LAUSR

The study on the prognostic utility of midregional pro-adrenomedullin (MR-proADM) following decompensation for systolic heart failure from the Interdisciplinary Network Heart Failure programme extends and corroborates insights gained from several previous studies on this emerging biomarker.1–5 While the exact pathophysiological triggers, the dominant tissue of its release into the circulation, and its clearance mechanisms are still incompletely understood, MR-proADM concentrations have consistently been shown to be closely associated with the risk of death.1–5 In most settings, the prognostic accuracy of MR-proADM for all-cause mortality was even higher compared with that provided by natriuretic peptides (NPs).1–5 In contrast, MR-proADM does not seem to provide incremental value in the prediction of rehospitalization or reverse remodelling.1–5 In order to put these findings into perspective regarding the possible clinical utility of MR-proADM, it might help to reflect on the number of novel biomarkers successfully introduced into the routine clinical care of patients with heart failure during the last 20 years. Despite the still unacceptable high rates of mortality and morbidity, particularly in patients with acute heart failure, only a single biomarker has made it into routine clinical practice: NPs.6–10 And even NPs were ‘a love only at second sight’. The heart failure community has been rather slow in their incorporation of NPs into their diagnostic and prognostic armamentarium.6–9,11,12 It took 22 years from the publication of the first diagnostic study in The Lancet documenting very high and unprecedented diagnostic accuracy of B-type natriuretic peptide (BNP), 14 years from the first diagnostic study showing very high diagnostic accuracy and incremental diagnostic value of BNP measured with a well-validated point-of-care assay, and 12 years from the first randomized controlled trial documenting substantial benefit for patients and physicians by using BNP concentrations in addition to the standard of care in the evaluation of patients with acute dyspnoea in the emergency department,