Hrev_master [page 49] [Emergency Care Journal 2024; 20:12463] Emergency Care Journal 2024 volume 20:12463 Abstract Chest pain is one of the most prevalent causes of Emergency Department (ED) admission and could be a presenting symptom of Acute Coronary Syndrome (ACS). The aim of this review was to provide an overview of the research about troponin and its limita- tions and new biomarkers used in patients with cardiovascular dis- eases, with a special focus on soluble Suppression of Tumorigenicity 2 (sST2) and Soluble Urokinase Plasminogen Activator Receptor (suPAR). In January 2024, a PubMed and Reviews in Cardiovascular Medicine (RCM) search was carried out to identify all relevant papers in the past five years. 80 articles were included in the final review. ssT2 and suPAR are involved in both acute and chronic cardiovascular disease and can predict the risk of adverse events. sST2 and suPAR are promising biomarkers that, in combination with troponin, could help in the management of patients with chest pain in the ED. Further studies are needed to validate their role in management of ACS in this specific setting. Introduction Chest pain is one of the most frequent symptoms of admission to the Emergency Department (ED). It represents a continuous defiance in emergency departments, which requires an accurate assessment in order to identify serious conditions that are poten- tially deadly and predict associated risks. Cardiovascular Disease (CVD) can present with different manifestations, of which chest pain represents the most frequent symptom. Although sometimes it is not related to acute syndromes that require immediate treatment, other times it indicates acute situations such as Acute Coronary Syndrome (ACS) which can endanger the patient’s life. CVD is a major disease globally and the leading cause of death and disabil- ity worldwide.1 CVD is typically diagnosed based on history, clin- ical examination, risk factors, ECG tracing, and laboratory criteria. Chest pain is a symptom of ACS, but also of other cardiothoracic situations as well as manifestations of non cardiothoracic syn- dromes. The risks of misdiagnosis are high. In spite of recent efforts to develop a model that could help in estimating the cardio- vascular risk in patients presenting to the emergency room with chest pain, we are still unable to rely on trustworthy instruments to estimate the risk of acute coronary syndromes in all patients.2 According to the Centers for Disease Control and Prevention, about 130 million patients visit the ED in the United States per year, and of these the 31% admitted to the ED with initially normal vital signs show deterioration in the first 24 hours.3 Despite the attempt to build standardized models for the correct management of patients with chest pain in the short and long term, there are no ideal criteria for determining the cardiovascular risk of patients who present with chest pain at the ED. Because of this, it is crucial to identify markers that help ED physicians diagnose and treat these conditions accurately for both immediate diagnosis and accu- rate long- and short-term risk assessment, as well as for guiding patients to the appropriate follow-up. Thanks to its high specificity and sensitivity, troponin, a reference biomarker for myocardial damage, is nearly always employed to diagnose Acute Myocardial Infarction (AMI) since it represents the main biomarker in the management of patient with chest pain in ED, which can be mea- sured in its two isoforms TnI and TnT. Since the plasma levels of these two molecules can rise in a variety of illnesses, including heart failure, chronic kidney disease, sepsis, and many others, dos- Correspondence: Andrea Piccioni, Department of Emergency Medicine, Gemelli Hospital, Catholic University of Rome, 00168 Rome, Italy. E-mail: andrea.piccioni@policlinicogemelli.it Key words: chest pain; acute coronary syndrome; biomarkers; high sensitivity troponin; suPAR; sST2. Conflict of interest: the authors declare no potential conflict of inter- est, and all authors confirm accuracy. Ethics approval: not applicable. Informed consent and patient consent for publication: not applicable. Received: 8 March 2024. Accepted: 4 June 2024. Early view: 18 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12463 doi:10.4081/ecj.2024.12463 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Multimarkers approach in chest pain management in Emergency department: a focus on the prognostic role of sST2 and suPAR Andrea Piccioni,1 Silvia Baroni,2 Licia Antonella Scatà,1 Marta Scaccia,1 Martina Candela,1 Alessandra Bronzino,1 Francesca Sarlo,2 Gabriele Savioli,3 Marcello Candelli,1 Marcello Covino,1 Antonio Gasbarrini,4 Francesco Franceschi1 1Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome; 2Department of Laboratory and Infectious Sciences, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Roma; 3Departement of Emergency, IRCCS Fondazione Policlinico San Matteo, Pavia; 4Medical and Surgical Science Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy Non -co mmerc ial us e o nly ing these molecules frequently results in false positive results. Furthermore, cardiac troponin levels in the peripheral blood can be detected for days following myocardial cell death, which typically occurs 2-4 hours after the ischemia event.2 However, the limita- tions of troponin entail the search for novel diagnostic biomarkers of ACS that could complement troponin. Therefore, in recent years, a number of emerging biomarkers have been proposed to facilitate the risk stratification of patients with CVD. These include sST2, suPAR, miRNA, galectin-3, GDF-15 and others. For this reason, the aim of this review is to evaluate, on the basis of the most recent literature, which biomarkers are currently most helpful in the diagnosis of patients with chest pain and to pre- dict cardiovascular risk, with a special focus on sST2 and SUPAR, beyond the widely used troponin, with the further aim of improv- ing patient management within the ED. Indeed, emergency depart- ment overcrowding is a huge problem which entails increased mor- tality rates, costs and prolonged length of stays, decreased treat- ment quality and decreased safety of acute care. The ability to reli- ably predict future cardiac event incidence in patients is essential for their effective care and for the more appropriate allocation of limited healthcare resources.4 By allowing more safe discharges in a short time, the patient flow could be improved and overcrowding avoided. In a clinical setting where diagnostic accuracy is crucial, the search for additional and complementary biomarkers to tro- ponin reflects the growing need to improve the sensitivity and specificity of diagnoses.5,6 cTN Cardiac troponin is one of the main biomarkers used in the assessment of cardiac damage. Its complex consists of the subunits troponin I (TnI), troponin T (TnT), and troponin C (TnC). During the cardiac cycle, this protein complex plays the main role in reg- ulating Ca2+-dependent muscle contraction. These three subunits serve different functions: TnI regulates the interaction between actin and myosin, thus enabling the relaxation of the heart. TnT is involved in tropomyosin binding, promoting a controlled interac- tion between actin and myosin. TnC, the calcium-sensitive subunit, initiates muscle contraction, activating the complex.7-9 This com- plex meticulously controls the heart muscle’s cycles of contraction and relaxation under normal circumstances. Troponin is typically found in extremely low amounts; it is released into the blood- stream when cardiac muscle cells experience injury and its concen- tration in the blood rises with increasing injury. Since TnT and TnI subunit assays are the most cardiac-specific and offer equivalent diagnostic accuracy, they are frequently tested in the context of myocardial damage.10 Because of their increased analytical preci- sion, high-sensitivity troponin (hs-cTn) tests have made it possible to develop decision-making algorithms that are more accurate. The recent guideline issued by the European Society of Cardiology reiterates the preeminent role of cardiac troponins. The Fourth Universal Definition of MI in fact provided that a rise or fall of tro- ponin I or T, when at least one hs-cTn value is above the 99th per- centile of a normal population establishes the diagnosis of acute myocardial infarction.11,12 This statement has been emphasized by recommendations issued by numerous scientific societies and sev- eral published articles.13 Because of troponins’ excellent diagnostic accuracy, individuals with chest pain can be quickly diagnosed with acute cardiac injury, facilitating safer and quicker “rule-in” and “rule-out” procedures. However, despite the broad support and evidence in favor of cardiac troponins, several studies highlight a persistent lack of confidence on the part of some physicians, who continue to use a combination of sometimes obsolete biomarkers. This discrepancy underscores the importance of carefully consid- ering the clinical context and the different subcategories of cardiac injury when adopting valid multi-marker approaches for the diag- nosis, prognosis and management of cardiac conditions. Four clin- ical factors, in addition to the presence or absence of MI, can influ- ence hs-cTn values in a patient presenting with a suspected ACS, according to the 2023 ESC Guidelines for the Management of Acute Coronary Syndromes. These variables are: age, renal dys- function, time from chest pain onset and sex.14 It is important to note that, despite the significant innovation represented, high-sen- sitivity troponin presents some limitations in the evaluation of sus- pected ACS. As non-cardiac disease can cause increased troponin levels, troponin results need to be interpreted within a clinical deci- sion protocol.8 In some cases, troponin baseline value is chronical- ly elevated and remains stable over time, as in Heart Failure (HF), a condition in which troponin has been shown to be an important prognostic factor. Elevated cardiac troponins (TnT and TnI) main- ly reflect the progressive death of cardiomyocytes and the exoso- mal release of cytosolic troponin and are associated with an increased rate of hospitalization and death.11 In contrast, a rising or falling troponin pattern can be attributable to a variety of underly- ing conditions other than ACS (e.g., valvular heart diseases, pul- monary embolism, sepsis, atrial fibrillation).8,10,12 Furthermore, due to a decreased renal clearance of troponin and a myocardial dam- age associated with CKD, increased hsTn concentrations may be found in individuals with severe chronic kidney disease, even in the absence of ACS.15 More crucial to proving the ACS hypothesis is the different increase and fall of hsTn. Regarding sex, significant variations in baseline results of extremely sensitive cardiac tro- ponin may be explained by anatomical differences in the heart between men and women; nevertheless, sex-specific thresholds for ACS diagnosis are debatable.16,17 Therefore, biotin, a water-soluble vitamin, could interfere with cardiac troponin assays. An elevated biotin concentration would in fact be responsible for falsely low hsTn results. For that reason, a safety communication to ward against this possible interference has recently been released by the Food and Drug Administration (FDA).18 This potential phe- nomenon is of increasing interest due to high-dose biotin supple- ments taken for multiple sclerosis, dietary multivitamin prepara- tions, and cosmetics. High-dose biotin could also be used by patients with metabolic disorders.12,19,20 hs-cTn may be susceptible to interfere from heterophile antibodies,8-20 hemolysis, biological variation of cardiac troponin T, cardiac troponin autoantibodies, rheumatoid factor, lipemia, and hyperbilirubinemia.12 Lastly, ele- vated values could be found in some patients with skeletal muscle disease.8 In conclusion, multiple biomarkers in addition to cardiac troponin should be used to gain a more comprehensive and differ- entiated perspective of cardiac conditions due to the aforemen- tioned restrictions. This method enables the evaluation of specific aspects of cardiac function, inflammatory responses and other fac- tors that may contribute to diagnosis and prognosis. The combina- tion of biomarkers improves the sensitivity and specificity of assessment, especially in complex situations, allowing for more precise and individualized management of cardiac conditions. sST2 Suppression of tumorigenesis-2 (ST2), originally described in 1989,21 is a member of interleukin (IL)-1 family receptors that Review [Emergency Care Journal 2024; 20:12463] [page 50] Non -co mmerc ial us e o nly exists in two forms: a membrane-bound receptor (ST2L) and a sol- uble one (sST2). The natural ligand of ST2 is IL-33, a member of the IL-1 family, that has been involved in the pathogenesis of sev- eral diseases.22 The IL-33/ST2L signaling inhibits Th1 cytokine production and leads to transcriptional activation of inflammatory genes, thereby increasing Th2 cytokine production that inhibits adverse cardiac remodeling and fibrosis, significantly reducing atherosclerosis progression.23,24 Therefore, the interaction of IL-33 and ST2L may represent a cardioprotective factor. Conversely, sST2 is known to bind IL-33 thus playing a role of a decoy recep- tor and attenuates positive cardiac effects of IL-33/ST2L path- way.22-28 ST2L and sST2 in the circulatory system are mainly found in the endothelial cells and secreted by fibroblasts and cardiomy- ocytes in response to mechanical stretching.22 Cytokines from damaged tissues seem to induce the production of sST2 by the neighboring cells.29 ST2 has gained interest as a relevant tool in many fields. It was originally thought to be primarily involved in inflammatory dis- eases and allergies, including asthma, rheumatoid arthritis and inflammatory bowel disease.21 Currently its role as a relevant biomarker for patients with var- ious cardiovascular diseases is recognized. An increasing number of recent studies have advocated an important prognostic value of sST2, in both chronic and acute heart failure since it is less influenced by age, renal function than traditional biomarkers (NT-proBNP and hs-TnT).30 sST2 in fact meets some interesting criteria of clinically useful biomarkers. First of all, it’s accurate and provides information to guide risk stratification; secondly it has a reasonable cost.28 A prospective cohort study by Wang et al. enrolled 331 patients with acute HF stratifying them according to sST2 levels. The study revealed that higher sST2 concentrations are strongly correlated with adverse outcomes.31,32 A systematic review and meta-analysis by Ip et al. demonstrat- ed that elevated levels of sST2 are a predictor of severe chronic HF and tend to be associated with a higher risk of mortality in chronic HF and stable CAD.29 A prospective study by Rezar et al. also sug- gests measuring serum sST2 levels 24 h after admission for prog- nostication after cardiopulmonary resuscitation.33 Furthermore, in the STADE-HF study, an ancillary study of a randomized trial: NCT02963272, sST2 showed to be better associated with the risk of hospitalization when compared to suPAR, which, in contrast, resulted associated with long term mortality.34 It was also revealed that sST2-guided therapy does not decrease readmissions. This study was aimed to evaluate a sST2-guided treatment in patients hospitalized for acute HF. Unlikely, the approach proposed failed.35 The American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for HF Management included as a risk stratification marker (class II level of evidence B) the measurement of sST2 levels in patients with ADHF. A cut-off value of sST2 ≥ 35 ng/mL is proposed as a predictor for worse prognosis in patients with HF.36 In the latest edition of the same guidelines, dated 2022, however, this recommendation is not reported.28 Concerning ACS, the role of sST2 in less clear. It seems to be involved in the progression of atherosclerosis. Several studies have proposed that the IL-33/ST2L interaction in the coronary arterial wall may prevent cardiomyocyte apoptosis, reduce myocardial fibrosis and myocardial maladaptive hypertrophy thus limiting plaque inflammation and evolution.21,26,29 Therefore, elevated sST2 levels would promote inflammation and result in plaque progres- sion preventing the circulating IL-33 from binding to ST2L. A recent review proposes sST2 assisted flowcharts as an innovative useful tool to manage very common clinical scenarios of the ED: Acute HF, type 1, and type 2 AMI.22 The predictive value of sST2 and IL-33 in patients with ACS has been investigated recently. A significant increase in sST2 and IL-33 was found in patients with AMI compared with healthy con- trols.25 A recent cross-sectional study found that sST2 levels did not correlate with infarct location in a statistically significant way. On the contrary, it was advocated that serum sST2 levels cor- related with baseline infarct volume and endocardial extent of infarction.37 A recent study by Zhang et al. also proposed that sST2 could be a useful tool in the detection of atherosclerotic plaques vulner- ability38 and this correlation was further investigated by Luo et al. who proposed a correlation between serum sST2 levels and the necrotic core in coronary lesions.39 Furthermore, Van den Berg et al. showed that post-ACS patients with persistently elevated sST2 concentrations are at higher risk of recurrent ACS or cardiac death during one year of follow-up.40 In agreement with these findings, a recent meta-analysis and a prospective observational study inves- tigated the association between sST2 and long-term prognosis of patients with CVD showing that elevated baseline sST2 concentra- tions were associated with higher risk of major adverse cardiovas- cular events (MACE).41,42 Chen et al. hypothesized that in a cohort of patients admitted to hospital with various forms of CVD higher sST2 level correlated with the risk of future hospital admission due to MACE within 1 year.43 suPAR The soluble urokinase plasminogen activator receptor (suPAR) is a soluble form of the urokinase plasminogen activator receptor (uPAR), bound to the cell membrane across a glycosylphos- phatidylinositol anchor, and released from the proteolytic cleavage of uPAR.44 This protein is anchored to the membranes of different types of cells, like endothelial and smooth cells, and it is involved in different pathophysiological pathways, like plasminogen activa- tion, fibrinolysis, angiogenesis, and inflammatory response, con- tributing to leukocyte migration.45,46 SuPAR is mainly localized in immunity cells; therefore, plasma levels of this protein correlate to immunological activation.3 A correlation between increased suPAR values and molecules involved in the inflammatory response like TNFα, IL-6, and CRP is known.45 SuPAR can be measured in different biological fluids, like plasma, urine, and cerebrospinal fluid;47 generally, it is assessed in plasma using the enzyme-linked immunosorbent test (ELISA).44 Commonly, values <3 ng/mL are considered normal, values > 6 ng/mL are indicative of abnormalities, and intermediate values (3-6 ng/mL) need to be contextualized.45 Literature reports varia- tions in suPAR values in relation to socio-biological factors. For example, differences based on sex and age are known; in their study, Rasmussen et al. showed that men and women ≥74 years present approximately the same suPAR levels, while in younger women suPAR levels are higher; however, in males suPAR appears to rise more with increasing age than in women.45 Furthermore, habits like drinking or smoking appear to be related to increased suPAR values.48 About that, Wohlwend et al. demonstrated higher suPAR plasma levels in smokers, an inverse proportionality between suPAR and HDL serum values, and the relationship between suPAR and endothelial dysfunction.49 Due to its involve- ment in various pathophysiological pathways and its examination Review [page 51] [Emergency Care Journal 2024; 20:12463] Non -co mmerc ial us e o nly in various situations for its diagnostic and prognostic role, suPAR has generated a great deal of fascination in recent years. It has been studied, for instance, in cases of septic shock, acute pancreatitis, cardiovascular and pulmonary disease, and SARS-CoV-2 infec- tion.47 A few numbers of studies show a relationship between suPAR and proinflammatory cytokines, including TNF-α, IL-1β, and IL-66,50 which may be connected to the susceptibility of the atherosclerotic plaque to rupture.47 Indeed, various cell types that express uPAR on their cell membranes have been discovered in the atherosclerotic arteries, including macrophages and endothelial cells. Proinflammatory cytokines and proteolytic enzymes are gen- erated throughout time, increasing the quantity of suPAR and encouraging uPAR cleavage.4 Hindi et al. showed increased circu- lation levels of suPAR in suPARTg animals with larger atheroscle- rotic plaques in a study based on transgenic mice (suPARTg). Several studies have examined the connection between cardiovas- cular disease and suPAR levels in recent years, considering the protein’s function in endothelial damage and inflammatory response.50 In one of their meta-analyses, Pruc et al. underline how suPAR seems to be involved in the pathogenesis of ACS. Indeed, in the 5 studies that they have examined, including 3417 patients (1148 with ACS and 2269 in the control group), they demonstrated a statistically significant relationship between ACS and suPAR lev- els.47 Literature shows many studies which suggest that prognostic data may be obtained from suPAR for patients with suspected AMI, considering the prognostic value in the short and long term. In their study, Sörensen et al. evaluated suPAR in a population of 1314 patients presenting to the emergency department for chest pain and suspected AMI. To evaluate the one-year mortality, these patients have been followed for 12 months. suPAR levels were slightly higher in the patients who were diagnosed with AMI than in the non-AMI patients; however, in this study, the difference did not reach statistical significance. Follow-up of 1 year documented 39 deaths among non-AMI patients and 29 among AMI patients; in this case, suPAR was revealed to be an independent risk factor for all-cause mortality.51 A recently published meta-analysis by Rehan et al. investigated the impact of suPAR in the setting of the emer- gency department, valuing different outcomes such as 30-day mor- tality, 90-day mortality, 30-day readmission, discharge within 24 hours and length of hospital stay. In particular, they showed that there is a higher risk of death within 30 and 90 days when suPAR concentrations are elevated. Indeed, they observed a significant association with 30-day readmissions and a lengthening hospital stay.3 Several studies demonstrated that suPAR is elevated in patients with cardiovascular disease and acute myocardial infarc- tion. In one of their studies, Chenevier-Gobeaux et al. considered the early prognostic value of suPAR in patients presenting to the ED with chest pain suggestive of ACS, compared to that of usual cardiac biomarkers. Their results showed that suPAR concentra- tions at the admission were higher in chest pain patients with a 30- day event in comparison to patients without, and a suPAR value at admission above 3.3 ng/mL was independently associated with a 30-day event. Therefore, suPAR demonstrated to be a strong pre- dictor of mortality and of readmission. They also showed an asso- ciation of HEART score (a ESC tool wich calculate the 10-year risk of fatal and non-fatal cardiovascular disease events, based on 5 points: history, ECG, age, risk factors, troponin) and biomarkers at admission; particularly, low suPAR, low NT-proBNP and a low HEART score had a high negative predictive value to exclude a 30- day event.52 In their study based on 1747 acute medical patients, Santeri et al. proposed possible cutoffs of suPAR to predict low, medium and high risk of 30- and 90-day follow-up. Of these patients, almost half had a suPAR level below 4 ng/mL, and the 30- and 90-day risk of mortality were below 1%, while patients with suPAR above 6 ng/mL had a high 90-day mortality of 20%. In con- sideration of these data, they suggest that a cut-off below 4 ng/mL seems useful as a potential discharge biomarker, and may be part of a decision to discharge the patient.53 In their review of 39 stud- ies, Vellisaris et al. summarizes the published literature about suPAR values in patients with cardiac diseases. They considered patients with acute coronary syndromes and congestive heart fail- ure, and demonstrated that suPAR elevation may be an indepen- dent predictor of mortality in these conditions, representing a promising prognostic and diagnostic indicator for improved accu- racy in patient risk stratification.54 In their study (STADE-HF study), Huet et al. showed high suPAR serum levels in case of HF, evaluating its use as a prognosis biomarker in global mortality and risk of readmission after acute HF. They measured suPAR level at patient admission in 47 patients from the control group; moreover, they measured sST2 in 50 patients belonging to the sST2 group. They proved that suPAR levels were independently associated with mortality at 1 month and 1 year for patients with acute HF, but without significant prediction of the hospitalization risk and it was a stronger predictor for mortality than other biomarkers (sST2, NT- proBNP or CRP).34 Bengaard et al. described an overall risk of readmission and mortality significantly increased for patients with higher suPAR,55 while Al-Badri et al. showed that high suPAR and hsTnI levels were independently associated with a higher risk of all�cause death and MACE.56 Moreover, hs-CRP, NT-proBNP, and suPAR showed different associations with cardiovascular death among apparently healthy younger and older men and women.57 Hodges et al. also demonstrated that suPAR is an inde- pendent predictor of death/myocardial infarction in patients with suspected or known coronary artery disease, but they showed that it is not associated with the presence or severity of coronary artery disease, probably because a high suPAR is reflecting end organ damage regardless the degree of atherosclerosis.58 In a their inter- esting study, Vellisaris et al. are agree that suPAR may be a promis- ing addition to the established biomarkers for the initial assessment of patients in the ED, management and risk stratification, but addi- tional studies are necessary to evaluate the usefulness of suPAR guided management algorithms.48 These results are in line with the recent literature and suggest that suPAR appears to be more effec- tive than diagnostic biomarkers, and it can predict the occurrence of cardiovascular disease and tends to positively correlate with its severity.47 For this reason, suPAR may be useful in the assessment of the emergency department’s risk stratification and in improving its management.59 However, further evidence is needed. Other biomarkers In the past few years, numerous inflammatory mediators have been studied as potential biomarkers of cardiovascular and ischemic heart disorders in addition to the molecules previously described. In particular, these are mediators implicated in the inflammatory response and in the process of formation and com- plication of atherosclerotic plaques which, as is known, are often implicated in cardiovascular disease. Indeed, a plaque complica- tion is actually the primary cause of AMI in most patients. Likewise, inflammatory processes in the core of a complex athero- matous plaque dictate its rupture and consequent ACS. While sST2 and suPAR, beyond troponin, seem to be the emerging biomarkers for ACS risk, involved in patient outcome prediction too, other biomarkers that are still under investigation appear to be signifi- Review [Emergency Care Journal 2024; 20:12463] [page 52] Non -co mmerc ial us e o nly cant in the prediction of cardiovascular events such as interleukin, miRs and GDF-15. Some examples are briefly shown below. Copeptin Copeptin, first described in 1972 by Holwerda, is a 39- aminoacid glycopeptide derived from the C-terminal segment of Arginine Vasopressin (AVP) precursor. AVP has a role in fluid imbalance and in vascular tone regulation, thus contributing to car- diovascular system homeostasis. Copeptin is released into the bloodstream, in equivalent amounts to AVP, so measuring copeptin appears to be a clinically valuable approach for assessing plasma amount of vasopressin. Unlike AVP, copeptin’s physiologic role is not yet clear. At present, copeptin was proven to show the same response as AVP to hypotension or hemodynamic stress.60-64 In recent years, Copeptin has gained growing interest as part of a Dual Marker Strategy (DMS) in combination with Cardiac Troponin (cTn) in promptly ruling out Acute Myocardial Infarction (AMI) in patients presenting with symptoms suggestive of ACS.63 Several studies, among which the most important is the Copeptin Helps in the Early Detection of Patients with Acute Myocardial Infarction (CHOPIN) trial, a multicenter international cohort study, support that copeptin and hs-cTnT in combination has the potential to allow a faster ruling of AMI when compared to the hs- cTnT-only-based algorithms and enables a useful reclassification of profile risk of patients.65-68 In fact, it has been shown that copeptin rises to peak values within 30 min after the onset of chest pain in patients with acute MI, thus covering the period where hsTn levels are still undetectable and gradually decreases within 12–36 hours in early presenters.66,69-72 Therefore, the DMS has been seen to early detect acute myocardial injury and also obviates the need for serial sampling. In contrast, it provides no further information that standard troponin in late presenters.68,69-71 Furthermore, In the Accelerated Rule-Out of AMI using copeptin and high sensitivity troponin (AROMI) trial, that enrolled 4351 patients with chest pain, it was found that an accelerated DMS that integrates prehospital copeptin and first in-hospital hs-cTnT can safely reduce patients’ length of stay in ED.73 In addition, the 2023 ESC Guidelines on patients without per- sistent ST-segment elevation states a possible value of copeptin as additional biomarker to high-sensitivity cTn, since copeptin may quantify the endogenous stress level that characterize MI even if its incremental value beyond cTn is referred as limited.14 Moreover, copeptin plays a role as a prognostic biomarker, being associated with the 1-year mortality and adverse outcomes not only in ACS but also in non-ACS conditions. 64-67 However, recent studies, suggest that serum levels of copeptin are upregulated under various conditions (e.g. heart failure, metabolic syndrome, hypertension, acute kidney injury, pulmonary embolism, sepsis, acute pancreatitis,ischemic stroke) and that they are linked to the severity of these clinical situation.62-64,66,67-70 Interleukins The Interleukin (IL) family includes numerous molecules implicated in various biochemical pathways and in the majority of inflammatory processes. In recent years, many of these have been studied for their role in CVD. Of these, the IL-17 family better cor- relates with the development of ACS; it has been demonstrated that both IL-17A and IL-17E plasma levels are increased in such patients. Furthermore, their increase correlates with the severity of the condition. Moreover, inflammatory cytokines such as IL-1β and IL-6 have adverse impacts on the structure and function of the heart. According to some studies, a correlation between sST2 and IL-1β has been identified in patients with HF: patients with heart failure who had low sST2 and low IL-1β, in particular, had a much decreased risk of dying from cardiovascular disease as compared to patients with high sST2 and high IL-1β.2,62 Adhesion molecules (ICAM-1 and VCAM-1) Adhesion molecules called VCAM-1 and ICAM-1 also appear to participate in the inflammatory process and, in particular, shown a role in drawing leukocytes to the endothelium during inflamma- tion and sustaining the inflammatory response. These leads to the creation of atheromatous plaques, which raises the risk of CVD and ACS.2 miRs miRs are small, non-coding RNAs, which are involved in the regulation of gene expression, modulating protein synthesis. Different miRs could be involved in atherosclerosis and CVD, such as miR-146a, miR-26a, miR-499, miR-133b and miR-21. Of these, miR-146a seems to be more involved in development of coronary heart disease. Xue et al. studied patients with acute myocardial infarction observing how miR-146a represents an opti- mal diagnostic biomarker of cardiovascular disease.74 However, while some miRs correlate positively with cardio- vascular risk, others correlate negatively, being downregulated in presence of myocardial damage.2 In recent years, several studies have addressed these molecules as possible biomarkers of cardiac damage and prediction of cardio- vascular risk; however, further evidence is needed. GDF-15 Growth differentiation factor 15 (GDF-15) is a biomarker belonging to the TGF-β cytokine, especially expressed in myocardium and endothelial cells, implicated in the inflammatory response and oxidative damage, considered as the triggers that can up regulate its expression.75 It has been mainly studied in the con- text of acute and chronic heart failure. However, it is currently being studied primarily for its role in chronic heart failure. Based on current evidence, high levels of GDF-15 are associated with a poor prognosis for patients with acute heart failure. The elevated serum level of GDF-15 was the most prognostic biomarker in com- parison to NT-proBNP, hs-CRP, and hs-TnT and an independent predictor of long-term mortality in advanced HF.62,76 Recent studies propose an association between elevated GDF-15 levels and differ- ent clinical conditions (e.g., ineffective erythropoiesis inflamma- tion, acute injury, cancer, and chronic kidney disease, ischemic stroke). Concerning ACS, it has been established that GDF-15 lev- els rise in just a few hours after MI.64 However, in consideration of its important functions, a role in acute care must be further evalu- ated; for these reasons focused studies are necessary. MR-proADM Mid regional pro adrenomedullin (MR-proADM) is the precur- sor of adrenomedullin, a protein expressed in different tissues and cells and involved in several pathways and biological mechanisms, such as natriuresis or vasodilatation. In recent years, it has been demonstrated that MR-proADM plays an important role in the course of cardiovascular disease, in relation to its multiple func- tions. A significant review by Berezin AE and Berezin AA, showed that circulating levels of MR-proADM were increased in patients with acute HF and STEMI, and also allowed to estimate adverse outcomes, including death. Additionally, serum levels of MR- Review [page 53] [Emergency Care Journal 2024; 20:12463] Non -co mmerc ial us e o nly proADM >0.70 nmol/L were proposed to be the rule-in criteria of AMI. In the same review, the results of the DANAMI-3 (The Danish Study of Optimal Acute Treatment of Patients with ST-seg- ment-elevation myocardial infarction) study have shown that ele- vated levels of MR-proADM were strong predictor of shortand long-term mortality and hospital admission for HF after AMI. Mostly, MR-proADM was able to predict major adverse cardiac events in patients suspecting AMI regardless of HF.62 MR- proADM also emerged as the best predictor of 1-year death after the diagnosis of acute HF in some recent studies.76 Galectin-3 Galectin-3 is a β-galactoside-binding protein expressed in myocardial cells and released from activated macrophages, and it is implicated in myocardial remodeling.63 It had been investigated as a biomarker of inflammation with a promising predictive value for heart failure and cardiovascular events. Galectin-3, like GDF- 15, has also been more investigated in heart failure. Different stud- ies showed that serum galectin-3 values were significantly higher in patients with acute HF. In a prospective study on chronic HF and coronary heart disease, increased galectin-3 levels in patients with HF were an independent predictor of all-cause mortality and rehos- pitalization within a 12-month follow-up period.77 Elevated levels of galectin-3 were also found in patients with adverse cardiac remodeling, but comparison of sST2 and galectin-3 has revealed the superiority of sST2 in long-term risk stratification.62,76 Patients who experienced early MACE had significantly higher galectin-3 and MR-proANP levels assessed on admission; however, a high concentration of galectin-3 observed on admission may also iden- tify patients at high risk of late MACE.78 H-FABP Heart-type Fatty Acid Binding Protein (H-FABP) is a low molecular weight protein that is expressed in cardiomyocytes and released when myocardial damage has occurred. This is the reason why it could be considered as an early predictor of ischemic heart damage. Its concentration increases before that of Troponin in ACS and is not affected by renal function. These features suggest H- FABP could be a useful tool in clinical practice.75 Furthermore, H- FABP and sST-2 are the most promising markers with better accu- racy in differential diagnosis between Takotsubo syndrome and acute coronary syndrome, which are clinically indistinguishable. In their study, Topf et al. show how H-FABP is significantly higher in ACS patients compared to TTS patients; whereas sST-2 was sig- nificantly elevated in TTS patients.75,79 Renelase Renalase is a new class of flavin adenine dinucleotide-contain- ing Monoamine Oxidases (MAOs). They are Involved in numer- ous cardiovascular diseases, such as HF, Coronary Artery Disease (CAD), hypertension, diabetes mellitus. Stojanovic et al. con- firmed that elevated plasma renalase concentration in chronic HF patients.80 Renalase may be a valuable prognostic factor for ischemia during exercise stress tests in chronic HF patients. Renalase, in line with sST2, galectin-3, and GDF-15, clearly demonstrated non-inferiority for ischemia prediction compared to BNP. In the HF, renalase discriminatory potential was similar to that of sST2, but better compared to those of galectin-3 and GDF- 15.80 Discussion ACS remains the leading cause of death in the world and car- ries the risk of the development of Major Adverse Cardiovascular Events (MACE). According to standard clinical care, sequential troponin measurement (0-1h) accompanied by ECG tracing repre- sents the goal standard of diagnosis. Despite several attempts to build standardized models for the correct management of patients presenting with chest pain and no diriment ECG findings and tro- ponin measurement, there are no ideal criteria for determining the likelihood of a cardiovascular etiology and the diagnostic pathway. Because of this, numerous biomarkers have gained growing inter- est with the purpose of helping ED physicians to diagnose and treat these conditions in a proper way also allowing faster discharge. This review has the aim to summarize the published literature in the last five years referring to the contemporary use of some promising biomarkers. The strengths and limitations of conven- tional biomarkers as cTn have also been evaluated. A PubMed and Reviews in Cardiovascular Medicine search was conducted from January 2019 to January 2024 aiming to identify all interesting publications. The search terms were: suPAR (or soluble urokinase plasminogen activator receptor), sST2 (or soluble suppression of tumorigenesis), acute coronary syndrome, cardiac troponin. A total of 80 articles were included in the final review. At first this review focuses on cardiac troponin (cTn) that, to date, is the main biomarker used in the assessment of cardiac damage, being released into the bloodstream when cardiac muscle is injured. For its elevated accuracy, numerous scientific societies indicate deter- mination of serum cTn as the choice criteria for the diagnosis of acute cardiac ischemia and to facilitate safer and quicker patients “rule-in” and “rule-out”. However, cTn values must be contextual- ized with the clinics and electrocardiographic findings. In fact, non-cardiac etiologies of myocardial damage can cause increased troponin levels.8,10,12,14 sST2 and suPAR (the two main biomarkers on which we focused) have been investigated for their diagnostic role and for their ability to predict short and long-term mortality. Recently, those tools have also been considered in the context of chronic car- diovascular pathologies. sST2 is the soluble form of ST2, a member of interleukin-1 family receptors. Cytokines from damaged tissues, such as myocardium, seem to induce the production of sST2, contributing to the persistence of the inflammatory process. 21,22,25-28 Recently, several studies have advocated an important prognostic value of sST2; indeed, its values do not depend on factors such as age or renal function than standard biomarkers.30 Different studies showed a correlation between its levels and chronic cardiovascular diseases associated with higher risk of MACE.29,41 In the ED setting, the role of sST2 in ACS is still unclear. Certainly, it seems to be involved in the progression of atheroscle- rosis and its complications, thus often representing the ACS trig- ger.20,25,28 Some studies showed a significant increase of sST2 and IL-33 in patients with AMI when compared to healthy controls.22 sST2 levels were also evaluated as a prognostic factor after car- diopulmonary resuscitation.33 In addition, other studies highlighted that patients with persistently elevated sST2 concentrations post- ACS have a higher risk of recurrence or death during one year after the event.40 Other studies analyzed are listed in Supplementary Table 1. Therefore, suPAR is another biomarker on which authors have shown great interest in recent years. It is the soluble form of the urokinase plasminogen activator receptor (uPAR), bound to differ- Review [Emergency Care Journal 2024; 20:12463] [page 54] Non -co mmerc ial us e o nly ent cell membranes and it is involved in several pathophysiological pathways.4,50,51 Commonly, values < 3 ng/mL are considered nor- mal, but literature reports variations in suPAR threshold in relation to socio-biological factors.44,48,50 Some studies showed a relation- ship between suPAR plasma levels and endothelial dysfunction, explaining its relationship with cardiovascular risk factors, since it correlates with the release of proinflammatory cytokines, which may be linked to the susceptibility of the atherosclerotic plaque.4,45,49,50 A statistically significant relationship between ACS and suPAR levels is demonstrated in different studies.47,58 In researches performed in the emergency setting, suPAR lev- els correlated positively with suspected AMI and assessed one- year mortality, resulting higher in patients who were diagnosed with AMI than in the non-AMI patients. It correlates also with post-discharge mortality.3,51 For these reasons, suPAR may be a promising addition to the consolidated biomarkers for the manage- ment of patients in the ED and for their risk stratification. However, further evidence is needed. Furthermore, other molecules which have attracted greater interest in the field of cardiovascular disease have been taken into account and their possible use in clinical practice is summarized below. For instance, Copeptin has gained attention as part of a dual marker approach, in combination with cardiac troponin (cTn), in promptly ruling out Acute Myocardial Infarction (AMI) when patients present with chest pain.63 Indeed, copeptin rises to peak values within 30 min after the onset of chest pain in patients with acute MI, unlike troponin whose levels may still be undetectable in the early hours; for this reason copeptin could allow a timely diag- nosis even before the troponin rise.66,69-72Also the latest 2023 ESC Guidelines indicate a possible value of copeptin as an additional biomarker to high-sensitivity cTn in patients without persistent ST- segment elevation states.14 Moreover, copeptin appears to be associated with 1-year mor- tality and adverse cardiovascular outcomes.64-67 In addition, IL- family molecules seem to be involved in the inflammatory mechanism underlying the complication of atherosclerotic plaque; in fact molecules such as IL-17 and inflam- matory cytokines like IL-1β and IL-6 correlate with the develop- ment of CAD.2,62 Adhesion molecules like VCAM-1 and ICAM-1 also have a role in drawing leukocytes to the endothelium during inflammation and sustaining the inflammatory response; for this reason they have shown a role in the atheromatous plaques cre- ation and complication which raises the risk of CVD and ACS.2 miRs, such as miR-146a, miR-26a, miR-499, miR-133b and miR- 21, could be involved in atherosclerosis and CVD. Of these, miR- 146a seems to be more implicated in development of CHD.2,72 GDF-15 has been largely studied in the context of acute and chron- ic heart failure. Based on the current evidence, high levels of GDF- 15 are associated with a poor prognosis.62 Likewise MR-proADM plays an important role in the course of cardiovascular disease. An increased value has been found in both chronic and acute cardio- vascular disease too. An interesting study has shown that elevated levels of MR-proADM were a strong predictor of short and long- term mortality and hospital admission for HF after AMI.62,76 Galectin-3, a protein expressed in myocardial cells and released from activated macrophages, had been investigated as a biomarker of inflammation with a promising predictive value for heart failure and cardiovascular events. Increased galectin-3 levels in patients with HF were an independent predictor of all-cause mortality and rehospitalization within a 12-month follow-up period.63,77,78 Elevated levels of galectin-3 were also found in patients with adverse cardiac remodeling, but sST2 seems to be superior in long- term risk stratification in HF.62 A high concentration of galectin-3 observed on admission may also identify patients at high risk of late MACE.78 H-FABP is a protein expressed in cardiomyocytes and released when myocardial damage has occurred, which seems to be deci- sive in the differential diagnoses of some conditions.79 Finally, Renalase, a new class of MAOs, are involved in numerous cardio- vascular diseases, such as HF, CAD, hypertension, diabetes melli- tus. Elevated plasma Renalase concentration had been found in chronic HF patients.80 In summary, several recent studies have addressed these molecules as possible biomarkers of cardiac damage and predic- tors of cardiovascular risk; however, larger further investigations are needed to better understand the correlation between these molecule levels and ACS risk, to allow prompt diagnosis and facil- itate patients’ management in the ED. Conclusions Biomarkers play a key role in risk stratification, diagnosis and prognosis assessment of patients with suspected ACS; indeed, some circulating biomarkers may reflect pathophysiological path- ways involved in ACS. sST2 and suPAR are promising biomarkers that, given the limitations of troponin, could help in the manage- ment of patients with chest pain in the ED. Further studies are needed to validate their role in management of ACS in this specific setting. Therefore, further evaluation to establish the diagnostic and prognostic value of these biomarkers is warranted. Additional future research should also compare the accuracy of these tools with the traditional approved biomarkers in the ED and to evaluate their introduction in clinical practice. References 1. Timmis A, Vardas P, Townsend N, et al. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J 2022;43:716-99. Erratum in: Eur Heart J 2022;43:799. 2. Piccioni A, Valletta F, Zanza C, et al. Novel biomarkers to assess the risk for acute coronary syndrome:beyond troponins. Internal Emerg Med 2020;15:1193–9. 3. Rehan ST, Hussain Hu, Ali E, et al. Role of soluble urokinase type plasminogen activator receptor (suPAR) in predicting mortality, readmission, length of stay and discharge in emer- gency patients: A systematic review and meta analysis. Medicine 2023;102:45. 4. Yang L, Yaqun D, Yinjie Z, et al. Prognostic value of soluble urokinase-type plasminogen activator receptor in coronary artery disease: A meta-analysis.Eur J Clin Invest 2022;52: e13867. 5. Holstein RM, Mäkinen MT, Castrén MK, Kaartinen JM. Utilization of prognostic biomarker soluble urokinase plas- minogen activator receptor in the emergency department: a tool for safe and more efficient decision-making. Biomarker Insights 2022;17: 1–7. 6. Holstei RM, Seppälä S, Kaartinen J, et al. Soluble urokinase plasminogen activator receptor (suPAR) in the emergency department (Ed): a tool for the assessment of elderly patients. J Clin Med 2022;11:3283. 7. Lazar DR, Lazar FL, Homorodean C, et al. High-sensitivity Review [page 55] [Emergency Care Journal 2024; 20:12463] Non -co mmerc ial us e o nly troponin: a review on characteristics, assessment, and clinical implications. Hindawi Disease Markers 2022;9713326. 8. Boone S, Peacock WF. Contemporary biomarker strategies for patients with chest pain. Rev Cardiovasc Med 2022;23:157. 9. Chuang AM, Nguyen MT, Kung WM, et al. High-sensitivity troponin in chronic kidney disease: Considerations in myocar- dial infarction and beyond. Rev Cardio-vasc Med 2020;21: 191–203. 10. Long B, Long DA, Tannenbaum L, Koyfman A. An emergency medicine approach to troponin elevation due to causes other than occlusion myocardial infarction. Am J Emerg Med 2020;38:998-1006. 11. Januzzi JL, Mahler SA, Christenson RH, et al. Recommendations for Institutions Transitioning to High- Sensitivity Troponin Testing: JACC Scientific Expert Panel. J Am Coll Cardiol 2019;73:1059–77. 12. Januzzi JL, McCarthy CP. Cardiac troponin and the true false positive. JACC: Case Reports 2020;2:461–463. 13. Sandoval Y, Apple FS, Mahle SA, et al. High-sensitivity car- diac troponin and the 2021AHA/ACC/ASE/CHEST/SAEM/ SCCT/SCMR guidelines for the evaluation and diagnosis of acute chest pain. Circulation 2022;146:569–81. 14. Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes Developed by the task force on the management of acute coro- nary syndromes of the European Society of Cardiology (ESC). Eur Heart J 2023;44;3720–826. 15. Chesnaye NC, Szummer K, Bárány P, et al. Association between renal function and troponin t over time in stable chronic kidney disease patients. J Am Heart Assoc 2019;8:e013091. 16. Bhatia PM, Daniels LB. Highly sensitive cardiac troponins: the evidence behind sex-specific cutoffs. J Am Heart Assoc 2020;9:e015272. 17. Karády J, Mayrhofer T, Ferencik M, et al. Discordance of high- sensitivity troponin assays in patients with suspected acute coronary syndromes. J Am Coll Cardiol 2021;77:1487–99. 18. U.S. Food and Drug Administration (FDA) safety communica- tion. Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference. 2019. Available at: https: //www.fda.gov/medical-devices/in-vitro-diagnostics/biotin- interference-troponin-lab-tests-assays-subject-biotin-interfer- ence 19. Mumma B, Diercks D, Twerenbold R, et al. Clinical risk assessment of biotin interference with a high-sensitivity car- diac troponin T assay. Clin Chem Lab Med 2020;58:1931–40. 20. Santos LG, Carvalho RR, Sá FM, et al. Circulating heterophile antibodies causing cardiac troponin elevation: an unusual dif- ferential diagnosis of myocardial disease. J Am Coll Cardiol Case Rep 2020;2:456–60. 21. Dudek M, Kałużna-Oleksy M, Migaj J, Straburzyńska-Migaj E. Clinical value of soluble ST2 in cardiology. Adv Clin Exp Med 2020;29:1205–10. 22. Aleksova A, Paldino A, Beltrami AP, et al. Cardiac biomarkers in the emergency department: the role of soluble ST2 (sST2) in acute heart failure and acute coronary syndrome—there is meat on the bone. J Clin Med 2019;8:270. 23. Liu R, Liu L, Wei C, Li D. IL-33/ST2 immunobiology in coro- nary artery disease: A systematic review and meta-analysis. Front Cardiovasc Med 2022;9:990007. 24. Liu L, Li S, Ding X, et al. Dynamic changes in soluble sup- pression of tumorigenicity 2 levels predict major adverse car- diovascular events in patients with ST-segment elevation myocardial infarction. Pol Arch Intern Med 2022;132:16317. 25. Sun Y, Pavey H, Wilkinson I, Fisk M. Role of the IL-33/ST2 axis in cardiovascular disease: A systematic review and meta- analysis. PLoS ONE 2021;16:e0259026. 26. Pascual-Figal DA, Bayes-Genis A, Asensio-Lopez MC, et al. The interleukin-1 axis and risk of death in patients with acutely decompensated heart failure. JACC 2019;73:1016-25 27. Meijers WC, Bayes-Genis A, MebazaA, et al. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC). Eur J Heart Failure 2021;23:1610–32. 28. Aimo A, Januzzi JL, Bayes-Genis A, et al. Clinical and Prognostic Significance of sST2 in Heart Failure. JACC 2019;74:2193-203. 29. Ip C, Luk KS, Yuen VLC, et al. Soluble suppression of tumori- genicity 2 (sST2) for predicting disease severity or mortality outcomes in cardiovascular diseases: A systematic review and meta-analysis. IJC Heart & Vasculature 2021;37:100887. 30. Zhang J, Chen Z, Ma M, He Y. Soluble ST2 in coronary artery disease: Clinical biomarkers and treatment guidance. Front Cardiovasc Med 2022;9:924461. 31. Clemente G, Soldano JS, Tuttolomondo A. Heart failure: is there an ideal biomarker? Rev Cardiovasc Med 2023;24:310. 32. Wang Z, Pan X, Xu H, et al. Serum soluble ST2 is a valuable prognostic biomarker in patients with acute heart failure. Front Cardiovasc Med 2022;9:812654. 33. Rezar R, Paar V, Seelmaier C, et al. Soluble suppression of tumorigenicity 2 as outcome predictor after cardiopulmonary resuscitation: an observational prospective study. Sci Rep 2021;11:21756. 34. Huet F, Dupuy AM, Duflos C, et al. Soluble urokinase-type plasminogen activator receptor strongly predicts global mor- tality in acute heart failure patients: insight from the STADE- HF registry”. Future Sci OA 2021;FSO697. 35. Huet F, Nicoleau J, Dupuy AM, et al. STADE-HF (sST2As a help for management of HF): a pilot study. ESC Heart Failure 2020;7:774–8. 36. Berezin AE, Berezin AA. Biomarkers in heart failure: from research to clinical practice. Ann Lab Med 2023;43:225-36. 37. Timothy SD, Hartopo AB, Anggraeni VY, Makrufardi F. Association of soluble ST2 and infarct location within 12–24 h in STEMI: A cross-sectional study. Ann Med Surgery 2021;70:102844. 38. Zhang Y, Fan Z, Liu H, et al. Correlation of plasma soluble suppression of tumorigenicity-2 level with the severity and sta- bility of coronary atherosclerosis. Coron Artery Dis 2020;31:628-35. 39. Luo G, Qian Y, Sheng X, et al. Elevated serum levels of solu- ble ST2 are associated with plaque vulnerability in patients with non-ST-elevation acute coronary syndrome. Front Cardiovasc Med 2021;8:688522. 40. Van den Berg VJ, Vroegindewey MM, Umans VA, et al. Persistently elevated levels of sST2 after acute coronary syn- drome are associated with recurrent cardiac events. Biomarkers 2022;27:264-9. 41. Liu N, Hang T, Gao X, et al. The association between soluble suppression of tumorigenicity-2 and long term prognosis in patients with coronary artery disease: A meta-analysis. PLoS ONE 2020;15:e0238775. 42. Kim HL, Lee JP, Wong N, et al. Prognostic value of serum sol- uble ST2 in stable coronary artery disease: a prospective obser- vational study. Sci Rep 2021;11:15203. Review [Emergency Care Journal 2024; 20:12463] [page 56] Non -co mmerc ial us e o nly 43. Chen D, Untaru R, Stavropoulou G, et al. Elevated soluble suppressor of tumorigenicity 2 predict hospital admissions due to major adverse cardiovascular events (MACE). J Clin Med 2023;12:2790. 44. Velissaris D, Zareifopoulos N, Koniari I, et al. Soluble uroki- nase plasminogen activator receptor as a diagnostic and prog- nostic biomarker in cardiac disease. J Clin Med Res 2021;13:133-42. 45. Rasmussen LJH, Petersen JEV, Eugen-Olsen J. Soluble uroki- nase plasminogen activator receptor (suPAR) as a biomarker of systemic chronic inflammation. Front Immunol 2021;12: 780641. 46. Goodchild TT, Li Z, Lefer DJ. Soluble urokinase plasminogen activator receptor: from biomarker to active participant in atherosclerosis and cardiovascular disease. J Clin Invest 2022;132:e165868. 47. Pruc M, Jannasz I, Swieczkowski D, et al. Diagnostic value of soluble urokinase-type plasminogen activator receptor in patients with acute coronary syndrome: A systematic review and meta-analysis. Cardiol J 2023;30:335-6. 48. Velissaris D, Zareifopoulos N, Karamouzos V, et al. Soluble urokinase plasminogen activator receptor (suPAR) in the emer- gency department: An update. Caspian J Intern Med 2022;13:650-65. 49. Wohlwend NF, Grossmann K, Aeschbacher S, et al. The asso- ciation of suPAR with cardiovascular risk factors in young and healthy adults. Diagnostics 2023;13:2938. 50. Hindy G, Tyrrell DJ, Vasbinder A, et al. Increased soluble urokinase plasminogen activator levels modulate monocyte function to promote atherosclerosis. J Clin Invest 2022;132:e158788. 51. Sörensen NA, Nikorowitsch J, Neumann JT, et al. Predictive value of soluble urokinase-type plasminogen activator receptor for mortality in patients with suspected myocardial infarction. Clin Res Cardiol 2019;108:1386-93. 52. Chenevier-Gobeaux C, Lemarechal H, Doumenc B, et al. Prognostic value of soluble urokinase plasminogen activator receptor in patients presenting to the emergency department with chest pain suggestive of acute coronary syndrome. Clin Biochem 2021;92:19-24. 53. Santeri S, Andersen AP, Nyyssönen K, et al. suPAR cut-offs for stratification of low, medium, and high-risk acute medical patients in the emergency department. BMC Emerg Med 2021;21:149. 54. Velissaris D, Zareifopoulosb N, Koniaric I, et al. Soluble urokinase plasminogen activator receptor as a diagnostic and prognostic biomarker in cardiac disease. J Clin Med Res 2021;13:133-42. 55. Bengaard AK, Versen E, Kallemose T, et al. Using soluble urokinase plasminogen activator receptor to stratify patients for medication review in the emergency department. Br J Clin Pharmacol 2022;88:1679-90. 56. Al-Badri A, Tahhan AS, Sabbak N, et al. Soluble urokinase- type plasminogen activator receptor and high-sensitivity tro- ponin levels predict outcomes in nonobstructive coronary artery disease. J Am Heart Assoc 2020;9:e015515. 57. Frarya CE, Biering-Sørensenc T, Nochiokad K, et al. Sex- and age-related differences in the predictive capability of circulat- ing biomarkers: from the MONICA 10 cohort. Scand Cardiovasc J 2021;55:65–72. 58. Hodges G, Lyngbæk S, Selmer C, et al. SuPAR is associated with death and adverse cardiovascular outcomes in patients with suspected coronary artery disease. Scand Cardiovasc J 2020;54:339–45. 59. Sarlo F, Urbani A, Baroni S. Urokinase-type plasminogen acti- vator soluble receptor (suPAR) assay in clinical routine: eval- uation one year after its introduction in the high automation corelab of the A. Gemelli hospital. Clin Chem Lab Med 2023;61:e33–5. 60. Abdelmageed M, Güzelgül F. Copeptin: Up-to-date diagnostic and prognostic role highlight. Anal Biochem 2023;15:115181. 61. Mu D, Zhong J, Li L, et al. Copeptin with high-sensitivity car- diac troponin to rule out non-ST-elevation myocardial infarc- tion early on: A systematic review and meta-analysis. Clin Biochem 2023;112:24-32. 62. Berezin AE, Berezin AA. Adverse cardiac remodelling after acute myocardial infarction: old and new biomarkers. Disease Markers Volume 2020;121580. 63. Katsioupa M, Kourampi I, Oikonomou E, et al. Novel biomarkers and their role in the diagnosis and prognosis of acute coronary syndrome. Life 2023;13:1992. 64. Ion A, Stafie C, Mitu O, et al. Biomarkers utility: at the border- line between cardiology and neurology. J Cardiovasc Dev Dis 2021;8:139. 65. Maisel A, Mueller C, Neath SX, et al. Copeptin helps in the early detection of patients with acute myocardial infarction: primary results of the CHOPIN trial (Copeptin Helps in the early detection Of Patients with acute myocardial INfarction). J Am Coll Cardiol 2013;62:150-60. 66. Jeong JH, Seo YH, Ahn JY, et al. Performance of copeptin for early diagnosis of acute myocardial infarction in an emergency department setting. Ann Lab Med 2020;40:7-14. 67. Waldsperger H, Biener M, Stoyanov KM, et al. Prognostic value of elevated copeptin and high-sensitivity cardiac tro- ponin t in patients with and without acute coronary syndrome: the ConTrACS Study. J Clin Med 2020;9:3627. 68. Mueller-Hennessen M, Lindahl B, Giannitsis E, et al. Combined testing of copeptin and high-sensitivity cardiac tro- ponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. Int J Cardiol 2019;276:261-7 69. Giannitsis E, Slagman A, Hamm CW, et al. Copeptin com- bined with either non-high sensitivity or high sensitivity car- diac troponin for instant rule-out of suspected non-ST segment elevation myocardial infarction. Biomarkers 2020;25:649-58. 70. Lattuca B, Sy V, Nguyen LS, et al. Copeptin as a prognostic biomarker in acute myocardial infarction. Int J Cardiol 2019;274:337-41. 71. Ahmed TAN, Johny JS, Abdel-Malek MY, Fouad DA. The additive value of copeptin for early diagnosis and prognosis of acute coronary syndromes. Am J Emerg Med 2021;50:413-21 72. Szarpak L, Lapinski M, Gasecka A, et al. Performance of copeptin for early diagnosis of acute coronary syndromes: a systematic review and meta-analysis of 14,139 patients. J Cardiovasc Dev Dis 2021;9:6. 73. Pedersen CK, Stengaard C, Bøtker MT, et al. Accelerated - Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study. Eur Heart J 2023;44:3875-88. 74. Xue S, Zhu W, Liu D, et al. Circulating miR-26a-1, miR-146a and miR199a-1 are potential candidate biomarkers for acute myocardial infrction. Molec Med 2019;25:18. 75. Topf A, Mirna M, Paar V, et al. The differential diagnostic value of selected cardiovascular biomarkers in Takotsubo syn- drome. Clin Res Cardiol 2022;111:197–206. 76. Castiglione V, Aimo A, Vergaro G, et al. Biomarkers for the Review [page 57] [Emergency Care Journal 2024; 20:12463] Non -co mmerc ial us e o nly diagnosis and management of heart failure. Heart Failure Reviews 2022;27:625–43. 77. Paul S, Harshaw-Ellis K. Evolving use of biomarkers in the management of heart failure. Cardiol Rev 2019;27:153–9. 78. Idzikowska K, Kacprzak M, Zielinska M. The prognostic value of cardiac biomarkers in patients with acute myocardial infarc- tion during and after hospitalization. Rev Cardiovasc Med 2022;23:320. 79. Topf A, Mirna M, Bacher N, et al. Analysis of selected cardio- vascular biomarkers in takotsubo cardiomyopathy and the most frequent cardiomyopathies. Front Cardiovasc Med 2021;8:700169. 80. Stojanovic D, Mitic V, Stojanovic M, et al. The discriminatory ability of renalase and biomarkers of cardiac remodeling for the prediction of ischemia in chronic heart failure patients with the regard to the ejection fraction. Front Cardiovasc Med 2021;8:691513. Review [Emergency Care Journal 2024; 20:12463] [page 58] Online Supplementary Materials Table 1. Brief summary of all studies performed on sST2 in relation to CVD. Table 2. Brief summary of all studies performed on suPAR in relation to CVD. Non -co mmerc ial us e o nly