The WAP Four-Disulfide Core Domain Protein HE4: A Novel Biomarker for Heart Failure

Rudolf A. de Boer*, Qi Cao, Douwe Postmus, Kevin Damman, Adriaan A. Voors, Tiny Jaarsma, Dirk J. van Veldhuisen, William D. Arnold, Hans L. Hillege, Herman H. W. Sillje

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

23 Citations (Scopus)


Objectives This study investigated clinical determinants and added prognostic value of HE4 as a biomarker not previously described in heart failure (HF).

Background Identification of plasma biomarkers that help to risk stratify HF patients may help to improve treatment.

Methods Plasma HE4 levels were determined in 567 participants of the COACH (Coordinating study evaluating outcomes of Advising and Counseling in Heart failure). Patients had been hospitalized for HF and were followed for 18 months. The primary endpoint of this study was a composite of all-cause mortality and HF hospitalization.

Results HE4 showed a strong correlation with HF severity, according to New York Heart Association functional class and brain natriuretic peptide (BNP) levels (p <0.001). HE4 also showed a positive correlation with GDF15 (p <0.001) and, in addition, correlated with kidney function (estimated glomerular filtration rate [eGFR]; p <0.001). Cox regression analysis revealed that a doubling of HE4 levels was associated with a hazard ratio (HR) of 1.73 (95% confidence interval [CI]: 1.53 to 1.95) for the primary outcome (p <0.001). After correction for age, gender, BNP, and eGFR, the HR was 1.46 (95% CI: 1.23 to 1.72; p <0.001), and after additional adjustment for GDF15, the HR lowered to 1.30 (95% CI: 1.07 to 1.59; p = 0.009). The area under the curve in the receiver-operating characteristic curve analysis increased from 0.727 to 0.752 when HE4 was included in the clinical evaluation (p = 0.051). The integrated discrimination improvement and net reclassification index for reclassification showed significant improvements when HE4 was added to the clinical model, and this remained significant after BNP inclusion in the model.

Conclusions HE4 plasma levels are correlated with markers of HF severity, show prognostic value, and can improve risk assessment in HF. (C) 2013 by the American College of Cardiology Foundation

Original languageEnglish
Pages (from-to)164-169
Number of pages6
JournalJACC. Heart failure
Issue number2
Publication statusPublished - Apr-2013


  • biomarker
  • HE4
  • heart failure
  • prognostic marker
  • WFDC-2

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