Background Soluble ST2 reflects activity of an IL-33 dependent cardioprotective signaling axis and is a diagnostic and prognostic marker in acute heart failure. The use of ST2 in chronic heart failure has not been well defined. Our objective was to determine whether plasma ST2 levels predict adverse outcomes in chronic heart failure in the context of current approaches. Methods and Results We determined the association between ST2 level and risk of death or transplantation in a multi-center prospective cohort of 1,141 chronic heart failure outpatients. Adjusted Cox models, receiver operating characteristic (ROC) analyses, and risk reclassification metrics were used to assess the value of ST2 in predicting risk beyond currently used factors. After a median of 2.8 years, 267 patients (23%) died or underwent heart transplantation. Patients in the highest ST2 tertile (ST2>36.3ng/ml) had a markedly increased risk of adverse outcomes compared to the lowest tertile (ST2≤22.3ng/ml), with an unadjusted hazard ratio (HR) of 3.2 (95%CI:2.2-4.7;p<0.0001) that remained significant after multivariable adjustment (adjusted HR 1.9[95%CI:1.3-2.9];p=0.002). In ROC analyses, the area under the curve (AUC) for ST2 was 0.75 (95%CI:0.69-0.79), which was similar to NT-proBNP (AUC 0.77 [95%CI:0.72-0.81];p=0.24 versus ST2), but lower than the Seattle Heart Failure Model (SHFM; AUC 0.81 ([95%CI:0.77-0.85];p=0.014 versus ST2). Addition of ST2 and NT-proBNP to the SHFM reclassified 14.9% of patients into more appropriate risk categories (p=0.017). Conclusions ST2 is a potent marker of risk in chronic heart failure and when used in combination with NT-proBNP offers moderate improvement in assessing prognosis beyond clinical risk scores.
BackgroundThis case report draws attention to the debated role of prophylactic oophorectomy in women undergoing definitive surgical resection of colon and rectal cancers. It can be challenging to discern the indications and appropriate patient population for this procedure based on the current literature. Potential benefits include treatment and prevention of metastatic disease, preventing development of primary ovarian cancer, and prolonging survival. Negative effects include an increase in operative time and potential morbidity, development of osteoporosis, the risk of cardiac events, and decreasing sexual function. Multiple patient factors such as age, menopausal status, patient preference, presence of hereditary conditions, exposure to radiation, site, and stage of disease should be considered.Case presentationWe present a case in which a premenopausal 49-year-old female underwent a prophylactic bilateral salpingo-oophorectomy concurrently with a low anterior resection following neoadjuvant chemoradiation for clinical stage III rectal cancer. On pathologic examination, resection margins and all 14 lymph nodes harvested were negative for malignancy. Interestingly, she was found to have micrometastatic adenocarcinoma in the bilateral ovaries which had appeared grossly normal at the time of surgery.ConclusionsAfter consideration of the current literature, patient preference, and our clinical judgment, our patient ultimately had a therapeutic effect after undergoing prophylactic bilateral oophorectomy concurrently with a low anterior resection for rectal cancer. The addition of prophylactic oophorectomy in a select population, specifically women 50 years of age or younger and/or women who are in the premenopausal state, may carry a survival benefit in the setting of definitive surgical resection of colon and rectal cancers.
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