# Patent

## Title
Making a prognosis in cases of cardiac disease using a combination of markers

## Abstract

The present invention concerns methods for diagnosing myocardial infarction, for performing risk stratification of myocardial infarction, for making a prognosis of a disease course in a myocardial infarction patient, for identifying a patient with elevated risk of myocardial infarction, or combinations thereof, wherein a determination of at least three markers is performed on a patient sample. Furthermore, kits for performing the methods are provided.

## Background
PRIORITY
This application claims the benefit of U.S. Provisional application 60/380,413 filed May 14, 2002, which is incorporated herein in its entirety.


BACKGROUND
A number of markers are used in the diagnosis of coronary diseases such as NSTEMI and acute coronary syndrome, e.g., troponin T, C-reactive protein (CRP) and brain-natriuretic peptide (BNP). The elevation of the concentration of one of these markers is associated with an elevation in the likelihood of ischemic events, including death. This is described, for example, in the publications Hamm et al. (New Engl. J. Med. 327 (1992), 146-150), Hamm et al. (New Engl. J. Med. 340 (1999), 1823-1629, Heeschen et al. (The Lancet 354 (1999), 1757-1962), Klootwijk and Hamm (The Lancet 353, Suppl. II (1999), 10-15), Wei et al. (Circulation 88 (1993), 1004-1009), De Lemos (New Engl. J. Med. 345 (2001), 1014-1021). In De Winter et al. (Cardiovasc. Res. 42 (1999), 240-245) and De Winter et al. (Clin. Chem. 46 (2000), 1597-1603). CRP and troponin I or troponin T are two independent markers for the risk stratification of patients with acute coronary syndrome.
The disadvantage of diagnostic procedures using one or two markers, is that all high-risk patients are not successfully identified. Therefore methods for diagnosing myocardial infarction and/or for risk stratification of acute coronary syndrome that have improved identification of high-risk patients is needed in the art.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 shows the curve for troponin T (TnT) assays carried out on 500 patients with acute coronary syndrome (NSTEMI).
FIG. 2 shows the curve for NT-ProBNP assays carried out on 500 patients with NSTEMI.
FIG. 3 shows the curve for CRP assays carried out on 500 patients with acute coronary syndrome (NSTEMI).
FIG. 4 shows the correlation between the NT-ProBNP value and the troponin T value for 500 patients with NSTEMI.
FIG. 5 shows the correlation between the NT-ProBNP value and the troponin T value for 1848 patients.
FIG. 6 shows the result of a 30-day follow-up for the part of all patients (a) or of the NSTEMI patients (b) with death or myocardial infarction (MI) with regard to parameters NT-ProBNP and troponin T as well as the combination thereof.



SUMMARY OF THE INVENTION
The present invention concerns methods and compositions for diagnosing myocardial infarction, in particular, Non-ST-Elevation Myocardial Infarction (NSTEMI), for risk stratification of the acute coronary syndrome, for determining presence or absence of elevated risk of myocardial infarction, for determining the prognosis of a patient with myocardial infarction, or a combination thereof whereby a determination of at least three markers is performed on a patient to be investigated. Furthermore, kits for performing methods of the invention are provided.
One embodiment of the invention provides a method for diagnosing myocardial infarction, for performing risk stratification of myocardial infarction, or both. The method comprises determining the presence, quantity, or both presence and quantity of at least three markers in a patient sample, wherein the at least three markers comprise at least one neurohormonal marker, at least one ischemic marker, and at least one inflammatory marker. Myocardial infarction is diagnosed or risk stratification is performed by the method. The neurohormonal marker can be selected from the group consisting of A-type natriuretic peptide (ANP), N-terminal fragment of pro-ANP (NT-ProANP), and B-type natriuretic peptide (BNP). The ischemic marker can be selected from the group consisting of troponin T and troponin I. The inflammatory marker can be selected from the group consisting of C-reactive protein (CRP), interleukin, and an adhesion molecule. The inflammatory marker can also be selected from the group consisting of IL-6, endothelial intercellular adhesion molecule (ICAM), and vascular adhesion molecule (VCAM). The presence, quantity, or both presence and quantity of the markers can be determined in parallel, can be determined on an automated analyzer, and can be determined using a rapid assay. A single patient sample can be used.
Another embodiment of the invention provides a method for identifying a patient with elevated risk of myocardial infarction. The method comprises determining the presence, quantity, or both presence and quantity of at least three markers in a patient sample. The at least three markers comprise at least one neurohormonal marker, at least one ischemic marker, and at least one inflammatory marker. A patient with elevated risk of acute myocardial infarction is identified using the method.
Yet another embodiment of the invention provides a method for making a prognosis of a disease course in a myocardial infarction patient. The method comprises determining the presence, quantity, or both presence and quantity of at least three markers in a patient sample. The at least three markers comprise at least one neurohormonal marker, at least one ischemic marker, and at least one inflammatory marker. A prognosis is made using the method.
Still another embodiment of the invention provides a reagent kit for diagnosing myocardial infarction, for performing risk stratification of myocardial infarction, for making a prognosis of a disease course in a myocardial infarction patient, for identifying a patient with elevated risk of myocardial infarction, or combinations thereof. The kit comprises at least one detection reagent for a neurohormonal marker, at least one detection reagent for an ischemic marker, and at least one detection reagent for an inflammatory marker.
DETAILED DESCRIPTION
Methods of the invention comprise determining the presence, quantity, or both presence and quantity of at least three markers in a patient sample, wherein at least one neurohormonal marker, at least one ischemic marker, and at least one inflammatory marker.
Surprisingly it has been found that neurohormonal markers, ischemic markers, and inflammatory markers represent three groups of independent risk indicators, so that, by combining these three marker groups according to the invention, an additively increased sensitivity and specificity is obtained. Therefore, higher predictive values and a higher diagnostic effectiveness are possible, especially in patients with elevated risk and/or an unfavorable prognosis. Methods and compositions of the invention are useful for, e.g., diagnosing myocardial infarction, including acute myocardial infarction, and for performing risk stratification of myocardial infarction, including acute myocardial infarction. Risk stratification is the quantification of a patient's overall short term and long term risk. See e.g., Guidelines for Risk Stratification after myocardial Infarction, Ann. Intern. Med. 126:556-582 (Parts I and II) (1997); Doukky & Calvin, Risk Stratification in patients with unstable angina and non-ST segment elevation myocardial infarction: evidence-based review (Parts I and II), J. Invasive Cardiol., 14(4):215-220 and 254-262. Methods and compositions of the invention can also be used to identify patients with elevated risk of myocardial infarction, including acute myocardial infarction, and prognosis of a disease course in an acute myocardial infarction patient, including acute myocardial infarction patients. The methods and compositions of the invention thus make it possible to establish an improved indication for suitable therapeutic measures.
When cardiac disease is present, in particular Non-ST-elevation myocardial infarction (NSTEMI), a higher number of patients with elevated risk and/or an unfavorable prognosis can be identified and handled adequately with the methods and compositions of the invention than with current diagnostic procedures that include the determination of individual markers. As a result of the combination of three different markers in making a diagnosis, the frequency of cases of death and other cardial complications can be further reduced.
Methods according to the invention comprise the determination of at least three markers, whereby at least one neurohormonal marker, at least one ischemic marker, and at least one inflammatory marker are determined.
A neurohormonal marker can be selected, for example, from atrial (A-type) natriuretic peptide (ANP), brain (B-type) natriuretic peptide (BNP), or N-terminal fragments of propeptides NT-ProANP and NT-ProBNP. ProBNP is a preferred neurohormonal marker.
Troponin T or troponin I, for example, can be ischemic markers.
An inflammatory marker can be selected, for example, from C-reactive protein (CRP), interleukins, particularly IL-6, and adhesion molecules such as VCAM and ICAM.
Determination of the presence, quantity or both presence and quantity of markers can be performed, for example, in parallel or multiple samples in one or more samples from a patient to be investigated. One or more samples collected from a patient, e.g., blood, serum, or plasma samples, are investigated in one or more tests simultaneously or immediately sequentially. The determinations can be performed on a single patient sample from the same patient.
Determination of the presence, quantity or both presence and quantity of markers can be performed, for example using any commercial assay. Automated analyzers can be used for the determination. As an alternative, rapid assays, e.g., for use in an emergency room, hospital ward, intensive care station, ambulance, or doctor's office, or as a patient self-test can also be used.
Determination of markers can be done using, for example, an immunoassay employing antibodies directed against the marker. Detection of C-reactive protein as an inflammatory marker, can be accomplished as described by, for example, Liuzzo et al. (N. Engl. J. Med. 331 (1994), 417-424), Kuller et al. (Am. J. Epidem. 144 (1996), 537-547), Price et al. (J. Immunol. Methods. 99 (1987), 205-211) or Eda et al. (J. Clin. Lab. Anal. 12 (1998)), 137-144). An example of a test for detection of C-reactive protein is an immunoturbidimetric test, e.g., the Tina-Quant®-Test from Roche Diagnostics GmbH, Mannheim.
The detection of BNP or NT-ProBNP as neurohormonal markers is described, for example, in Richards et al. (Circulation 97 (1998), 1921-1929), Struthers (Eur. Heart J. 20 (1999), 1374-1375), Hunt et al. (Clin. Endocrinol. 47 (1997), 287-296), Talwar et al. (Eur. Heart J. 20 (1999), 1736-1744), Darbar et al. (Am. J. Cardiol. 78 (1996), 284-287) and in EP-A-0 648 228 and WO 00/45176. An example of a test is an electrochemiluminescence immunoassay, e.g., the electrochemiluminescence immunoassy (ECLIA) test format from Roche Diagnostics GmbH, Mannheim.
Troponin T, as an example of an ischemic marker, can be determined as described in, for example, to Katus et al. (Mol. Cell. Cardiol. 21 (1989), 1349-1353), Hamm et al. (N. Engl. J. Med 327 (1992), 146-150), Ohmann et al. (N. Engl. J. Med. 335 (1996), 1333-1334), Christenson et al. (Clin. Chem. 44 (1998), 494-501) and numerous other publications, and to EP-A-0 394 819. Tests for the detection of troponin T include, for example, electrochemiluminescence immunoassays, e.g., the Elecsys® Troponin-T and Elecsys® Troponin T STAT test formats from Roche Diagnostics GmbH, Mannheim.
Compositions of the invention include reagent kits for diagnosing acute coronary syndrome. A kit contains detection reagents for determining the presence, quantity, or both presence and quantity of at least three markers. The kit comprises at least one detection reagent for a neurohormonal marker at least one detection reagent for an ischemic marker, and at least one detection reagent for an inflammatory marker.
A reagent kit can be designed so that the reagents are adapted for performing parallel determinations of markers and, in particular, for performing determinations on a single patient sample. Detection reagents can be used that make it possible to determine all three markers using a single test format, e.g., an Enzymun-Test®, an electrochemiluminescence test, a turbidimetric test, or a rapid assay on a test strip.
A reagent kit can be used, e.g., to identify patients with acute coronary syndrome that have an elevated risk and/or an unfavorable prognosis. A reagent kit can be designed so that the reagents are adapted for performing determinations on an automated analyzer or a rapid assay.
The invention shall be explained further by the following non-limiting examples. All patents, patent applications, and other scientific or technical writings referred to anywhere herein are incorporated by reference in their entirety. The invention illustratively described herein suitably can be practiced in the absence of any element or elements, limitation or limitations that are not specifically disclosed herein. Thus, for example, in each instance herein any of the terms “comprising”, “consisting essentially of”, and “consisting of” may be replaced with either of the other two terms. The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention that in the use of such terms and expressions of excluding any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the invention claimed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments, optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the description and the appended claims.
In addition, where features or aspects of the invention are described in terms of Markush groups or other grouping of alternatives, those skilled in the art will recognize that the invention is also thereby described in terms of any individual member or subgroup of members of the Markush group or other group.
EXAMPLES
Example 1
Investigations of three markers troponin T, NT-ProBNP and CRP were carried out on 500 patients with acute coronary syndrome (NSTEMI). Troponin T STAT-Tests from Roche Diagnostics GmbH, Mannheim were used to determine troponin T. The Tina-Quant® CRP Tests from Roche Diagnostics GmbH, Mannheim were used to determine CRP, and ECLIA Tests from Roche Diagnostics, Mannheim were used to determine NT-ProBNP. Each test was performed according to the manufacturer's instructions.
All three parameters differentiate between patients with unfavorable 30-day diagnosis with regard for death and myocardial infarction and patients with 30 event-free days.
FIG. 1 shows the curve for troponin T (TnT)
FIG. 2 shows the curve for NT-ProBNP
FIG. 3 shows the curve for CRP.
Additionally, it was determined via a multivariant analysis that the three parameters are independent of each other.
FIG. 4 shows the correlation between the NT-ProBNP value and the troponin T value. It can be seen that some of the investigated patients have increased values only with regard to one of the parameters.
Example 2
Investigations of the three markers troponin T, NT-ProBNP and CRP were carried out on 1848 patients. The respective ELISA test by Roche was used to determine all three parameters. The results of Example 1 were confirmed. A cut-off value (distinction between positive and negative) of 0.1 pg/l was used for the troponin T test (detection limit 0.01 pg/l). A cut-off value of 400 ng/l was used for the NT-ProBNP test (detection limit 5 ng/l). A cut-off value of 15.0 mg/l was used for the CRP test (detection limit 0.5 mg/l). The NT-ProBNP value is of great importance especially for short-term prognosis, e.g. for the course of the next 72 h.
FIG. 5 shows the correlation between the NT-ProBNP value and the troponin T value.
FIG. 6 shows the result of a 30-day follow-up for the part of all patients (a) or of the NSTEMI patients (b) with death or myocardial infarction (MI) with regard to parameters NT-ProBNP and troponin T as well as the combination thereof.

## Claims

1. A method for making a short-term prognosis up to 30 days for a myocardial infarction patient by determining the level of three markers from a sample from the patient, wherein the three markers consist of N-terminal fragment of pro-BNP (NT-ProBNP) marker, at least one ischemic marker selected from the group consisting of troponin T and troponin I, and at least one inflammatory marker selected from the group consisting of C-reactive protein (CRP) and IL-6, comparing the pro-BNP (NT-ProBNP) level, the level of at least one of the ischemic markers and at least one of the inflammatory markers to a control, wherein an elevation of each the pro-BNP (NT-ProBNP), at least one of the ischemic markers, and at least one of the inflammatory markers as compared to the control indicates a less favorable prognosis.

2. The method according to claim 1, wherein the level of the markers are determined in parallel.

3. The method according to claim 1, wherein a single patient sample is used.

4. The method according to claim 1, wherein the presence, quantity, or both presence and quantity of said markers is determined on an automated analyzer.

5. The method according to claim 1, wherein the presence, quantity, or both presence and quantity of said markers is determined using an enzyme immunoassay, an electrochemiluminescence immunoassay, an immunoassay, or a turbidimetric test.

6. The method of claim 1, wherein the short-term prognosis is for the course of 72 hours.

7. The method of claim 1, wherein the short-term prognosis is for the course of 5 days.

8. The method of claim 1, wherein the short-term prognosis is for the course of 10 days.