Prognostic Value of Serial ST2 Measurements in Patients With Acute Heart Failure

Laura C. van Vark*, Ivonne Lesman-Leegte, Sara J. Baart, Douwe Postmus, Yigal M. Pinto, Joke G. Orsel, B. Daan Westenbrink, Hans P. Brunner-la Rocca, Addy J. M. van Miltenburg, Eric Boersma, Hans L. Hillege, K. Martijn Akkerhuis, TRIUMPH Investigators

*Corresponding author for this work

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BACKGROUND Several clinical studies have evaluated the association between ST2 and outcome in patients with heart failure (HF). However, little is known about the predictive value of frequently measured ST2 levels in patients with acute HF.

OBJECTIVES This study sought to describe the prognostic value of baseline and repeated ST2 measurements in patients with acute HF.

METHODS In the TRIUMPH (Translational Initiative on Unique and novel strategies for Management of Patients with Heart failure) clinical cohort study, 496 patients with acute HF were enrolled in 14 hospitals in the Netherlands between 2009 and 2014. Repeated blood samples (7) were drawn during 1-year follow-up. ST2 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured in a central laboratory. The primary endpoint was the composite of all-cause mortality and HF rehospitalization. Associations between repeated biomarker measurements and the primary endpoint were assessed using a joint model.

RESULTS Median age was 74 years, and 37% of patients were women. The primary endpoint was reached in 188 patients (40%) during a median follow-up of 325 days (interquartile range: 85 to 401). The median baseline ST2 level was 71 ng/ml (interquartile range: 46 to 102). After adjustment for clinical factors and NT-proBNP, baseline ST2 was associated with an increased risk of the primary endpoint, and the hazard ratio per 1 SD increase of the baseline ST2 level (on the log(2) scale) was 1.30 (95% confidence interval: 1.08 to 1.56; p = 0.005). When repeated measurements were taken into account, the adjusted hazard ratio per 1 SD increase of the ST2 level (on the log(2) scale) during follow-up increased to 1.85 (95% confidence interval: 1.02 to 3.33; p = 0.044), adjusted for clinical factors and repeated measurements of NT-proBNP. Furthermore, ST2 levels appeared to elevate several weeks before the time of the primary endpoint.

CONCLUSIONS Repeated ST2 measurements appeared to be a strong predictor of outcome in patients with acute HF, independent of repeatedly measured NT-proBNP. Hence ST2 may be helpful in clinical practice for prognostication and treatment monitoring. (TRanslational Initiative on Unique and novel strategies for Management of Patients with Heart failure [TRIUMPH]; NTR1893) (C) 2017 by the American College of Cardiology Foundation.

Original languageEnglish
Pages (from-to)2378-2388
Number of pages11
JournalJournal of the American College of Cardiology
Issue number19
Publication statusPublished - Nov 2017


  • biomarker
  • heart failure
  • prognosis
  • repeated measurements
  • ST2

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