European Heart Journal (2019) 40, 1643–1650 CLINICAL REVIEW doi:10.1093/eurheartj/ehy234 Translational medicine Circulating non-coding RNAs in biomarker-guided cardiovascular therapy: a novel tool for personalized medicine? David de Gonzalo-Calvo1,2,3,4*, Angela Vea1, Christian Bär3, Jan Fiedler3, Liam S. Couch3,5, Carlos Brotons6, Vicenta Llorente-Cortes1,2,4, and Thomas Thum3,5,7* 1 Biomedical Research Institute Sant Pau (IIB Sant Pau), Av. Sant Antoni Maria Claret 167, Pavelló del Convent, 08025 Barcelona, Spain; 2Institute of Health Carlos III, CIBERCV, Av. Monforte de Lemos 5, 28029 Madrid, Spain; 3Institute of Molecular and Translational Therapeutic Strategies (IMTTS), IFB-Tx, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; 4Institute of Biomedical Research of Barcelona (IIBB)-Spanish National Research Council (CSIC), C/ Rosselló 161, 08036 Barcelona, Spain; 5National Heart and Lung Institute, Imperial College London, Dovehouse Street, SW3 6LR, London, UK; 6Biomedical Research Institute Sant Pau (IIB Sant Pau), Sardenya Primary Health Care Center, C/ Sardenya 466, 08025 Barcelona, Spain; and 7Excellence Cluster REBIRTH, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany Received 23 October 2017; revised 22 December 2017; editorial decision 26 March 2018; accepted 6 April 2018; online publish-ahead-of-print 24 April 2018 Current clinical guidelines emphasize the unmet need for technological innovations to guide physician decision-making and to transit from conventional care to personalized cardiovascular medicine. Biomarker-guided cardiovascular therapy represents an interesting approach to inform tailored treatment selection and monitor ongoing efficacy. However, results from previous publications cast some doubts about the clinical applicability of biomarkers to direct individualized treatment. In recent years, the non-coding human transcriptome has emerged as a new opportunity for the development of novel therapeutic strategies and biomarker discovery. Non-coding RNA (ncRNA) signatures may provide an accurate molecular fingerprint of patient phenotypes and capture levels of information that could complement traditional markers and established clinical variables. Importantly, ncRNAs have been identified in body fluids and their concentrations change with physiology and pathology, thus representing promising non-invasive biomarkers. Previous publications highlight the translation- al applicability of circulating ncRNAs for diagnosis and prognostic stratification within cardiology. Numerous independent studies have also evaluated the potential of the circulating non-coding transcriptome to predict and monitor response to cardiovascular treatment. However, this field has not been reviewed in detail. Here, we discuss the state-of-the-art research into circulating ncRNAs, specifically microRNAs and long non-coding RNAs, to support clinical decision-making in cardiovascular therapy. Furthermore, we summarize current methodological and conceptual limitations and propose future steps for their incorporation into personalized cardiology. Despite the lack of robust population-based studies and technical barriers, circulating ncRNAs emerge as a promising tool for biomarker-guided therapy. ................................................................................................................................................................................................... Keywords Biomarker • Cardiovascular disease • Long non-coding RNAs • MicroRNAs • Non-coding RNAs • Personalized medicine • Precision medicine Biomarker-guided cardiovascular .. .. highly effective and well-tolerated therapeutic interventions.1,2 .. therapy .. Despite this, CVD persists as the leading cause of death worldwide .. (http://www.who.int/cardiovascular_diseases). This is in part due Recent decades have seen advances in the treatment of .. to the interindividual variability in the response to medical .. cardiovascular disease (CVD) due to the development of . treatments.3 * Corresponding authors. Tel: þ49 511 532 5272, Fax: þ49-511 532 5274, Email: thum.thomas@mh-hannover.de (T.T.); Tel: þ34 935565903, Fax: þ34 935565559, Email: david. degonzalo@gmail.com (D.d.G.-C.) C The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology. V This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1644 D. de Gonzalo-Calvo et al. The variability in therapeutic outcomes differs according to demo- graphic, clinical, environmental, and genetic factors.3,4 Nevertheless, therapy is rarely tailored, as evidence-based medicine assumes a uniform patient phenotype.5 Several authors have proposed to incorporate molecular profiling into clinical decision-making to allow patients, or subgroups of patients, to receive precision medical care.6,7 Tailored therapies based on a refined understanding of patient’s mo- lecular characteristics could be administered to those who are antici- pated to benefit most, whereas simultaneously limiting ineffective or harmful interventions.5,8 This would ultimately lead to improved clinical outcomes, increased patient quality of life, and better allocation of health care resources. In this context, utilizing biomarkers to objectively assist in individualized treatment has gained attention in recent years.9 Indeed, drug-diagnostic co-development (‘companion diagnostics’) has become increasingly important in the pharmaceutical industry.10 Biomarker-guided therapy, the use of biomarkers to tailor medical treatment, could assist in: (i) selection of therapy, (ii) evaluation of ef- ficacy, (iii) optimal dose selection, and (iv) recognition and avoidance Figure 1 Biomarker-guided therapy. of side-effects (Figure 1). Reflecting this, previous studies have illus- trated the usefulness of circulating biomarkers to tailor cardiovascu- lar therapy.11 Most notably, N-terminal prohormone of brain .. natriuretic peptide (NT-proBNP)-guided treatment has been sug- .. stages, further efforts are needed to demonstrate the clinical safety .. and efficacy of ncRNAs in cardiovascular therapy. gested to reduce or delay cardiovascular outcomes and to improve .. cost-effectiveness compared to guideline-based therapy.12 Despite .. .. promising findings, other data cast doubts as to whether circulating .. biomarkers can support clinical decision-making.13 Genome se- .. Circulating non-coding RNAs .. quence variations, including single nucleotide polymorphisms (SNPs), .. In addition to the relevance of ncRNAs as targets or tools for ther- .. could act as biological markers of the response to certain drugs.14 .. apy, a plethora of reports suggest that the transcriptomic signature, Nevertheless, genomics alone provide an incomplete picture of the .. particularly from ncRNAs, could give insights into both physiological .. patient’s phenotype.15 Thus, there is a clinical need for innovative bio- .. and pathological states of a patient.18 Indeed, transcriptome- markers to tailor cardiovascular therapy. .. originating biomarkers may provide a deep characterization of dis- .. .. ease phenotypes and could offer information that is not captured by .. .. traditional markers or clinical characteristics.28 Despite this, only a Non-coding RNAs, an emerging .. small percentage of the non-coding transcriptome has been explored .. concept in disease and therapy .. for this purpose.25 ncRNA expression exhibits high variations be- .. tween cells, is highly dynamic and rapidly alters in response to stres- Although 80% of the human genome is transcribed, only 1–3% of all .. .. sors. Indeed, a close correlation between dysregulation of the transcripts are further translated into proteins (Figure 2).16 The vast .. ncRNA profile and the pathophysiology of numerous cardiovascular majority of the human transcriptome represents non-coding RNAs .. .. conditions has been demonstrated.29 Furthermore, ncRNA altera- (ncRNAs) (Figure 2),17 which play key regulatory functions.18,19 .. tions could be indicative of complex interaction between genetic and .. Contrary to the number of protein-coding genes, which is relatively .. environmental factors. Diet, exercise, biological rhythms, or other static since the evolution of multicellularity,17 the amount of ncRNAs .. exogenous factors not routinely considered during clinical evaluation .. has continued to increase along with the complexity of the organ- .. influence ncRNA expression.30 Therefore, the non-coding transcrip- ism.20 This suggests a fundamental role of ncRNAs in the evolution of .. tome provides an interesting opportunity for the identification of .. biological complexity. .. novel tools to assist in clinical decision-making. Non-coding transcripts participate in most cellular processes, and .. Supporting their potential as easily accessible and minimally invasive .. therefore, play a causative role in a number of diseases.21,22 .. biomarkers, the presence of ncRNAs has been extensively described .. Accordingly, the manipulation of ncRNA expression has emerged as .. in a large number of body fluids.31 From a clinical perspective, the a novel and promising therapeutic approach.23,24 Of note, clinical tri- .. non-coding transcriptome, in particular microRNAs (miRNAs) and .. als have evaluated the safety, efficacy, and tolerability of ncRNAs in .. long non-coding RNAs (lncRNAs), have the optimal biochemical the treatment of various diseases, such as chronic hepatitis C (www. .. properties to be excellent biomarkers. Indeed, miRNAs and lncRNAs .. clinicaltrials.gov, NCT01200420) and kidney disease (www.clinical .. are stable against degradation, have a long half-life in biological sam- trials.gov, NCT02855268). Excellent publications have recently .. ples and can be obtained by standard laboratory techniques.32,33 RNA .. reviewed the role of ncRNAs as potential therapeutic targets in .. can be quantified with high sensitivity and specificity through quantita- CVD,18,19,25–27 and therefore this issue is beyond the scope of this re- .. tive reverse transcription-polymerase chain reaction (RT-qPCR), a .. view. Since the great majority of investigations are in pre-clinical . technique readily available in clinical laboratories. In comparison to Circulating non-coding RNAs in biomarker-guided therapy 1645 Figure 2 Coding and non-coding transcriptome. Although approximately 80% of the human genome is transcribed, only 1–3% of this corresponds to protein-coding nucleotide sequences (messenger RNAs, green circles). The remaining 97–99% corresponds to RNAs not translated into proteins: non-coding RNAs (orange), except for some specific exceptions. The non-coding RNA transcriptome includes: circular RNA (circRNAs), enhancer RNAs (eRNAs), germline small RNAs (gsRNAs), long non-coding RNAs (lncRNAs), microRNAs (miRNA), piwi-interacting RNAs (piRNAs), riboso- mal RNAs (rRNAs), ribozymes, small conditional RNAs (scRNAs), small interfering RNAs (siRNAs), small nuclear RNAs (snRNAs), small nucleolar RNAs (snoRNAs), transfer RNAs (tRNAs), and Y RNA (YRNA). The symbols used are merely indicative. .. peptide biomarkers, ncRNAs can be quantified even at low amounts. .. Despite a number of publications have addressed these issues in the Furthermore, global profiles can be obtained in a single experiment .. cardiovascular context, this research field has not been reviewed in de- .. using RT-qPCR panels, next-generation sequencing or microarrays. .. tail. Here, we summarize the current knowledge on ncRNAs, specifical- Most studies on circulating ncRNAs as cardiovascular biomarkers .. ly miRNAs and lncRNAs, as biomarkers to predict and monitor the .. are focused on the potential clinical application of miRNAs and .. response to cardiovascular treatment. lncRNAs in the diagnosis of disease and assessment of cardiovascular .. .. risk.34–36 These approaches provide valuable information on patient se- .. lection for given therapies (Figure 3). However, the role of ncRNAs as .. .. Circulating microRNAs in diagnostic and prognostic biomarkers is beyond the interest of the cur- .. .. biomarker-guided cardiovascular rent review and has been extensively reviewed elsewhere.37,38 .. .. Treatment selection and monitoring are key aspects of medical man- .. therapy agement (Figure 3). Based on their biological characteristics, the ncRNA .. profile may reflect the molecular configuration required for any inter- .. miRNAs are a group of small ncRNAs (19–25 nucleotides in length) .. vention to exert its therapeutic effect, providing an innovative approach .. that regulate gene expression at the post-transcriptional level. for treatment allocation. Additionally, the post-baseline changes in the .. Approximately 2500 human miRNAs have been annotated in the .. ncRNA signature may be useful to monitor ongoing effectiveness. . miRBase database (http://www.mirbase.org).39 miRNAs are 1646 D. de Gonzalo-Calvo et al. Figure 3 Potential clinical application of circulating non-coding RNAs in personalized cardiovascular medicine. predicted to target >60% of protein-coding genes,40 and play a key .. miRNAs, including miR-126 and other platelet-enriched miRNAs .. role in development, homeostasis, and response to stress.41,42 .. (miR-191 and miR-223), decreased with further platelet inhibition. .. miRNAs are usually expressed in complex networks that enable sub- .. These findings were validated in patients with symptomatic carotid tile control of the cellular phenotype.43 .. artery atherosclerosis under treatment with dipyridamole or clopi- .. In addition to their intracellular localization, miRNAs have also .. dogrel, in addition to aspirin. The same group demonstrated that cir- been described in the extracellular milieu. Extracellular miRNAs are .. culating miRNAs are closely correlated with platelet activation .. protected from degradation by packaging in lipid vesicles and by bind- .. biomarkers in general population.51 The circulating signature of ing to proteins or lipoproteins.44,45 Extracellular miRNAs participate .. miRNAs was also associated with the residual platelet activity in .. in intercellular communication at autocrine, paracrine, and endocrine .. patients with acute coronary syndrome on antiplatelet therapy.51 It is levels.46,47 They have been implicated in both physiological and adap- .. worth of noting that the authors suggested a role for the small .. tive responses,30 as well as in the onset and development of disease .. ncRNA family, YRNAs, as novel biomarkers to monitor antiplatelet .. states, including in CVD.48 .. therapy.51 Interestingly, a score based on the plasma miR-92a levels Results from a number of publications support the promising role .. and the platelet distribution width (PDW), can identify aspirin resist- .. of circulating miRNAs in the prediction of the therapeutic response .. ance post-baseline with a specificity of 97.5% and a sensitivity of and monitoring the effectiveness of treatment (Table 1). .. 80.0% in patients with intermittent claudication on daily aspirin .. .. monotherapy (75 mg/day, 100 mg/day, or 150 mg/day).52 Antiplatelet therapy .. Results from these studies were validated in alternative sources of .. Antiplatelet therapy is the cornerstone treatment in patients at high .. miRNAs. Kok et al.53 performed miRNA microarray analysis using risk of thrombosis.63 Since resistance to the therapy has been associ- .. platelet RNA obtained from a small cohort of healthy male subjects .. ated with higher incidence of cardiovascular events,63 non-responder .. without personal history of CVD. Results showed that altered patients may benefit from alternative antiplatelet therapies. .. expression of miR-19b-1-5p, miR-548e, miR-587, miR-1225-3p, .. The development of robust laboratory tests to monitor response to .. miR-1271, and miR-1537-5p correlated with the extent of platelet ag- .. antiplatelet therapy is thus of clinical importance. However, the cur- .. gregation reduction after 2 weeks of aspirin therapy (100 mg/day). rent methodology has provided varying results.64 .. Lower platelet miR-19b-1-5p expression after aspirin therapy was .. Results from different studies suggest the potential of circulating .. associated with platelet aggregation in the presence of indomethacin, miRNA levels as surrogate biomarkers of antithrombotic therapy effi- .. which mimics the effect of aspirin. As such, miR-19b-1-5p may be a .. cacy. In 2013, de Boer et al.49 demonstrated that aspirin administra- .. suitable biomarker to identify aspirin insensitivity. It should be noted tion (300 mg/day) resulted in a significant reduction in circulating .. that a previous publication demonstrated that the platelet miRNA .. levels of miR-126 in patients with type 2 diabetes mellitus (T2DM) .. profile is remarkably stable and is not affected by a single-dose of as- and without a history of CVD after 6 weeks of treatment. miR-126 .. pirin in a small healthy cohort.54 However, single-dose treatment .. levels also showed a direct correlation with platelet activation follow- .. may not have an immediate effect on platelet miRNAs.54 .. ing treatment, irrespective of dose. Indeed, aspirin inhibited in vitro .. Shi et al.55 explored the association between platelet miRNA ex- transfer of platelet-enriched miRNAs from the platelets to the extra- .. pression and the responsiveness to a clopidogrel loading dose .. cellular milieu. The potential of circulating miR-126 to monitor aspirin .. (300 mg) in a cohort of non-diabetic coronary heart disease patients therapy was corroborated by Willeit et al.50 who evaluated a panel of .. with non-ST elevation acute coronary syndrome (NSTE-ACS). .. 92 miRNAs in plasma of healthy volunteers after treatment with .. Logistic regression analyses demonstrated that among a number of 10 mg prasugrel, followed by combination therapy with varying as- .. factors potentially associated with platelet reactivity (age, obesity, .. pirin doses in successive weeks. Plasma levels of 15 circulating . smoking, genotype, and other medication), miR-223 expression was Circulating non-coding RNAs in biomarker-guided therapy 1647 Table 1 Studies focused on circulating microRNAs in biomarker-guided therapy Therapy Patients/Subjects/Model Source Main findings References .................................................................................................................................................................................................................... 49 Aspirin Patients with T2DM and without Plasma Therapy reduces circulating miR-126 levels a history of CVD 50 Aspirin Healthy subjects Plasma Therapy reduces the circulating levels of a panel of miRNAs, including platelet-enriched miRNAs Patients with symptomatic ca- rotid atherosclerosis 51 Aspirin Healthy volunteers Plasma Interindividual variability in circulating miRNA profile decreased with prolonged therapy Patients with a history of ACS Platelet-related miRNAs correlated with platelet function tests Bruneck cohort Platelet-related miRNAs correlated with platelet activation markers 52 Aspirin Patients with intermittent Plasma Combination of circulating miR-92a and PDW is a predictor of aspirin claudication resistance 53 Aspirin Healthy subjects without history Platelets Changes in expression levels of miR-19b-1-5p, miR-548e, miR-587, of CVD miR-1225-3p, miR-1271, and miR-1537-5p correlate with a reduc- tion in platelet aggregation Platelet miR-19b-1-5p expression is associated with aspirin insensitivity 54 Aspirin Healthy subjects Platelets No change in miRNA expression 55 Clopidogrel CHD patients with NSTE-ACS Platelets Platelet miR-223 expression is a predictor of clopidogrel responsiveness 56 CRT Patients with HF eligible for CRT Serum No differences in miRNA expression profile between responders and non-responders at baseline Different changes in circulating miRNA between responders and non- responders after the therapy At follow-up, circulating miR-26b-5p, miR-29a-3p, miR-30e-5p, miR- 92a-3p, and miR-145-5p were differentially expressed between res- ponders and non-responders 57 CRT Patients with HF referred for Plasma Higher levels of circulating miR-30d, miR-142-5p, and miR-766 in res- CRT ponders at baseline Association between circulating miR-30d levels and CRT responsiveness Reduction in circulating miR-30d levels at 6 months in responders 58 LVAD Patients with severe advanced HF Plasma Circulating miR-483-3p monitors the response to LVAD therapy Circulating miR-1202 predicts the response to LVAD therapy 59 LVAD Patients with end-stage HF Plasma / Reduction in circulating levels of heart-enriched miRNAs in response Serum to LVAD therapy 60 LVAD Patients with end-stage HF Plasma Circulating miR-21 decreased at 1, 3, and 6 months after LVAD implantation 61 Antihypertensive Hypertension-induced heart dis- Plasma Reduction of circulating levels of miR-16, miR-20b, miR-93, miR-106b, ease rat models miR-223, and miR-423-5p in response to antimiR-208a and ACE in- hibitor therapies Circulating miR-19b could serve as a specific biomarker for antimiR- 208 therapy 62 CPAP Patients with RH and OSA Plasma A cluster of circulating miRNAs (miR-100-5p, miR-378-3p, and miR- 486-5p) predict blood pressure response Different profile in miRNA changes between responders and non- responders ACE, angiotensin-converting enzyme; ACS, acute coronary syndrome; CPAP, continuous positive airway pressure; CHD, coronary heart disease; CRT, cardiac resynchroniza- tion therapy; CVD, cardiovascular disease; HF, heart failure; LVAD, left ventricular assist device; NSTE-ACS, non-ST elevation acute coronary syndrome; OSA, obstructive sleep apnoea; PDW, platelet distribution width; RH, resistant hypertension; T2DM, type 2 diabetes mellitus. 1648 D. de Gonzalo-Calvo et al. .. an independent predictor associated with clopidogrel responsiveness .. treatments. Thus, post-baseline circulating miRNA levels may be use- [Odds ratio (OR) 0.189, 95% Confidence Interval (CI) 0.043-0.836]. .. ful to assist in monitoring of efficacy of CRT. .. Plasma miR-223 showed a clinically acceptable discriminative value .. [Area Under the Curve (AUC) 0.706, 95% CI 0.521-0.891] and the as- .. Left ventricular assist devices .. sociation with clopidogrel responsiveness remained significant even .. The use of LV assist devices (LVAD) in patients with advanced HF is after adjusting for CYP2C19*2 (OR 0.193, 95% CI 0.044–0.855), a .. limited by high rates of adverse events and cost.67,68 Various clinical .. genetic polymorphism that influences the response to clopidogrel. .. variables have been studied to select patients based on anticipated These observations suggest that miRNAs are able to reveal meas- .. therapeutic response.68 However, appropriate patient stratification .. urable changes in platelet activation and aggregation after antiplatelet .. remains challenging.69 therapies and may serve as indicators of compliance in both general .. The potential of circulating miRNAs to predict the response to .. and specific patient populations. However, due to the high incidence .. LVAD has been previously evaluated in patients with severe .. advanced HF. Morley-Smith et al.58 classified the clinical response to of suboptimal responses63 and the number of alternatives in antipla- .. telet therapy, the further development of novel biomarkers to pre- .. LVAD therapy based on NT-proBNP concentration at 3 months. .. Selected patients whose change in NT-proBNP was above the 50th dict the response to the treatment seems fundamental. .. .. percentile were identified as ‘poor responders’ and patients below .. the 50th percentile as ’good responders’. Using a screening approach Cardiac resynchronization therapy .. Cardiac resynchronization therapy (CRT) has emerged as a well- .. including 1113 miRNAs, the authors demonstrated that miR-1202 .. was a useful biomarker to predict the response to LVAD therapy. established therapy for advanced heart failure (HF).65 However, a sig- .. nificant number of patients do not show objective evidence of a clin- .. Baseline circulating miR-1202 levels stratified the cohort into poor .. and good responders with greater accuracy than baseline NT- ical benefit.66 Implantation of a CRT device is invasive and has high .. .. proBNP (AUC 0.976, 95% CI 0.904–1.000 vs. AUC 0.071, 95% CI costs. Therefore, there is great interest in identifying patients who .. are most likely to benefit. Melman et al.57 evaluated the role of circu- .. 0.000–0.210). Thus, miR-1202 emerges as an interesting biomarker .. to select LVAD therapy or alternative interventions, such as urgent lating miRNAs as biomarkers to predict the response to CRT in a co- .. hort of patients referred for CRT pacemaker implantation with and .. cardiac transplantation. .. Within the same study, circulating miR-483-3p levels were upregu- without subsequent echocardiographic improvement after 6 months. .. Responders were defined as individuals with an increase in left ven- .. lated following intervention, with >2-fold-change from baseline even .. after 3 months. This up-regulation mirrored the improvement in LV tricular ejection fraction (LVEF) >_ 10% between baseline and follow- .. up transthoracic echocardiography. After an initial discovery phase .. function. Other studies similarly support the alteration in the circulat- .. ing miRNA signature after LVAD implantation.59,60 Since the evalu- using a 766 miRNA array and a subsequent validation phase, plasma .. miR-30d was identified as a predictor of therapeutic response in .. ation of the changes in ventricular function after LVAD implantation .. has limitations,58 serial measurements of the circulating miRNA signa- multivariate models, even after adjusting for serum creatinine, previ- .. .. ture could be an interesting and easily accessible tool to complement ous revascularization, preimplantation QRS duration, and LVEF (OR .. the current methodology for monitoring the therapeutic response to 2.52, 95% CI 1.07–5.94). The discriminative ability was superior to .. .. LVAD. clinical variables such as QRS duration in univariate logistic regression .. analyses (OR 2.32, 95% CI 1.16–4.67 vs. OR 1.00, 95% CI 0.82–1.34). .. .. Antihypertensive therapy Thus, preimplantation circulating miR-30d could be a biomarker for .. Efforts have been made to predict and monitor antihypertensive the selection of CRT or alternative medical interventions. .. .. therapy using circulating miRNAs. Sánchez-de-la-Torre et al.62 ana- Interestingly, using in vitro and in vivo models, the authors demon- .. lysed a panel of 84 miRNAs functionally associated with the cardio- strated that miR-30d mediates cardiac hypertrophy and protection .. .. vascular system in plasma samples from 38 patients with resistant against inflammation-induced cardiomyocyte apoptosis. .. hypertension (RH) and obstructive sleep apnoea (OSA) at baseline .. Marfella et al.56 evaluated 84 miRNAs previously associated with .. and after 3 months of adherent continuous positive airway pressure the pathogenesis of the failing heart in 81 patients with HF eligible for .. .. (CPAP) use. Pre-treatment levels of a cluster of miRNAs, miR-100- CRT. At 12 months, patients were categorized as responders if they .. 5p, miR-378-3p, and miR-486-5p, discriminated between non- exhibited LV reverse remodelling [reduction >10% in LV end-systolic .. .. responders and patients with a favourable decrease in blood pressure volume (LVESV) index and an increment of >10% in LVEF] or non- .. (AUC 0.92, 95% CI 0.79–0.99). Supporting previous results from dif- responders (reduction <10% in LVESV index and an increment .. .. ferent medical treatments, the changes in plasma miRNA profile after of <10% in LVEF). In contrast to previous findings, similar levels of .. the treatment differed between responders and non-responders. circulating miRNAs were observed between responders and .. .. Notably, the authors developed a predictive screening algorithm non-responders at baseline, which makes the potential for patient .. (HIPARCOScore) based on the specific cluster of miRNAs to identify .. stratification by preimplantation miRNA levels unclear. However, the .. those responders. authors reported higher expression levels of circulating miR-26b-5p, .. Dickinson et al.61 demonstrated that circulating miRNAs are bio- .. miR-29a-3p, miR-30e-5p, miR-92a-3p, and miR-145-5p after .. markers of therapeutic efficacy in different hypertension-induced 12 months of CRT in responders (fold-changes from 15.2 to 6.2) .. heart disease rat models. Although the clinical application of the .. compared to non-responders (fold-changes from 5.6 to 2.1). These .. results is limited due to the lack of patient-based data, this study pro- miRNAs were directly associated with changes in LVEF and NT- .. vides interesting conceptual implications. Different miRNA profiles .. proBNP, even after adjusting for age, gender, functional class, and . were observed in response to established and experimental Circulating non-coding RNAs in biomarker-guided therapy 1649 therapies; angiotensin-converting enzyme (ACE) inhibitor (captopril) .. of circulating lncRNAs in biomarker-guided therapy.74 Our group has .. and antimiR-208a treatment. The results support the potential of cir- .. recently proposed the potential of circulating lncRNA as blood- .. culating miRNAs as specific treatment biomarkers. Indeed, circulating .. based biomarkers to guide pioglitazone therapy.75 After analysing a levels of miR-19b only changed in response to antimiR-208a therapy. .. panel of lncRNAs related to cardiovascular pathology in a cohort of .. Furthermore, levels of circulating miRNAs correlated with the ex- .. patients with well-controlled T2DM, we reported that pre- pression of the myosin isoform Myh7, suggesting that miRNAs could .. treatment levels of the circulating lncRNA smooth muscle and endo- be an interesting tool to monitor the improvement in cardiac ... thelial cell-enriched migration/differentiation-associated long non- .. function. .. coding RNA (SENCR) are positively associated with the rate of .. change in diastolic function after 24 weeks of pioglitazone therapy. Of .. .. note, levels of circulating SENCR before pioglitazone therapy Circulating long non-coding .. .. allowed the discrimination of responders from non-responders RNAs in biomarker-guided .. (AUC 0.763, 95% CI 0.558–0.967). Thus, pre-treatment levels of cir- .. cardiovascular therapy .. culating SENCR may constitute a clinically useful biomarker for the .. identification of patients that will benefit from pioglitazone adminis- .. lncRNAs comprise a vast family of ncRNAs longer than 200 nucleoti- .. tration (Figure 4). .. des that participate in multiple biological processes, including imprint- .. ing, scaffold/guide for epigenetic and transcription factors, .. Limitations and perspectives .. The reproduction of current results in independent and multicentre transcription activation, RNA splicing, nuclear trafficking, and regula- .. tion of the miRNA function.29,70 Several lines of evidence indicate .. studies with large population sizes will be a key step to obtain con- .. that lncRNAs play an essential role in development, homeostasis, and .. vincing evidence for clinical applicability. Only few overlapping disease.18 lncRNAs exhibit cell type-specific expression, precise sub- .. ncRNAs on similar therapies have been described, possibly due to .. cellular localization, and dysregulated expression in pathological con- .. the great heterogeneity in the selection of patients and the evaluation ditions.71 Around 28 000 human lncRNAs have been annotated .. of numerous therapeutic responses. Another aspect to be consid- .. according to the GENCODE project.72 .. ered is the inadequate control for confounders. Circulating levels of Compared to miRNAs, the characterization of extracellular .. ncRNAs are affected by factors such as age, sex, cardiovascular risk .. lncRNAs is poor. The precise mechanism of lncRNA release into the .. factors, and pharmacological treatments. These should be considered .. in the interpretation of results. The effects of disease stage and sub- extracellular space and their role in intercellular communication is .. not yet understood. Despite this, lncRNAs have also been detected .. type on ncRNA expression are additional sources of variation that .. in stable form in extracellular fluids.32 .. should be similarly considered. The use of ncRNA clustering may Circulating lncRNAs, such as the long intergenic non-coding RNA .. provide higher accuracy than single ncRNAs. The inclusion of novel .. predicting cardiac remodelling (LIPCAR), are robust biomarkers of .. members of the non-coding transcriptome that exhibit a great poten- cardiovascular conditions.32,73 However, the literature pertaining to .. tial to be used as biomarkers, such as circular RNAs (circRNAs),76 is .. the role of circulating lncRNAs as biomarkers to tailor cardiovascular .. also required. Unfortunately, a remarkable proportion of published therapy is scarce. In contrast, oncological research supports the use .. studies have not compared patterns of circulating ncRNAs with Figure 4 Potential clinical application of the long non-coding RNA smooth muscle and endothelial cell-enriched migration/differentiation-associ- ated long non-coding RNA (SENCR) in patient stratification to pioglitazone therapy. 1650 D. de Gonzalo-Calvo et al. .. Conflict of interest: T.T. is founder of Cardior Pharmaceuticals GmbH established indicators (e.g. peptide biomarkers). Furthermore, most .. studies have evaluated the univariate association between ncRNAs .. and holds and licenced patents about the therapeutic and diagnostic use .. of ncRNAs. There is no conflict of interest for other authors. and treatment response. It is fundamental to explore whether the .. addition of specific ncRNAs, or a signature of diverse ncRNAs, to .. .. 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