Increased 90-day mortality in patients with acute heart failure with elevated neopterin: secondary results from the Biomarkers in Acute Heart Failure (BACH) study.

Introduction: Elevated cardiac troponin (cTn) levels are associated with adverse events in patients with chronic and acute decompensated heart failure. Neopterin,a moderator of cellular immune response, predicts future cardiac and vascular adverse events in patients with chronic coronary artery disease. Hypothesis: The aim of this study was to evaluate the prognostic value of neopterin in the setting of acute heart failure by itself and in relation to troponin. Methods: The biomarkers in AHF (BACH trial) was a prospective,15 center, international study of 1641 patients presenting to the ED with dyspnea. A secondary end-point of this study was to test for non inferiority of neopterin versus troponin for predicting outcome over a period of 90 days and to assess whether neopterin adds predictive value for all cause mortality at 90 days to a clinical model with troponin. Results: In a population of 1641 patients, 511 had a final diagnosis of HF and data on troponin levels. Neopterin (HR 3.052; p = .004) and troponin (HR 4.083; p = .003) are both independent predictors of 90 day mortality. When both biomarkers were elevated,mortality substantially increased (HR 7.341; p = .000). In a multivariate analyses including gender, diabetes, third heart sound and diastolic blood pressure neopterin remained an independent predictor of death (p = .004). Conclusion: The novel immune/inflammatory biomarker, neopterin, shows indipendent prognostic value in patients presenting with acute decompensated heart failure. In patients with low troponin, elevated levels of neopterin portend an increased 90 day mortality. These findings suggest an important prognostic role for neopterin.