ethics Committee of the Area Vasta Toscana Centro to which the Santo Stefano Hospital in Prato belongs. Freely given, written informed consent to participate in the study was obtained from all patients.

The present study incorporated a population subset derived from a patient cohort who attended the outpatient clinic of 2nd Department of Internal Medicine of the Santo Stefano Hospital in Prato, between November 2018 and September 2020. As this was a non-interventional, observational study, diagnostic procedures and treatment plans were not modified.

A total of 102 patients diagnosed with HFpEF were included consecutively. Forty-nine patients diagnosed with non-valvular (mitral and aortic valve) PAF (AF duration longer than one month) were recruited into the HFpEF-PAF group. Fifty-three age-matched patients with HFpEF-SR were recruited into the control group. Both HFpEF and AF diagnosis were made according to the 2016 guidelines of the European Society of Cardiology (ESC) [10,11]. At enrollment, the relevant demographic and clinical data of each patient, including age, gender, Body Mass Index (BMI), Body Surface Area (BSA), heart rate, New York Heart Association (NYHA) functional class, risk factors such as smoke, presence of co-morbidities (diabetes mellitus, hypertension, coronary artery disease, myocardial infarction, chronic obstructive pulmonary disease, kidney dysfunction with estimated Glomerular Filtration Rate (eGFR) >30mL/min/1.73m² (calculated by using the Cockroft-Gault formula), intake of Angiotensin- Converting-Enzyme Inhibitors (ACE-I) or Angiotensin Receptor Blockers (ARB), beta blockers (BB), diuretics, were recorded for all patientsand compiled in a database. Age under 18 years, recent onset acute coronary syndrome (< three months), pulmonary embolism, complex ventricular arrhythmias, idiopathic pulmonary fibrosis, chronic pancreatitis, liver cirrhosis, renal failure with eGFR <30 mL/ min/1.73m² (stages four and five of the Kidney Disease Improving Global Outcomes classification [12]), malignancy any prior blood transfusions, carotid artery disease, were exclusion criteria in this study. Blood samples, collected from all patients, were preserved and processed throughout the study.

Echocardiographic assessment

Only one cardiologist, blinded to patient clinical history, performed and interpreted al echocardiograms, and verified left ventricular volumetric analysis. The Left Ventricular Ejection Fraction (LVEF) was calculated by using the modified biplane Simpson’s method [13]. Measurements were obtained as the mean value from the apical 4- and 2-chamber views. The LAV was calculated by using the biplane method of discs (modified Simpson’s rule) by using the apical 4- and 2-chamber views at end diastole of the atria. Measurements were obtained as the mean value from the apical 4- and 2-chamber views. The LAVI was then calculated as LAV divided by BSA [13].

Laboratory analysis

Blood samples were collected from all patients (at rest) at a single assessment time point upon study inclusion by venepuncture with serum monovettes and centrifuged at 2,500 g at 20°C for ten minutes. The aliquoted samples were cooled down in liquid nitrogen before being stored at -80°C for further analysis. After thawing, the samples were gently mixed by inverting and centrifuged at 2,500 g for ten minutes at 20°C.

Determination of Gal-3 level was prospectively completed by using the VIDAS Galectin-3 kit (BioMérieux, Marcy-l’Etoile, France) which is a quantitative, one-step immunoassay sandwich assay with fluorescence detection. The kit measuring range is 3.3-100 ng/mL. Briefly the system measures Gal-3 in human serum or plasma (200 μL) by using the Enzyme-Linked Fluorescent Assay (ELFA) technique in 20 minutes. All stages of the assay are performed automatically by the instrument, calculating the concentration of Gal-3 relative to a stored calibration curve. This test has already been validated in HF patients [14].

For Gal-3, there are Food and Drug Administration (FDA) approved partition values that can be used in risk assessment analyses to predict morbid and mortal outcomes. When Gal-3 is >17.8 ng/mL, there is an increase in risk [15]. Serum Gal-3 levels were also measured in a control group of 26 subjects of age, sex, and race distribution similar to this study population, without histories of any disease, who underwent routine screening visits in the outpatient clinics.

The serum level of NT-proBNP, used as a reference biomarker, was measured using an NT-proBNP II assay on a VIDAS analyzer (BioMérieux) using the ELFA technique. The limit of detection for this dosage was 10 pg/mL. Serum creatinine concentrations were measured using the Creatinine Jaffe Gen. 2 test on an AU5800 analyzer (Beckman Coulter). The following blood tests were also performed: cystatin-C (Quantikine Human Cystatin C Immunoassay, R&D Systems, Minneapolis, MN, USA), blood count (including neutrophil/lymphocyte ratio-N/LR-), platelet count, high sensitive C-reactive protein (hs-CRP), thyroid stimulating hormone, low density lipoprotein-cholesterol, all of them by the common commercial kits used in the analysis laboratory of the Santo Stefano Hospital in Prato.

Statistical analysis

Continuous variables are expressed as mean ± standard deviation or median (interquartile range) when appropriate. Categorical variables are expressed as percentages. To compare parametric continuous variables the Student’s t-test was used; to compare nonparametric continuous variables the Mann-Whitney U-test was used. To compare categorical variables the chi-square-test was used. The Pearson and Spearman correlation coefficient were used to respectively determine parametric and nonparametric measure of statistical dependence between two variables. Multivariate logistic regression analysis adjusted for age, sex and traditional clinical AF risk factors was used to examined the relation of AF with high levels of Gal-3 (>17.8 ng/mL). A 2-tailed p-value of less than 0.05 was considered to indicate statistical significance. The statistical analyses were performed using software (SPSS 25.0.0.0, SPSS Inc, Chicago, IL).

Results

Baseline characteristics

As we can see in the participant flow diagram of Figure 1, fortynine patients with HFpEF-PAF and 53 patients with HFpEF-SR were included in the study. Of the 60 potentially enrolled HFpEFPAF patients, five were excluded because of renal failure with eGFR <30 mL/min/1.73m², three because of chronic pancreatitis and one because of liver cirrhosis. Two additional patients refused to undergo laboratory tests. Of the 59 potentially enrolled HFpEFSR patients, four were excluded because of renal failure with eGFR <30 mL/min/1.73m² and two additional patients refused to undergo laboratory tests.