<International Circulation>:  What biomarker do you think really works?

  《国际循环》：您认为有哪些有效的生物标志物？
    Prof. Felker:  If you look at the guidelines， by far the strongest evidence base we have for biomarkers is using the natriuretic peptides (BNP and NT-proBNP)， and making the diagnosis of heart failure in patients who present with shortness of breath. If you look at the US Guidelines， that is the only Class I indication for using a biomarker in the heart failure guidelines. That would be the most completely proven， though not necessarily the best. I think they are clearly very useful for prognosis and I think there are several of them for that: the natriuretic peptides， ST2 seems to be very powerful for prognosis. Understanding about prognosis is only useful if you can do something about it. Just saying you are going to do well or you are not going to do well is not very useful if you can’t do anything about it. They are most useful if they have some therapeutic imperative associated with them - if you measure something and it says this， so you need to do this treatment - and we actually have relatively little data to guide us in that way. That is the direction the field is moving in at present. We are transitioning from an era in which we mostly measured things and looked at outcomes， to what we can use to help us treat people in the face of a multitude of heart failure treatments. It stands to reason that some are going to be more effective in one patient than another and the question is， how do you figure out which is which? We have a lot of biomarkers that can give us insight into what is going on with the patient， but to use a military analogy， it is like the difference between intelligence and actionable intelligence. We have intelligence; we have biomarkers that can tell us this patient has a lot of inflammation or this patient has a lot of fibrosis going on. What is not yet totally clear is how we can close that loop and to take that information and do something in particular that we wouldn’t have done already. That’s the key. It is not helpful if it just tells us to do something we were going to do anyway. It can’t just tell us more; it has to tell us something new. Measuring two biomarkers that measure the same thing is not going to be useful. Multiple biomarkers are only useful when they allow you to zone in on some salient feature relevant to what you are trying to figure out.

    Felker教授：如果你查阅指南，目前为止生物标志物方面我们最强的证据就是使用脑钠肽(BNP和NT-proBNP)，对有呼吸困难的患者进行心衰的诊断。如果你看美国指南，这是在心衰方面生物标志物的唯一一个I级适应证。尽管可能不是最好的，却是得到完全证实的。我认为脑钠肽显然对诊断非常有用，其他的如ST2也对预测预后很有价值。只有在我们能够进行干预的前提下，预测预后才有用。如果只是说预后好或者不好，但是没法进行任何干预，那么就不是很有用了。如果能有一些和它们相关的治疗方法的话，那就最好——如果你测量了某个标志物并且得到某种结果的话，就需要接受这种治疗——然而事实上我们这方面的资料相对来说还很少。这就是生物标志物方面目前的发展方向。我们正在从主要是测量标志物和关注预后的时代，向面对众多心衰治疗的方法，如何治疗患者的时代转变。有些治疗方法对于一部分患者来说，比对另一部分患者更有效。问题是，你如何来判断哪些患者适合哪些治疗方法？我们有很多能够让我们了解患者现状的生物标志物，但是用军事作类比，这就像情报和可信情报之间的差异。我们有情报，我们有生物标志物，这些生物标志物能够告诉我们患者处于高炎症状态，或者患者正在发生纤维化。尚不完全明确的是我们如何使这个链条完整，通过得到的信息来做一些事，尤其是做尚没有进行的事。这就是关键之处。如果生物标志物只是告诉我们去做我们原本也肯定要去做的事情，那么就它起不到作用。它不应只是告诉我们更多，而必须告诉我们新的信息。对于同一个目的测量两种生物标志物也不必要。多个生物标志物只在对你所探寻的目的相关的一些显著特征进行分类的时候才有用。