Osteoarthritic process modifies expression response to NiTi alloy presence.

Nickel-titanium alloy (nitinol, NiTi) is a biomaterial with unique thermal shape memory, superelasticity and high damping properties. Therefore NiTi has been used in medical applications. In this in vitro study, the effect of NiTi alloy (with two surface modifications - helium and hydrogen) on gene expression profile of selected interleukins (IL-1ß, IL-6 and IL-8) and matrix metalloproteinases (MMP-1 and MMP-2) in human physiological osteoblasts and human osteoarthritic osteoblasts was examined to respond to a question of the different behavior of bone tissue in the implantation of metallic materials in the presence of cells affected by the osteoarthritic process. The cells were cultivated in contact with NiTi and with or without LPS (bacterial lipolysaccharide). Changes in expression of target genes were calculated by 2-ΔΔCt method. An increased gene expression of IL-1ß in osteoarthritic osteoblasts, with even higher expression in cells collected directly from the metal surface was observed. In case of physiological osteoblasts, the change in expression was detected after LPS treatment in cells surrounding the disc. Higher expression levels of IL-8 were observed in osteoarthritic osteoblasts after NiTi treatment in contact with alloy, and in physiological osteoblasts without relation to location in combination of NiTi and LPS. IL-6 was slightly increased in physiological osteoblastes after application of LPS. MMP-1 expression level was obviously significantly higher in osteoarthritic osteoblasts with differences regarding the metal surface and location. MMP-2 expression was decreased in both cell lines after LPS treatment. In conclusion, results of present study show that the NiTi alloy and the treatment by LPS, especially repeated doses of LPS, change the gene expression of selected ILs and MMPs in human osteoblast cell cultures. Some of the changes were depicted solely to osteoarthritic osteoblasts.

Relationship of epigenetic variability of miR-124 to extracellular matrix remodelling and age-related MMP-3 expression in rheumatoid arthritis.

The aim of study was to examine relation among miR-124 and serum levels of selected cytokines and chemokines, MMP-3, production of auto-antibodies, and factors describing clinical activity (DAS28) and radiographic progression in rheumatoid arthritis (RA). A total of 80 RA patients according to the ACR classification criteria, and 32 control subjects were recruited into study. The measurements of miR-124 and U-6 expression, CRP, anti-CCP, rheumatoid factors (RFs), radiographs of both hands with calculation of total sharp score (TSS), DAS28 and cytokines, chemokines and MMP levels in serum were obtained from all RA patients. miR-124 was down-regulated in RA patients compared to controls (7-fold decrease). The miR-124 expression correlated to MMP-3 levels (p < 0.001), which were in multivariate analysis associated to age of RA onset. Higher levels were detected in younger subjects. No relation of miR-124 expression to measures of RA activity (DAS28 score; TSS), auto-antibodies (anti-CCP, RF, RF IgG, RF IgA, RF IgM), acute inflammatory markers (CRP, IL-6), and other cytokine and chemokines (IL-13, IL-15, IL-8, TNF-α, MCP-1, RANTES) was observed. In conclusion, we present a down-regulation of miR-124 in RA patients and its correlation to MMP-3 levels, which associated to age of RA onset.

Biocompatibility of NiTi alloys in the cell behaviour.

Metallic biomaterial alloys composed of nickel and titanium have unique thermal shape memory, superelastic, and high damping properties, which are widely used in the medicine. The major parameter evaluated in the studies regarding the behaviour of the material in the contact with organism or cells is biocompatibility. The aim of the studies is to clarify the differences in the proliferation, growth, and morphology especially in the cell cultures. The cytotoxicity is affected among other by release of the metal ions in the presence of the metal alloy, which is further dependent on the possible treatments of the material and the corrosive properties. To evaluate the cytotoxicity, wide range of tests including the Sulforhodamine B assay and MTT tests, expression profiles, cell survival tests such as apoptotic test are used. The review compares the cell behaviour in contact with the material alloys composed of nickel and titanium with respect to different materials composition and different surface treatment that affects the ion release. Even though the results published so far are controversial, almost all data suggest sufficient biocompatibility in medical use.

Plastic response of macrophages to metal ions and nanoparticles in time mimicking metal implant body environment.

The paradigm of using metal biomaterials could be viewed from two sides - treatment of wide spectrum of degenerative diseases, and debris release from materials. After implant insertion, metal nanoparticles (NPs) and ions are released not only upon the first contact with cells/tissues, but in continual manner, which is immediately recognized by immune cells. In this work, the effects of metal nanoparticles (TiO2, Ni) and ions (Ni2+, Co2+, Cr3+, Mo6+) on primary human M0 macrophages from the blood samples of osteoarthritic patients undergoing total arthroplasty were studied in order to monitor immunomodulatory effects on the cells in a real-time format. The highest NiNPs concentration of 10 µg/ml had no effect on any of macrophage parameters, while the Ni2+ ions cytotoxicity limit for the cells is 0.5 mM. The cytotoxic effects of higher Ni2+ concentration revealed mitochondrial network fragmentation leading to mitochondrial dysfunction, accompanied by increased lysosomal activity and changes in pro-apoptotic markers. The suppression of M2 cell formation ability was connected to presence of Ni2+ ions (0.5 mM) and TiO2NPs (10 µg/ml). The immunomodulatory effect of Mo6+ ions, controversially, inhibit the formation of the cells with M1 phenotype and potentiate the thread-like shape M2s with increased chaotic cell movement. To summarize, metal toxicity depends on the debris form. Both, metal ions and nanoparticles affect macrophage size, morphological and functional parameters, but the effect of ions is more complex and likely more harmful, which has potential impact on healing and determines post-implantation reactions.

Effect of titanium nanostructured surface on fibroblast behavior.

As the consumption of implants increases, so do the requirements for individual types of implants, for example, improved biocompatibility or longevity. Therefore, the nano-modification of the titanium surface is often chosen. The aim was to characterize the modified surface with a focus on medical applications. The titanium surface was modified by the anodic oxidation method to form nanotubes. Subsequently, the material was characterized and analyzed for medical applications-surface morphology, surface wettability, chemical composition, and release of ions into biological fluids. A human gingival fibroblasts (HGFb) cell line was used in the viability study. A homogeneous layer of nanotubes of defined dimensions was formed on the titanium surface, ensuring the material's biocompatibility-the preparation conditions influence the resulting properties of the nanostructured surface. Nanostructured titanium exhibited more suitable characteristics (e.g., wettability, roughness, ion release) for biological applications than compared to pure titanium. It was possible to understand the behavior of the modified layer on the titanium surface and its effect on cell behavior. Another contribution of this work is the combination of material characterization (ion release) with the study of cytocompatibility (direct contact of cells with metals).

Circulating cytokine pattern and factors describing rheumatoid arthritis: IL-15 as one of the biomarkers for RA?

The aim of study was to examine relationship among levels of cytokines (IL-6, IL-13, IL-15, TNF-α) and chemokine (IL-8), production of autoantibodies, radiographic progression, and factors describing rheumatoid arthritis (RA). A total of 156 RA patients according to ACR criteria, and 55 control subjects were recruited into study. We observed higher levels of IL-15 within RA patients compared to healthy controls. Correlations among cytokine levels and the measures of rheumatoid factors, anti-CCP, measures of disease activity, and radiographic progression were observed. We conclude that IL-15 level in circulation could serve as one of the biomarkers for RA detection.

Effect of Nitinol surface with nanotubes and/or ordered nanopores on cell behavior.

Recent medical applications have specific requirements on materials and Nitinol can fulfill them due to its exceptional characteristics, which can be further improved by modifications of the material surface. Various surface nanostructuring methods are utilized to enhance characteristics of oxide layer, which naturally develops on the Nitinol surface, leading to improved biocompatibility and corrosion resistance. This review is focused on studies investigating the behavior of various cell types on surface nanotubes and ordered nanopores prepared by anodic oxidation, a technique allowing fabrication of nanostructures with defined parameters. Results showed that certain dimensions of nanotubes positively affect adhesion and viability of osteoblasts and endothelial cells on the surface, contrary to negative effect on smooth muscle cells, both required by the medical applications. Furthermore, increased antibacterial effect correlated with the nanostructure topography and release rates of Ni ions.

Cytocompatibility and Bioactive Ion Release Profiles of Phosphoserine Bone Adhesive: Bridge from In Vitro to In Vivo.

One major challenge when developing new biomaterials is translating in vitro testing to in vivo models. We have recently shown that a single formulation of a bone tissue adhesive, phosphoserine modified cement (PMC), is safe and resorbable in vivo. Herein, we screened many new adhesive formulations, for cytocompatibility and bioactive ion release, with three cell lines: MDPC23 odontoblasts, MC3T3 preosteoblasts, and L929 fibroblasts. Most formulations were cytocompatible by indirect contact testing (ISO 10993-12). Formulations with larger amounts of phosphoserine (>50%) had delayed setting times, greater ion release, and cytotoxicity in vitro. The trends in ion release from the adhesive that were cured for 24 h (standard for in vitro) were similar to release from the adhesives cured only for 5−10 min (standard for in vivo), suggesting that we may be able to predict the material behavior in vivo, using in vitro methods. Adhesives containing calcium phosphate and silicate were both cytocompatible for seven days in direct contact with cell monolayers, and ion release increased the alkaline phosphatase (ALP) activity in odontoblasts, but not pre-osteoblasts. This is the first study evaluating how PMC formulation affects osteogenic cell differentiation (ALP), cytocompatibility, and ion release, using in situ curing conditions similar to conditions in vivo.

Kinetics of Biomarkers of Oxidative Stress in Septic Shock: A Pilot Study.

Septic shock is a major cause of mortality in ICU patients, its pathophysiology is complex and not properly understood. Oxidative stress seems to be one of the most important mechanisms of shock progression to multiple organ failure. In the present pilot study, we have analysed eight oxidative-stress-related biomarkers in seven consecutive time points (i.e., the first seven days) in 21 septic shock patients admitted to the ICU. Our objective was to describe the kinetics of four biomarkers related to pro-oxidative processes (nitrite/nitrate, malondialdehyde, 8-oxo-2'-deoxyguanosine, soluble endoglin) compared to four biomarkers of antioxidant processes (the ferric reducing ability of plasma, superoxide dismutase, asymmetric dimethylarginine, mid-regional pro-adrenomedullin) and four inflammatory biomarkers (CRP, IL-6, IL-10 and neopterin). Furthermore, we analysed each biomarker's ability to predict mortality at the time of admission and 12 h after admission. Although a small number of study subjects were recruited, we have identified four promising molecules for further investigation: soluble endoglin, superoxide dismutase, asymmetric dimethylarginine and neopterin.

Ni and TiO2 nanoparticles cause adhesion and cytoskeletal changes in human osteoblasts.

Titanium-based alloys have established a crucial role in implantology. As material deteriorates overtime, nanoparticles of TiO2 and Ni are released. This study is focused on the impact of TiO2 and Ni nanoparticles with size of 100 nm on cytoskeletal and adhesive changes in human physiological and osteoarthritic osteoblasts. The impact of nanoparticles with concentration of 1.5 ng/mL on actin and tubulin expression and gene expression of FAK and ICAM-1 was studied. The cell size and actin expression of physiological osteoblasts decreased in presence of Ni nanoparticles, while TiO2 nanoparticles caused increase in cell size and actin expression. Both cell lines expressed more FAK as a response to TiO2 nanoparticles. ICAM-1 gene was overexpressed in both cell lines as a reaction to both types of nanoparticles. The presented study shows a crucial role of Ni and TiO2 nanoparticles in human osteoblast cytoskeletal and adhesive changes, especially connected with the osteoarthritic cells. Graphical abstract.

Oxidative Stress in Takotsubo Syndrome-Is It Essential for an Acute Attack? Indirect Evidences Support Multisite Impact Including the Calcium Overload-Energy Failure Hypothesis.

Indirect evidences in reviews and case reports on Takotsubo syndrome (TTS) support the fact that the existence of oxidative stress (OS) might be its common feature in the pre-acute stage. The sources of OS are exogenous (environmental factors including pharmacological and toxic influences) and endogenous, the combination of both may be present, and they are being discussed in detail. OS is associated with several pathological conditions representing TTS comorbidities and triggers. The dominant source of OS electrones are mitochondria. Our analysis of drug therapy related to acute TTS shows many interactions, e.g., cytostatics and glucocorticoids with mitochondrial cytochrome P450 and other enzymes important for OS. One of the most frequently discussed mechanisms in TTS is the effect of catecholamines on myocardium. Yet, their metabolic influence is neglected. OS is associated with the oxidation of catecholamines leading to the synthesis of their oxidized forms - aminochromes. Under pathological conditions, this pathway may dominate. There are evidences of interference between OS, catecholamine/aminochrome effects, their metabolism and antioxidant protection. The OS offensive may cause fast depletion of antioxidant protection including the homocystein-methionine system, whose activity decreases with age. The alteration of effector subcellular structures (mitochondria, sarco/endoplasmic reticulum) and subsequent changes in cellular energetics and calcium turnover may also occur and lead to the disruption of cellular function, including neurons and cardiomyocytes. On the organ level (nervous system and heart), neurocardiogenic stunning may occur. The effects of OS correspond to the effect of high doses of catecholamines in the experiment. Intensive OS might represent "conditio sine qua non" for this acute clinical condition. TTS might be significantly more complex pathology than currently perceived so far.

Prognostic value of oxidative stress in patients with acute myocardial infarction complicated by cardiogenic shock: A prospective cohort study.

INTRODUCTION: Cardiogenic shock is a frequent complication of acute myocardial infarction. Similar to ischemia/reperfusion injury, excessive production of reactive oxygen species can be expected in those who experience cardiogenic shock. The aims of this study were to describe the extent and time course of oxidative stress and evaluate the prognostic value of oxidative stress markers in patients who experienced ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. METHODS: Plasma/serum levels of selected biomarkers of oxidative stress (oxidised guanine species (OGS), malondialdehyde, and glutathione peroxidase 3) and markers, which simultaneously reflect severe cellular damage (ferric ion reducing antioxidant power (FRAP), Cu/Zn-superoxide dismutase (SOD), and glutathione) were measured seven times per week in a prospective cohort of 82 patients with STEMI complicated by cardiogenic shock. RESULTS: We found elevated OGS levels in patients who died during three months, which persisted significantly increased the next 12 h compared to surviving patients. A similar time course pattern also exhibited concentrations of FRAP and SOD. The other markers did not change significantly and did not show differences between surviving and non-surviving patients during the monitored period. In addition, a strong relationship between OGS, FRAP, and SOD levels (on admission and 12 h after admission) and 3-month mortality was found. CONCLUSION: Levels of OGS, FRAP, and SOD within 12 h after hospital admission were revealed as early predictors of the adverse development of STEMI complicated by cardiogenic shock.

Prognostic value of high-sensitivity cardiac troponin I in heart failure patients with mid-range and reduced ejection fraction.

BACKGROUND: The identification of high-risk heart failure (HF) patients makes it possible to intensify their treatment. Our aim was to determine the prognostic value of a newly developed, high-sensitivity troponin I assay (Atellica®, Siemens Healthcare Diagnostics) for patients with HF with reduced ejection fraction (HFrEF; LVEF < 40%) and HF with mid-range EF (HFmrEF) (LVEF 40%-49%). METHODS AND RESULTS: A total of 520 patients with HFrEF and HFmrEF were enrolled in this study. Two-year all-cause mortality, heart transplantation, and/or left ventricular assist device implantation were defined as the primary endpoints (EP). A logistic regression analysis was used for the identification of predictors and development of multivariable models. The EP occurred in 14% of the patients, and these patients had higher NT-proBNP (1,950 vs. 518 ng/l; p < 0.001) and hs-cTnI (34 vs. 17 ng/l, p < 0.001) levels. C-statistics demonstrated that the optimal cut-off value for the hs-cTnI level was 17 ng/l (AUC 0.658, p < 0.001). Described by the AUC, the discriminatory power of the multivariable model (NYHA > II, NT-proBNP, hs-cTnI and urea) was 0.823 (p < 0.001). Including heart failure hospitalization as the component of the combined secondary endpoint leads to a diminished predictive power of increased hs-cTnI. CONCLUSION: hs-cTnI levels ≥ 17 ng/l represent an independent increased risk of an adverse prognosis for patients with HFrEF and HFmrEF. Determining a patient's hs-cTnI level adds prognostic value to NT-proBNP and clinical parameters.

Effect of Ni ion release on the cells in contact with NiTi alloys.

Nickel-titanium alloys have been used in medical applications for several years; however, biocompatibility of the material remains controversial. In the present study, the human umbilical vein endothelial cells (HUVEC) were cultured in contact with the nitinol used in two different heat treatment  surface modifications-helium and hydrogen. The amount of Ni ions released from these alloys in contact with HUVEC was measured in media and in the cells by ICP-MS. An increased release of Ni ions was detected in He alloy compared with H2 alloy modification with an elevation with the metal exposition duration (24 h vs. 72 h). The cells contained the Ni ions in both selected alloy modifications with the lower levels in H2 alloys. To evaluate the potential of multiple metal applications, similar values were observed in media and in cell suspension for all surface modification combinations. The model analysis of effect of metal ion release on distant cells in the body showed that the concentration is interestingly similar to concentrations in cells in direct contact with the metal alloy. The cells are able to regulate the concentration of Ni ions within the cell. According to our best knowledge, the study for the first time describes the presence of Ni ions released from nitinol directly in the cells. In the case of the H2 modification, the lowest levels of Ni ions were detected both in medium and in the cells, which likely increases the biocompatibility of the nitinol alloy.

Prognostic value of NT-proBNP added to clinical parameters to predict two-year prognosis of chronic heart failure patients with mid-range and reduced ejection fraction - A report from FAR NHL prospective registry.

BACKGROUND: According to guidelines, the prognosis of patients with chronic heart failure can be predicted by determining the levels of natriuretic peptides, the NYHA classification and comorbidities. The aim our work was to develop a prognostic score in chronic heart failure patients that would take account of patients' comorbidities, NYHA and NT-proBNP levels. METHODS AND RESULTS: A total of 1,088 patients with chronic heart failure with reduced ejection fraction (HFrEF) (LVEF<40%) and mid-range EF (HFmrEF) (LVEF 40-49%) were enrolled consecutively. Two-year all-cause mortality, heart transplantation and/or LVAD implantation were defined as the primary endpoint (EP). The occurrence of EP was 14.9% and grew with higher NYHA, namely 4.9% (NYHA I), 11.4% (NYHA II) and 27.8% (NYHA III-IV) (p<0.001). The occurrence of EP was 3%, 10% and 15-37% in patients with NT-proBNP levels ≤125 ng/L, 126-1000 ng/L and >1000 ng/L respectively. Discrimination abilities of NYHA and NT-proBNP were AUC 0.670 (p<0.001) and AUC 0.722 (p<0.001) respectively. The predictive value of the developed clinical model, which took account of older age, advanced heart failure (NYHA III+IV), anaemia, hyponatraemia, hyperuricaemia and being on a higher dose of furosemide (>40 mg daily) (AUC 0.773; p<0.001) was increased by adding the NT-proBNP level (AUC 0.790). CONCLUSION: The use of prediction models in patients with chronic heart failure, namely those taking account of natriuretic peptides, should become a standard in routine clinical practice. It might contribute to a better identification of a high-risk group of patients in which more intense treatment needs to be considered, such as heart transplantation or LVAD implantation.

Polymorphism in the tumor necrosis factor-alpha gene promoter is associated with severity of rheumatoid arthritis in the Czech population.

Rheumatoid arthritis (RA) is a model of multigenic inflammatory disorder in which tumor necrosis factor-alpha (TNF-alpha) plays an important role. Genetic factors may be implicated in the susceptibility to disease initiation as well as in severity of disease course. Elevated levels of TNF-alpha in the plasma and synovial fluid from RA patients may be associated with polymorphisms in the promoter region of the TNF-alpha gene. The aim of this study was to elucidate putative association between the -308 G/A polymorphism in the promoter region of the TNF-alpha gene and susceptibility to onset and severity of RA. A total of 130 RA patients and a control group of 150 healthy subjects with similar age and sex distribution were available for the study. All patients fulfilled the American College of Rheumatology revised criteria for RA. RA patients had a disease duration of at least 2 years. Radiographs of both hands of all RA patients were scored with the Steinbrocker method. There were 15 patients of stage I (nonerosive form) of RA and 114 patients of stages II-IV (erosive form). To assess the RA patient's functional ability, the Health Assessment Questionnaire (HAQ) was used. The -308 G/A promoter polymorphism of the TNF-alpha gene was detected by polymerase chain reaction and restriction fragment length polymorphism analysis. No differences in genotype distribution and allelic frequences of -308 G/A TNF-alpha promoter polymorphism have been found between RA patients and the control group. Significant differences have been observed within the RA group divided according to the radiographic progression of disease based on the Steinbrocker radiographic score and functional ability (HAQ). These results suggest an association of the -308 G/A polymorphism of the TNF-alpha gene with the severity of RA.

Association of the 5A/6A promoter polymorphism of the MMP-3 gene with the radiographic progression of rheumatoid arthritis.

Matrix metalloproteinases (MMPs) as a family of zinc-dependent endopeptidases have been involved in remodeling the extracellular matrix (ECM) in rheumatoid arthritis (RA). In RA patients synovial fluid and serum include enhanced levels of MMP-3. The 5A/6A polymorphism in the MMP-3 gene promoter can contribute to the severity of RA on account of a higher promoter activity of the 5A allele in vitro. The aim of the study was to associate the 5A/6A polymorphism of the MMP-3 gene with radiographic progression of RA. A total of 128 RA patients according to the ACR criteria were available for the study. Radiographs of both hands, obtained from all RA patients, were scored using the modified Sharp/van der Heijde method and the Steinbrocker method. The total Sharp score (TSS) and the annual radiographic progression rate (TSS/year) were calculated. Significant association with the 5A/6A polymorphism was found between patients with TSS/year 1.00 in allelic frequencies (Pa = 0.046) and also in genotype distribution (Pg = 0.04). Compared to other genotypes the prevalence of 5A/5A genotype was lower within patients with TSS/year

Relationship of long-term prognosis to MMP and TIMP polymorphisms in patients after ST elevation myocardial infarction.

The influence of polymorphisms in the large group of MMP and TIMP genes on clinical outcomes in patients after ST elevation myocardial infarction (STEMI) treated with primary PCI was analysed. In total, 550 consecutive Caucasian patients with STEMI were included in the present study, with a median of 32 months. We analysed 19 polymorphisms in the genes coding MMP and TIMP genes. The MMP-1 -519A/G and -422A/T polymorphisms are associated with combined endpoint after myocardial infarction. The hazard ratio for AT variant of MMP-1 -422A/T was 1.75 (p < 0.001); the variants with at least one A allele of MMP-1 -519A/G have less risk of combined endpoint. The TT variants of -1562C/T MMP-9 and at least one T allele of +92C/T MMP-13 were considered in a trend to affect disease progression and long-term survival after myocardial infarction. According to reclassification analysis NRI and IDI, long-term risk stratification using MMP-1 -422A/T and -519A/G polymorphisms gives additional information to the commonly used GRACE risk score. Patient stratification after myocardial infraction (MI) according to risk genotypes of MMP-1 polymorphisms could have important clinical implications for identification of patients at risk and therapeutic strategies.

Prognostic impact of neutrophil gelatinase-associated lipocalin and B-type natriuretic in patients with ST-elevation myocardial infarction treated by primary PCI: a prospective observational cohort study.

OBJECTIVES: Neutrophil gelatinase-associated lipocalin (NGAL) from a pathophysiological perspective connects various pathways that affect the prognosis after myocardial infarction. The objective was to evaluate the benefits of measuring NGAL for prognostic stratification in addition to the Thrombolysis in Myocardial Infarction (TIMI) score, and to compare it with the prognostic value of B-type natriuretic peptide (BNP). DESIGN: Prospective observational cohort study. SETTING: One university/tertiary centre. PARTICIPANTS: A total of 673 patients with ST segment elevation myocardial infarction were treated by primary percutaneous coronary intervention. NGAL and BNP were assessed on hospital admission. PRIMARY OUTCOME: 1-year mortality. SECONDARY OUTCOMES: 1-year hospitalisation due to acute heart failure, unplanned revascularisation, reinfarction, stroke and combined end point of 1-year mortality and hospitalisation due to heart failure. STATISTICAL METHODS: Using the c-statistic, the ability of NGAL, BNP and TIMI score to predict 1-year mortality alone and in combination with readmission for heart failure was evaluated. The addition of the predictive value of biomarkers to the score was assessed by category free net reclassification improvement (cfNRI) and the integrated discrimination index (IDI). RESULTS: The NGAL level was significantly higher in non-survivors (67 vs 115 pg/mL; p<0.001). The area under the curve (AUC) values for mortality prediction for NGAL, BNP and TIMI score were 75.5, 78.7 and 74.4, respectively (all p<0.001) with optimal cut-off values of 84 pg/mL for NGAL and 150 pg/mL for BNP. The addition of NGAL and BNP to the TIMI score significantly improved risk stratification according to cfNRI and IDI. A BNP and the combination of the TIMI score with NGAL predicted the occurrence of the combined end point with an AUC of 80.6 or 82.2, respectively. NGAL alone is a simple tool to identify very high-risk patients. NGAL >110 pg/mL was associated with a 1-year mortality of 20%. CONCLUSIONS: The measurement of NGAL together with the TIMI score results in a strong prognostic model for the 1-year mortality rate in patients with STEMI.