Tar Choon Aw

The 2026 AHA/ACC/ESC/WHF Expert Consensus Document on the Second Universal Definition of Heart Failure marks an important recalibration of how heart failure is recognized, classified, and studied. The document retains the central insight of the 2021 First Universal Definition—that heart failure is a clinical syndrome supported by structural, functional, biomarker, or congestion evidence—but moves the field toward earlier detection, etiologic precision, and trajectory-based care. This is a comprehensive commentary on the latest updates from the Second Universal Definition of Heart Failure. Its most visible changes include reaffirmation of the stage A to D continuum, stronger emphasis on pre-heart failure, simplification of ejection-fraction phenotypes into clinically actionable groups, a universal classification of causes, and new language for improvement, remission, recovery, worsening heart failure, and decompensated heart failure. For laboratory medicine, the definition is especially relevant because of its emphasis on natriuretic peptides, cardiac troponins, urine albumin–creatinine ratio, and emerging artificial-intelligence electrocardiography. This commentary reviews the main changes in the second definition, highlights implications for heart failure with preserved ejection fraction, obesity, cardiometabolic disease, global implementation, and frameworks for integrated clinical and laboratory pathways.

The ADA 2026 Standards of Care in Diabetes introduces pivotal updates that refine diagnostic and therapeutic workflows. Expanding upon the 2025 guidelines, the 2026 edition broadens continuous-glucose-monitoring (CGM) eligibility to include all individuals on insulin or non-insulin therapies where CGM aids management. Significant new guidance addresses hyperglycemia management in oncology, identifying metformin as the preferred first-line intervention for drug-induced glycemic excursions. Additionally, type 1-diabetes (T1D) risk stratification is refined; a confirmed single IA-2 autoantibody now warrants monitoring levels similar to the Stage 2 disease. Furthermore, prerequisites for automated-insulin-delivery (AID) initiation have been removed to streamline technology access. For laboratory professionals, these revisions emphasize the critical role of advanced glycemic metrics and precise autoantibody profiling in complex clinical contexts.

Background: The 99th-percentile upper reference limit (99% URL) is essential for high-sensitivity cardiac troponin I (hs-cTnI) assays to diagnose acute coronary syndromes. We derived the gender-specific 99% URLs for the new Snibe hs-cTnI assay and verified its high-sensitivity performance. Methods: The Snibe hs-cTnI assay has a claimed limit of blank/detection/quantitation of 0.5/1.0/2.0 ng/L, a precision of 5.67% (@ 9.83 ng/L), 4.65% (@ 21.0 ng/L) and 3.77% (@ 174 ng/L), an analytical measuring range of 1.00–500,000 ng/L, and a claimed 99% URL of 20.1/11.8/17.5 ng/L (males/females/overall). Assay precision was evaluated using kit control materials. A total of 846 (M 444, F 402) anonymized leftover samples from healthy individuals were assessed for the derivation of 99% URLs. Results: The inter-assay CV was 6.2/4.4% (@ 10.1/20.6 ng/L). The 10/20% CV corresponded to a concentration of 5.2/3.0 ng/L. The assay recorded detectable hs-cTnI values in 64% of women and 70% of men. Hs-cTnI values were significantly lower in females than males (females vs. males median 2.6 vs. 3.2 ng/L, Mann–Whitney p = 0.005). The derived 99% URL for the population was 7.7 ng/L (90% CI 6.93–22.8 ng/L) for women and 13.7 ng/L (90% CI 10.6–41.4 ng/L) for men. When confined to subjects ≥40 years old only, males had a 99% URL of 14.8 ng/L (n = 412, 90% CI 10.6–41.4 ng/L) and 8.1 ng/L (n = 377, 90% CI 6.95–22.8 ng/L) for females, respectively. Conclusions: The Snibe hs-cTnI assay fulfills the requirements of a hs-cTn assay. Gender-specific 99% URLs are derived for this assay and they increased with age.

Background: We evaluated the Sysmex Highly Integrated Single-Cartridge Luminescence Immunoassay System (HISCL) hs-cTnT assay, and compared its performance to the Roche assay, with derivation of 99th-percentile upper reference limits (99% URLs) for healthy subjects. We assessed the effect of increasing age/decreasing eGFR on the HISCL hs-cTnT. Methods: We verified assay limits of blank/detection, precision and the functional sensitivity. Samples were analyzed on both the Sysmex HISCL and Roche Elecsys analyzers for method comparison. Results: The HISCL assay limit of blank/detection was 1.3/1.9 ng/L, and concentrations corresponding to 20/10% CVs were 1.8/3.3 ng/L. Assay precision of kit controls at 3253 ng/L was 2.2% and at 106 ng/L was 2.5%. Linear regression analysis (n = 2151) showed good agreement (r = 0.95) with the Roche hs-cTnT. Bland–Altman (Roche/HISCL) analysis for samples with hs-cTnT ≤ 52 ng/L showed a mean absolute difference of 3.5 ng/L; for hs-cTnT > 52 ng/L, the mean difference was 2.8%. In a cardio-renal healthy population (n = 1004), the 99% URLs were 14.4/17.0/13.9 ng/L for overall/male/female, respectively; assay CV% was below 10% at these levels. More than 50% of the hs-cTnT in the healthy male and female subjects were measurable above the limit of detection. Hs-cTnT increased with increasing age and decreasing eGFR. Conclusions: In conclusion, the Sysmex HISCL hs-cTnT fulfils the criteria for a high-sensitivity assay, with specific 99th URLs for males and females. Expectedly, the baseline Sysmex hs-cTnT increases with age and decreasing eGFR.

Introduction: Elevated troponin, while essential for diagnosing myocardial infarction, can also be present in non-myocardial infarction conditions. The myocardial-ischaemic-injury-index (MI3) algorithm is a machine learning algorithm that considers age, sex and cardiac troponin I (TnI) results to risk-stratify patients for type 1 myocardial infarction. Method: Patients aged ≥25 years who presented to the emergency department (ED) of Singapore General Hospital with symptoms suggestive of acute coronary syndrome with no diagnostic 12-lead electrocardiogram (ECG) changes were included. Participants had serial ECGs and high-sensitivity troponin assays performed at 0, 2 and 7 hours. The primary outcome was the adjudicated diagnosis of type 1 myocardial infarction at 30 days. We compared the performance of MI3 in predicting the primary outcome with the European Society of Cardiology (ESC) 0/2-hour algorithm as well as the 99th percentile upper reference limit (URL) for TnI. Results: There were 1351 patients included (66.7% male, mean age 56 years), 902 (66.8%) of whom had only 0-hour troponin results and 449 (33.2%) with serial (both 0 and 2-hour) troponin results available. MI3 ruled out type 1 myocardial infarction with a higher sensitivity (98.9, 95% confidence interval [CI] 93.4–99.9%) and similar negative predictive value (NPV) 99.8% (95% CI 98.6–100%) as compared to the ESC strategy. The 99th percentile cut-off strategy had the lowest sensitivity, specificity, positive predictive value and NPV. Conclusion: The MI3 algorithm was accurate in risk stratifying ED patients for myocardial infarction. The 99th percentile URL cut-off was the least accurate in ruling in and out myocardial infarction compared to the other strategies.

Diabetes mellitus is a major risk factor for both cardiovascular and chronic kidney disease (CKD) while CKD is also associated with cardiovascular morbidity. In fact, cardiovascular disease is the leading cause of death in patients with diabetes mainly from heart failure or myocardial infarction. The newer therapeutic agents in diabetes have positive impact on both cardiovascular and renal outcomes. Thus, the American Diabetes Association (ADA)’s annual update on the Standards of Medical Care in Diabetes is an important resource for all caregivers involved in diabetes management as it incorporates the latest scientific research, clinical evidence, and emerging technologies in diabetes management. The 2025 guidelines present significant updates that reflect a deeper understanding of diabetes management, emphasizing expanded usage of technologies such as continuous glucose monitoring, personalized pharmacological approaches, and lifestyle interventions. This commentary provides an analysis of the key updates in the 2025 ADA guidelines exploring implications for clinical practice, laboratory assessments, and public health policy. Where relevant, comparisons to the 2024 version will be made.

Although the Coronavirus disease 2019 (COVID-19) pandemic has ended, there are still many important lessons we can learn, as the pandemic profoundly affected every area of laboratory practice. During the pandemic, extensive changes to laboratory staffing had to be implemented, as many healthcare institutions required regular screening of all healthcare staff. Several studies examined the effectiveness of different screening regimens and concluded that repeated testing, even with lower sensitivity tests, could rival the performance of gold-standard RT-PCR testing in the detection of new cases. Many assay evaluations were performed both in the earlier and later periods of the pandemic. They included both nucleocapsid/spike antibodies and automated antigen assays. Early in the pandemic, it was generally agreed that the initial nucleocapsid antibody assays had poor sensitivity when used before 14 days of disease onset, with total or IgG antibodies being preferred over the use of IgM. Spike antibody assays gradually replaced nucleocapsid antibody assays, as most people were vaccinated. Spike antibodies tracked the rise in antibodies after vaccination with mRNA vaccines and became invaluable in the assessment of vaccine response. Studies demonstrated robust antibody secretion with each vaccine dose and could last for several months post-vaccination. When antigen testing was introduced, they became effective tools to identify affected patients when used serially or in an orthogonal fashion with RT-PCR testing. Despite the numerous findings during the pandemic period, research in COVID-19 has slowed. To this day it is difficult to identify a true neutralizing antibody test for the virus. An appropriate antibody level that would confer protective immunity against the plethora of new variants remains elusive. We hope that a summary of events during the pandemic could provide important insights to consider in planning for the next viral pandemic.

Diabetes markedly increases susceptibility to adverse cardiovascular events, including heart failure (HF), leading to heightened morbidity and mortality rates. Elevated levels of natriuretic peptides (NPs), notably B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), correlate with cardiac structural and functional abnormalities, aiding in risk stratification and treatment strategies in individuals with diabetes. This article reviews the intricate relationship between diabetes and HF, emphasizing the role of NPs in risk assessment and guiding therapeutic strategies, particularly in individuals with type 2 diabetes mellitus (T2DM). We also explore the analytical and clinical considerations in the use of natriuretic peptide testing and the challenges and prospects of natriuretic-peptide-guided therapy in managing cardiovascular risk in patients with diabetes. We conclude with some reflections on future prospects for NPs.

Diabetes markedly increases susceptibility to adverse cardiovascular events, including heart failure (HF), leading to heightened morbidity and mortality rates. Elevated levels of natriuretic peptides (NPs), notably B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), correlate with cardiac structural and functional abnormalities, aiding in risk stratification and treatment strategies in individuals with diabetes. This article reviews the intricate relationship between diabetes and HF, emphasizing the role of NPs in risk assessment and guiding therapeutic strategies, particularly in individuals with type 2 diabetes mellitus (T2DM). It also explores the challenges and prospects of natriuretic peptide-guided therapy in managing cardiovascular risk in patients with diabetes.