WO2019005963A1 - Use of activin for detecting postpartum cardiac dysfunction - Google Patents

Abstract

Aspects of the invention utilize Activin A as a biomarker for assessing, predicting, monitoring postpartum (post pregnancy) cardiac dysfunction.

Description

USE OF ACTIVIN FOR DETECTING POSTPARTUM CARDIAC

DYSFUNCTION

CROSS REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to U.S. Provisional Patent Application No. 62/525,472 filed June 27, 2017 and U.S. Provisional Patent Application No. 62/634,270 filed February 23, 2018. The entire contents of each of the above-referenced disclosures are specifically incorporated herein by reference.

BACKGROUND OF THE INVENTION

A. Field of the Invention [0002] This invention generally concerns the field of medicine. In particular, it generally concerns methods for prognosis, detection, and/or diagnosis of postpartum cardiac dysfunctions based on activin levels, e.g., activin A levels.

B. Description of Related Art

[0003] Pregnancy may be complicated in different ways. It is on one hand associated with pregnancy related mortality of the pregnant woman and, on the other hand, also associated with increased morbidity and mortality of the newborn. Maternal mortality at a rate of 14.5 per 100,000 live births, is more frequent in pregnant women above the age of 39 years and may be caused by hemorrhage, thrombotic pulmonary embolism, infections, cardiomyopathy, and cardiovascular and non-cardiovascular conditions as well as hypertensive disorders among which preeclampsia is the most frequent (Berg 2010, Obstetrics and Gynecology 116: 1302-09).

[0004] Hypertensive disorders occurring during pregnancy represent a major cause of maternal morbidity and mortality worldwide, and are also associated with increased perinatal mortality. Preeclampsia (PE) complicates approximately 2 to 8 percent of all pregnancies and is a major contributor to maternal and fetal mortality (Duley 2009, Semin Perinatol 33 : 130- 37). Preeclampsia usually occurs during pregnancy; however, it may also develop postpartum. Preeclampsia is generally defined as pregnancy associated or induced hypertension and is characterized by hypertension and proteinuria. In addition to preeclampsia, there are further preecl amp si a-r elated adverse outcomes which may develop after childbirth. All conditions are associated with adverse outcomes for the mother postpartum. Severe complications of PE include (1) HELLP syndrome characterized by hemolysis, elevated liver enzymes and low platelets, and (2) eclampsia characterized by the development of seizures. Whereas both these conditions are rare, they are associated with poor prognosis.

[0005] In many diseases and conditions, such as postpartum cardiac dysfunction, a favourable outcome of prophylactic and/or therapeutic treatments is strongly correlated with early and/or accurate prediction, diagnosis, prognosis, and/or monitoring of a disease or condition. Therefore, there exists a need for additional and preferably improved methods for early and/or accurate prediction, diagnosis, prognosis and/or monitoring of diseases and conditions to guide the treatment choices.

SUMMARY OF THE INVENTION [0006] The discovery of the biomarker and the associated methods described herein provides a solution to the detection, diagnosis, and monitoring problems associated with hypertensive disorders of pregnancy (HDP). In particular, diagnostic levels of activin, e.g., activin A, can provide for prediction, treatment, or prophylaxis of postpartum cardiac dysfunction. By way of example, the inventors have discovered that activin and more specifically activin A is a biomarker for postpartum cardiac dysfunction, which results in the identification or prediction of postpartum cardiac dysfunction enhancing the ability to treat the postpartum mother sooner and more effectively. Without wishing to be bound by theory, it is believed that the use of activin as a biomarker antepartum, postpartum, or antepartum and postpartum results in an improved outcome for those postpartum mothers with a propensity or at risk for developing cardiac dysfunction.

[0007] Aspects of the invention utilize activin or more specifically activin A as a biomarker for assessing, predicting, or monitoring postpartum (post pregnancy) cardiac dysfunction. Women with hypertensive disorders of pregnancy (HDP) are associated with subclinical changes in cardiac function. These changes eventually lead to heart failure. There currently are no biomarkers for assessing or predicting postpartum cardiac dysfunction in these women. The inventors have shown antepartum correlations (during pregnancy) and postpartum correlations (post pregnancy) of activin levels with postpartum cardiac dysfunction.

[0008] Certain embodiments are directed to methods for identifying a propensity or risk for postpartum cardiac dysfunction in a female subject by determining antepartum, postpartum, or antepartum and postpartum activin levels. In certain aspects the methods include the steps of: (a) measuring the quantity or levels of activin in a biological sample from the subject; (b) identifying a subject as at risk for a postpartum cardiac dysfunction if the quantity of activin measured is higher than a reference value for activin in subject(s) not developing cardiac dysfunction or a predetermined activin threshold or reference level(s); and (c) treating the subject for postpartum cardiac dysfunction if the subject is identified as at risk for postpartum cardiac dysfunction. In certain aspects postpartum activin levels are determine for a subject that has given birth in the previous 3, 6, 9, to 12 months (postpartum subject) In certain embodiments antepartum biological samples (antepartum subject) can be obtained 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more times during gestation or after delivery. Samples can be obtained at 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 or 41 weeks of gestation, including all days/weeks and ranges there between, and antepartum activin levels determined and/or assessed. Samples can be obtained at 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, or more weeks after delivery, including all days/weeks and ranges there between, and postpartum activin levels determined and/or assessed. In a particular aspect both antepartum and postpartum activin levels are determined. The biological sample can be a blood sample or a blood fraction such as a plasma or a serum sample. Preferably, the sample is a venous blood, venous serum, or venous plasma sample from the female subject. In certain aspects the subject is identified as at risk for a postpartum cardiac dysfunction if activin levels are greater than 1, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50 ng/mL or higher; or alternatively, statistically higher than activin levels that in subjects not having postpartum cardiac dysfunction. In certain aspects, for example, statistical analyses are conducted using SAS 9.4 (SAS Institute, Cary, NC), or similar methods. Two-tailed p-values of < 0.05 were considered statistically significant in certain instances. In a particular aspect the subject is identified as at risk for postpartum cardiac dysfunction if activin levels are statistically different from subjects not having postpartum cardiac dysfunction or activin levels greater than 3.25 ng/mL or higher. In certain aspects the subject has been previously diagnosed with a HDP during the most recent pregnancy or a previous pregnancy.

[0009] Additionally or alternatively cardiac function can be assessed using one or more of the following: (i) a systolic blood pressure and a diastolic blood pressure; (ii) an ejection fraction; (iii) a stroke volume, wherein a product of the stroke volume and a heart rate determines cardiac output; (iv) a vascular resistance; (v) a global longitudinal strain; (vi) a fluid status of a person; (vii) pulmonary artery systolic pressure along with pulmonary artery diastolic pressure; and (viii) systolic dysfunction and diastolic dysfunction. The methods described herein can further include or take into consideration assessing global longitudinal strain (GLS)(abnormal LGS being <-18%), blood pressure (BP)(abnormal BP being a systolic BP≥ 140 mmHg and/or a diastolic BP≥ 90 mmHg), or GLS and BP.

[0010] In some embodiments activin is measured by an immunoassay. Activin can be measured by a competitive binding assay, a sandwich assay, and/or an immunoprecipitation assay. In particular aspects activin is measured by enzyme-linked immunosorbent assay (ELISA).

[0011] In certain aspects the cardiac dysfunction is cardiac hypertrophy, cardiac remodeling, septic cardiomyopathy, peripartum cardiomyopathy, or heart failure. The treatment of the subject for postpartum cardiac dysfunction can include administering a therapeutically effective amount of non-steroidal anti-inflammatory agents (NSAIDs) such as aspirin or functionally similar agents, an activin A antagonist (e.g., a neutralizing antibody), a calcium channel blocker, a statin, a cholesterol absorption inhibitor, a low molecular weight heparin, an antiarrhythmic agent, an alpha adrenergic agonist, a beta adrenergic blocking agent, an aldosterone antagonist, an angiotensin-converting-enzyme ("ACE") inhibitor, an ACE/NEP inhibitor, an angiotensin II receptor blocker ("ARB"), endothelin antagonists, a neutral endopeptidase inhibitor, a phosphodiesterase inhibitor, a fibrinolytic, a GP Ilb/IIIa antagonist, a direct thrombin inhibitor, an indirect thrombin inhibitor, a lipoprotein-associated phospholipase A2 ("LpPLA2") modulator, a direct factor Xa inhibitor, an indirect factor Xa inhibitor, an indirect factor Xa/IIa inhibitor, a diuretic, a nitrate, a thromboxane antagonist, a platelet aggregations inhibitor, a cyclooxygenase inhibitor, a B-type natriuretic peptide, a NV1FGF modulator, a HT1B/5-HT2A antagonist, a guanylate cyclase activator, an e-NOS transcription enhancer, an anti-atherogenic, a renin inhibitor, an inhibitor of adenosine diphosphate ("ADP")-induced platelet aggregation, a HE-1 inhibitors, or combinations thereof. Non-limiting examples of NSAIDs include, but are not limited to, aspirin, ibuprofen, salicylates, acetominophen, cuelecoxib (CELEBREX™), diclofenac (VOLTAREN™), etodolac (LODINE™), fenoprofen (NALFON™), indomethacin (INDOCIN™), ketoralac (TORADOL™), oxaprozin (DAYPRO™), nabumentone (RELAFEN™), sulindac (CLINORIL™), tolmentin (TOLECTIN™), rofecoxib (VIOXX™), naproxen (ALEVE™, NAPROSYN™), ketoprofen (ACTRON™) and nabumetone (RELAFEN™). Such NSAIDs function by inhibiting a cyclooxygenase enzyme (e.g., COX-1 and/or COX-2).

[0012] In some embodiments the subject can be at least, at most, or about 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 or more years old. The subject can present with other indicators for a propensity for a HDP. In certain aspects the subject is obese, has a history of cardiac disorders, is a smoker, is an alcoholic, is malnourished, is of African-American descent, and/or has had multiple pregnancies.

[0013] Some embodiments are directed to methods for diagnosing cardiac dysfunction in a subject that has given birth in the previous 3, 6, 9, or 12 months and has been diagnosed with a hypertensive disorder of pregnancy (HDP). The method includes the steps of: (a) measuring the quantity of activin in a biological sample from the subject that has previously been diagnosed with a hypertensive disorder of pregnancy (HDP); and (b) diagnosing, categorizing, or characterizing the subject with a postpartum cardiac dysfunction if the quantity of activin measured is higher than a reference value for activin. In certain aspects the subject is diagnosed as having postpartum cardiac dysfunction if activin levels are greater than 1, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50 ng/mL or higher. In a particular aspect the subject is identified as having a postpartum cardiac dysfunction if activin levels are greater than 3.25 ng/mL or higher. In certain aspects the methods further include treating the subject for cardiac dysfunction.

[0014] In certain aspects the activin detected or measured in the various embodiments is activin A. Certain aspects specifically exclude detecting or measuring one or more of pentraxin-3, P-selectin, endoglin, endothelial nitric oxide synthase, placental growth factor, placental protein- 13, inhibin-A, PGI2, TGF-βΙ, TGF-p3, BMP2, BMP7, and/or sFlt-1

[0015] Other embodiments are directed to methods for monitoring a subject that has been diagnosed with a hypertensive disorder of pregnancy (HDP). In certain aspects the subject has given birth in the previous 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 days, weeks, or months. Monitoring can include the step of periodically measuring the quantity of activin A in a biological sample from the subject. The monitoring method can include treating the subject for postpartum cardiac dysfunction if the quantity of activin A measured is higher than a reference value for activin A. In certain aspects the reference value for activin A levels can be 1, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50 ng/mL or higher. In a particular aspect, the subject is treated for cardiac dysfunction if activin A levels are greater than 3.25 ng/mL or higher. The activin A levels can be measured on an hourly, daily, weekly, or monthly basis.

[0016] The term "subject" for purposes of treatment refers to any female animal classified as a mammal, e.g., human and non-human mammals. Examples of non-human animals include dogs, cats, cattle, horses, sheep, pigs, goats, rabbits, and other socially or economically important animals. Except when noted, the terms "patient" or "subject" are used herein interchangeably. Preferably, the subject is a human female. [0017] Other embodiments of the invention are discussed throughout this application. Any embodiment discussed with respect to one aspect of the invention applies to other aspects of the invention as well and vice versa. Each embodiment described herein is understood to be embodiments of the invention that are applicable to all aspects of the invention. It is contemplated that any embodiment discussed herein can be implemented with respect to any method or composition of the invention, and vice versa.

[0018] The use of the word "a" or "an" when used in conjunction with the term "comprising" in the claims and/or the specification may mean "one," but it is also consistent with the meaning of "one or more," "at least one," and "one or more than one." [0019] The term "effective," as that term is used in the specification and/or claims, means adequate to accomplish a desired, expected, or intended result.

[0020] The use of the term "or" in the claims is used to mean "and/or" unless explicitly indicated to refer to alternatives only or the alternatives are mutually exclusive, although the disclosure supports a definition that refers to only alternatives and "and/or." [0021] As used in this specification and claim(s), the words "comprising" (and any form of comprising, such as "comprise" and "comprises"), "having" (and any form of having, such as "have" and "has"), "including" (and any form of including, such as "includes" and "include") or "containing" (and any form of containing, such as "contains" and "contain") are inclusive or open-ended and do not exclude additional, unrecited elements or method steps. [0022] Other obj ects, features and advantages of the present invention will become apparent from the following detailed description. It should be understood, however, that the detailed description and the specific examples, while indicating specific embodiments of the invention, are given by way of illustration only, since various changes and modifications within the spirit and scope of the invention will become apparent to those skilled in the art from this detailed description.

[0023] Any embodiment disclosed herein can be implemented or combined with any other embodiment disclosed herein, including aspects of embodiments for compounds can be combined and/or substituted and any and all compounds can be implemented in the context of any method described herein. Similarly, aspects of any method embodiment can be combined and/or substituted with any other method embodiment disclosed herein. Moreover, any method disclosed herein may be recited in the form of "use of a composition" for achieving the method. It is specifically contemplated that any limitation discussed with respect to one embodiment of the invention may apply to any other embodiment of the invention. Furthermore, any composition of the invention may be used in any method of the invention, and any method of the invention may be used to produce or to utilize any composition of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS [0024] The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present invention. The invention may be better understood by reference to one or more of these drawings in combination with the detailed description of the specification embodiments presented herein.

[0025] FIG. 1. Higher levels of antepartum activin predict early postpartum cardiac dysfunction, which can identify high risk women for increased surveillance.

[0026] FIG. 2A-B. Antepartum activin predicts postpartum cardiac dysfunction.

[0027] FIG. 3. Receiver-operating characteristic curves for patients stratified by models with clinical characteristics only (C=0.76), abnormal antepartum activin A only (C=0.74), and the addition of both clinical and biomarker characteristics (C=0.93). Clinical characteristics included maternal race, mean arterial blood pressure, and gestational age at the time of the blood sample.

DETAILED DESCRIPTION OF THE INVENTION

[0028] Hypertensive disorders of pregnancy (HDP) include a heterogeneous collection of diseases and conditions associated with hypertension during pregnancy and/or postpartum (e.g., up to 9 months postpartum). HDP may be conveniently classified as (A) Hypertension Induced by Pregnancy, which can be sub-classified as (i) without proteinuria or (generalized) edema, (ii) with proteinuria or (generalized) edema (i.e., preeclampsia), and (iii) eclampsia. (B) Coincidental Hypertension (chronic hypertension). (C) Hypertension Worsened by Pregnancy (Pregnancy Aggravated Hypertension), including (i) superimposed preeclampsia, and (ii) superimposed eclampsia.

[0029] Recent studies identify preeclampsia (PE) groups based on gestation time, preferably: (a) early onset (i.e., clinical manifestation < 34 weeks of gestation); (b) preterm (i.e., clinical manifestation > 34 and < 37 weeks of gestation); (c) term (i.e., clinical manifestation 37 weeks of gestation). HPD may otherwise be categorized as pre-existing or gestational, optionally adding "with preeclampsia" to either category if maternal or fetal symptoms, signs or test results necessitate this addition. [0030] Non-proteinuric hypertension of pregnancy may be conveniently defined as blood pressure of systolic BP≥ 140 mmHg and/or a diastolic BP≥ 90 mmHg measured on two separate occasions over 4 hours apart, e.g., about 4 hours to about 168 hours apart. When the hypertension was measured before pregnancy or is measured before 20 weeks of gestation, one may commonly denote such as chronic hypertension. When the hypertension is measured in a previously normotensive woman after 20 weeks of gestation, one may denote such as pregnancy-induced hypertension. Typically, pregnancy-induced hypertension will resolve within 12 weeks postpartum. When blood pressure of at least 140/90 mmHg is measured but does not persist for more than 6 hours, one may denote such as transient hypertension. [0031] Proteinuric hypertension of pregnancy may be as defined in the previous paragraph, further accompanied by≥ 300 mg of total protein in a 24-urine collection.

[0032] HDP also encompasses diseases and conditions commonly denoted in the art as gestational hypertension, mild preeclampsia, pregnancy-induced hypertension, specific hypertension of pregnancy, toxemia of pregnancy, etc. [0033] Aspects of the invention utilize activin A as a biomarker for assessing, predicting, or monitoring postpartum (post pregnancy) cardiac dysfunction. Women with hypertensive disorders of pregnancy (HDP) are associated with subclinical changes in cardiac function. These changes eventually lead to heart failure. There currently are no biomarkers for assessing or predicting postpartum cardiac dysfunction in these women. The inventors have previously shown antepartum correlations (during pregnancy), but there are no postpartum correlations (post pregnancy).

[0034] In further aspects, women with hypertensive disorders of pregnancy (HDP) have an increased risk of subsequent heart failure and cardiovascular disease when compared to women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of activin A, is associated with myocardial dysfunction and can be a relevant biomarker. In certain embodiments elevated levels of antepartum Activin A levels can be correlated with postpartum cardiac dysfunction in women with HDP.

A. Activin Detection and Measurement

[0035] Activins interact with two structurally related classes of serine/threonine kinase receptors (type I and type II). Inhibin antagonizes activin by binding to the proteoglycan, betaglycan, and forming a stable complex with and thereby sequestering type II activin receptors while excluding type I receptors. Two major forms of activin exist: activin A is a homodimer of beta A-subunits and activin B is a homodimer of beta B-subunits. (Vale, et al., Recent Prog Horm Res V. 44: 1-34, 1988). Heterodimers of an a-subunit that is dissimilar to either β-subunit results in the functional antagonist inhibin.

[0036] Certain aspects are directed to activin recognized by antibodies that bind full-length activin, and/or regions of activin. A beta A subunit can have an amino acid sequence of MPLLWLRGFLLASCWIIVRSSPTPGSEGHSAAPDCPSCALAALPKDVPNSQPEMVEA VKKHIL MLHLKKRPDVTQPVPKAALLNAIRKLHVGKVGENGYVEIEDDIGRRAEM ELMEQTSEIITFAESGTARKTLHFEISKEGSDLSVVERAEVWLFLKVPKA RTRTKV TIRLFQQQKHPQGSLDTGEEAEEVGLKGERSELLLSEKVVDARKSTWHVFPVSSSIQR LLDQGKS SLD VRIACEQCQESGASL VLLGKKKKKEEEGEGKKKGGGEGGAGADEEK EQSHRPFLMLQARQSEDHPHRRRRRGLECDGKVNICCKKQFFVSFKDIGW DWIIAP SGYHANYCEGECPSHIAGTSGSSLSFHSTVINHYRMRGHSPFA LKSCCVPTKLRPMS ML YYDDGQNIIKKDIQ MIVEECGC S (SEQ ID NO: l) or a variant thereof. A beta B subunit can have an amino acid sequence of MDGLPGRALGAACLLLLAAGWLGPEAWGSPTPPPTPAAPPPPPPPGSPGGSQDTCTS CGGFRRPEELGRVDGDFLEAVKRHILSRLQMRGRPNITHAVPKAAMVTALRKLHAG KVREDGRVEIPHLDGHASPGADGQERVSEIISFAETDGLASSRVRLYFFIS EGNQ LF VVQASLWLYLKLLPYVLEKGSRRKVRVKVYFQEQGHGDRW MVEKRVDLKRSGW HTFPLTEAIQALFERGERRL LDVQCDSCQELAVVPVFVDPGEESHRPFVVVQARLG DSRHRIRKRGLECDGRT LCCRQQFFIDFRLIGW DWIIAPTGYYGNYCEGSCPAYL AGVPGSASSFHTAVVNQYRMRGL PGTVNSCCIPTKLSTMSMLYFDDEYNIVKRDV PNMIVEECGCA (SEQ ID NO:2) and variants thereof. Variants have at least the same essential biological and immunological properties as the activin polypeptides. A variant can have an amino acid sequence which differs due to at least one amino acid substitution, deletion and/or addition wherein the amino acid sequence of the variant is still, preferably, at least 70%, 80%, 85%, 90%, 92%, 95%, 97%, 98%, or 99% identical with the amino sequence of SEQ ID NO: l or SEQ ID NO:2. Activin binding agents include antibodies that specifically bind to activin or portions of activin.

[0037] In some embodiments, the level of the at least one biomarker is measured by contacting the sample with a detection agent that specifically binds to the respective marker, thereby forming a complex between the agent and said marker, detecting the level of complex formed, and thereby measuring the level of said marker. The term "measuring" the level of a marker as referred to herein refers to the quantification of the biomarker, e.g., to determining the level of the biomarker in the sample, employing appropriate methods of detection described herein.

[0038] Activin can be detected using methods generally known in the art. Methods of detection generally encompass methods to quantify the level of activin in the sample (quantitative method). It is generally known to the skilled artisan which of the following methods are suitable for qualitative and/or for quantitative detection of a biomarker. Samples can be conveniently assayed for, e.g., proteins using Westerns and immunoassays, like ELISAs, RIAs, fluorescence-based immunoassays, which are commercially available. Further suitable methods to detect biomarker include measuring a physical or chemical property specific for the peptide or polypeptide such as its precise molecular mass or MR spectrum. Said methods comprise, e.g., biosensors, optical devices coupled to immunoassays, biochips, analytical devices such as mass-spectrometers, MR-analyzers, or chromatography devices. Further, methods include microplate ELISA-based methods, fully-automated or robotic immunoassays (available for example on Elecsys™ analyzers), CBA (an enzymatic Cobalt Binding Assay, available for example on Roche-Hitachi™ analyzers), and latex agglutination assays (available for example on Roche-Hitachi™ analyzers). For the detection of biomarker proteins as referred to herein a wide range of immunoassay techniques using such an assay format are available, see, e.g., U.S. Patents 4,016,043; 4,424,279; and 4,018,653 for example. These include both single-site and two-site or "sandwich" assays of the noncompetitive types, as well as in the traditional competitive binding assays. These assays also include direct binding of a labeled antibody to a target biomarker.

[0039] Biomarkers can also be detected by generally known methods including magnetic resonance spectroscopy (NMR spectroscopy), Gas chromatography-mass spectrometry (GC- MS), Liquid chromatography-mass spectrometry (LC-MS), High and ultra-HPLC HPLC such as reverse phase HPLC, for example, ion-pairing HPLC with dual UV-wavelength detection, capillary electrophoresis with laser-induced fluorescence detection, anion exchange chromatography and fluorescent detection, and/or thin layer chromatography.

[0040] Measuring the level of a peptide or polypeptide may include the steps of (a) contacting the peptide with a specific binding agent, (b) (optionally) removing non-bound binding agent, (c) measuring the level of bound binding agent, i.e., the complex of the binding agent formed in step (a). Also, the level of a peptide or polypeptide may be determined as follows: (a) contacting a solid support comprising a binding agent for the peptide or polypeptide with a sample comprising the peptide or polypeptide, and (b) measuring the level of peptide or polypeptide which is bound to the support. The binding agent is present on a solid support in immobilized form. The solid support can be commercially available column materials, polystyrene beads, latex beads, magnetic beads, colloid metal particles, glass and/or silicon chips and surfaces, nitrocellulose strips, membranes, sheets, duracytes, wells and walls of reaction trays, plastic tubes etc.

[0041] The term "binding agent" refers to a molecule that comprises a binding moiety which specifically binds the respective biomarker, e.g., activin and more specifically activin A. Examples of "binding agent" are an aptamer, antibody, antibody fragment, peptide, peptide nucleic acid (PNA) or chemical compound. [0042] The term "specific binding" or "specifically bind" refers to a binding reaction wherein binding pair molecules exhibit a binding to each other under conditions where they do not significantly bind to other molecules. The term "specific binding" or "specifically binds", when referring to a protein or peptide as biomarker, refers to a binding reaction wherein a binding agent binds to the corresponding biomarker with an affinity of at least 10^"7 M, 10^"8 M or 10^"9 M for its target molecule. The term "specific" or "specifically" is used to indicate that other molecules present in the sample do not significantly bind to the binding agent specific for the target molecule. Preferably, the level of binding to a molecule other than the target molecule results in a binding affinity which is only 10% or less, more preferably only 5% or less of the affinity to the target molecule. B. Cardiac Dysfunction and Treatments Thereof

[0043] The term "cardiac dysfunction" refers to a pathological decline in cardiac performance. Cardiac dysfunction may be manifested through one or more parameters or indicia including changes to stroke volume, ejection fraction, end diastolic fraction, stroke work, arterial elastance (defined as the ratio of left ventricular (LV) end-systolic pressure and stroke volume), or an increase in heart weight to body weight ratio. Unless otherwise noted, cardiac dysfunctions encompass any cardiac disorders or aberrant conditions that are associated with or induced by the various hypertension disorder of pregnancy or other cardiac injuries described herein. Specific examples of cardiac dysfunction include cardiac hypertrophy, cardiac remodeling, septic cardiomyopathy, peripartum cardiomyopathy, or heart failure. [0044] Cardiomyopathy is the deterioration of the function of the myocardium (i.e., the actual heart muscle) for any reason. People with cardiomyopathy are often at risk of arrhythmia and/or sudden cardiac death. Cardiomyopathies can generally be categorized into extrinsic cardiomyopathies and intrinsic cardiomyopathies. Extrinsic cardiomyopathies are cardiac disorders where the primary pathology is outside the myocardium itself. Most cardiomyopathies are extrinsic as the underlying myocardial injury is due to extrinsic factors such as ischemia. Examples of extrinsic cardiomyopathies include ischemic cardiomyopathy and cardiomyopathy due to systemic diseases. Ischemic cardiomyopathy is a weakness in the muscle of the heart due to inadequate oxygen delivery to the myocardium with coronary artery disease being the most common cause. Intrinsic cardiomyopathies are cardiac disorders where weakness in the muscle of the heart is not due to an identifiable external cause. Intrinsic cardiomyopathies include dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM or HOCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and restrictive cardiomyopathy (RCM). Unless otherwise noted, the term cardiomyopathy encompasses postpartum cardiomyopathy.

[0045] The term "cardiac remodeling" generally refers to the compensatory or pathological response following myocardial injury. Cardiac remodeling is viewed as a key determinant of the clinical outcome in heart disorders. It is characterized by a structural rearrangement of the cardiac chamber wall that involves cardiomyocyte hypertrophy, fibroblast proliferation, and increased deposition of extracellular matrix (ECM) proteins.

[0046] Cardiac fibrosis refers to an abnormal thickening of the heart valves due to inappropriate proliferation of cardiac fibroblasts. Cardiac fibrosis is a major aspect of the pathology typically seen in the failing heart. The proliferation of interstitial fibroblasts and increased deposition of extracellular matrix components results in myocardial stiffness and diastolic dysfunction, which ultimately leads to heart failure.

[0047] Organ hypertrophy is the increase of the size of an organ or in a select area of the tissue (e.g. , heart or skeletal muscles). It should be distinguished from hyperplasia which occurs due to cell division increasing the number of cells while their size stays the same; hypertrophy occurs due to an increase in the size of cells, while the number of cells stays the same. Heart hypertrophy is the increase in size of the ventricle chambers of the heart. Changes can be beneficial or healthy if they occur in response to aerobic or anaerobic exercise, but ventricular hypertrophy is generally associated with pathological changes due to high blood pressure or other disease states. Although ventricular hypertrophy may occur in either the left or right or both ventricles of the heart, left ventricular hypertrophy (LVH) is more commonly encountered. [0048] Accordingly, one aspect of the present invention is a method for treating or preventing a cardiac dysfunction or its associated cardiomyopathies in a subject. The term "treating" or "alleviating" includes the administration of compounds or agents to a subject to prevent or delay the onset of the symptoms, complications, or biochemical indicia of a disease (e.g., a cardiac dysfunction), alleviating the symptoms or arresting or inhibiting further development of the disease, condition, or disorder. Subjects in need of treatment include patients already suffering from the disease or disorder as well as those prone to have the disorder or those in whom the disorder is to be prevented. As used herein, the terms "treating," "alleviating," or similar terminology do not imply a cure for heart failure, cardiomyopathy, cardiac hypertrophy or any other disease or condition, rather, this terminology is used to refer to any clinically detectable improvement in the disease or condition being treated or alleviated, including, but not limited to, improvement in stroke volume, ejection fraction, end diastolic fraction, stroke work, or arterial elastance, a decrease in heart weight to body weight ratio, improvement in subjective well-being experienced by the patient, or any other clinically detectable improvement, such as, but not limited to, reduction in fatigue, increase in physical strength, or other detectable variable. As used herein, the term "therapeutically effective amount" refers to the amount of a therapy (e.g., a prophylactic or therapeutic agent) which is sufficient to reduce or ameliorate the severity and/or duration of a cardiac dysfunction or condition or one or more symptoms thereof, prevent the advancement of a disease or condition, cause regression of a disease or condition, prevent the recurrence, development, or onset of one or more symptoms associated with a disease or condition, or enhance or improve the prophylactic or therapeutic effect(s) of another therapy (e.g., prophylactic or therapeutic agent).

[0049] Treatment may be prophylactic (to prevent or delay the onset of the disease, or to prevent the manifestation of clinical or subclinical symptoms thereof) or therapeutic suppression or alleviation of symptoms after the manifestation of the disease. In the treatment of cardiac remodeling and/or heart failure, a therapeutic agent may directly decrease the pathology of the disease, or render the disease more susceptible to treatment by other therapeutic agents.

[0050] The term "agent" includes any substance, molecule, element, compound, entity, or a combination thereof. It includes, but is not limited to, e.g. , protein, polypeptide, small organic molecule, polysaccharide, polynucleotide, and the like. It can be a natural product, a synthetic compound, or a chemical compound, or a combination of two or more substances. Unless otherwise specified, the terms "agent", "substance", and "compound" are used interchangeably herein.

[0051] Treating can include administering a therapeutically effective amount of activin A antagonist, calcium channel blockers, statins, cholesterol absorption inhibitors, low molecular weight heparins, antiarrhythmic agents, alpha adrenergic agonists, beta adrenergic blocking agents, aldosterone antagonists, angiotensin-converting-enzyme ("ACE") inhibitors, ACE/NEP inhibitors, angiotensin II receptor blockers ("ARBs"), endothelin antagonists, neutral endopeptidase inhibitors, phosphodiesterase inhibitors, fibrinolytics, GP Ilb/IIIa antagonists, direct thrombin inhibitors, indirect thrombin inhibitors, lipoprotein-associated phospholipase A2 ("LpPLA₂") modulators, direct factor X_a inhibitors, indirect factor X_a inhibitors, indirect factor X Qa inhibitors, diuretics, nitrates, thromboxane antagonists, platelet aggregations inhibitors, cyclooxygenase inhibitors, B-type natriuretic peptides, NV1FGF modulators, HT1B/5-HT2A antagonists, guanylate cyclase activators, e-NOS transcription enhancers, anti-atherogenics, CPU inhibitors, renin inhibitors, inhibitors of adenosine diphosphate ("ADP")-induced platelet aggregation, and HE-1 inhibitors. Calcium channel blockers can include, but are not limited to, amlodipine besilate, felodipine, diltiazem, nifedipine, nicardipine, nisoldipine, bepridil, and verapamil. Statins can include, but are not limited to, atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, and simvastatin. Cholesterol absorption inhibitors can include, but are not limited to, ezetimibe and AZD4121. Cholesteryl ester transfer protein ("CETP") inhibitors, can include, but are not limited to, torcetrapib. Low molecular weight heparins can include, but are not limited to, dalteparin sodium, ardeparin, certoparin, enoxaparin, parnaparin, tinzaparin, reviparin, nadroparin, warfarin, ximelagatran, and fondaparin. Antiarrythmic agents can include, but are not limited to, dofetilide and ibutilide fumarate, metoprolol, metoprolol tartrate, propranolol, atenolol, ajmaline, disopyramide, prajmaline, procainamide, quinidine, sparteine, aprindine, lidocaine, mexiletine, tocamide, encamide, flecamide, lorcamide, moricizine, propafenone, acebutolol, pindolol, amiodarone, bretylium tosylate, bunaftine, dofetilide, sotalol, adenosine, atropine and digoxin. Alpha-adrenergic agonists can include, but are not limited, to doxazosin mesylate, terazoson, and prazosin. Beta-adrenergic blocking agents can include, but are not limited to, carvedilol, propranolol, timolol, nadolol, atenolol, metoprolol, bisoprolol, nebivolol, betaxolol, acebutolol, and bisoprolol. Aldosterone antagonists can include, but are not limited to, eplerenone, and spironolactone. Angiotensin-converting enzyme ("ACE") inhibitors can include, but are not limited to, moexipril, quinapril hydrochloride, ramipril, lisinopril, benazepril hydrochloride, enalapril, captopril, spirapril, perindopril, fosinopril, and trandolapril. ACE/NEP inhibitors can include, but are not limited to, ramipril. Angiotensin II receptor blockers ("ARBs") can include, but are not limited to, olmesartan medoxomil, candesartan, valsartan, telmisartan, irbesartan, losartan, and eprosartan. Endothelin antagonists can include, but are not limited to, tezosentan, bosentan, and sitaxsentan sodium. Neutral endopeptidase inhibitors can include, but are not limited to, candoxatril and ecadotril. Phosphodiesterase inhibitors can include, but are not limited to, milrinoone, theophylline, vinpocetine, EHNA (erythro-9-(2-hydroxy-3-nonyl)adenine), sildenafil citrate, and tadalafil. Fibrinolytics can include, but are not limited to, reteplase, alteplase, and tenecteplase. GP Ilb/IIIa antagonists can include, but are not limited to, integrillin, abciximab, and tirofiban. Direct thrombin inhibitors can include, but are not limited to, ximelagatran and AZD0837. Indirect thrombin inhibitors can include, but are not limited to, odeparcil. Direct Factor Xjnhibitors can include, but are not limited to, fondaparinux sodium, apixaban, razaxaban, rivaroxaban (BAY 59-7939), KFA-1982, DX-9065a, AVE3247, otamixaban (XRP0673), AVE6324 and SAR377142. Indirect Factor X_a inhibitors can include, but are not limited to, idraparinux (long-acting pentasaccharide), fondaparinux sodium (pentasaccharide), and SSR126517. Indirect X_a/II_a inhibitors can include, but are not limited to, enoxaparin sodium, (short-acting hexadecasaccharide), AVE5026, SSR128428 (long-acting hexadecasaccharide), and SSR128429. Diuretics can include, but are not limited to, chlorthalidone, ethacrynic acid, furosemide, amiloride, chlorothiazide, hydrochlorothiazide, methylchtothiazide, and benzthiazide. Nitrates can include, but are not limited to, isosorbide-5-mononitrate. Thromboxane antagonists can include, but are not limited to, seratrodast, picotamide and ramatroban. Platelet aggregation inhibitors can include, but are not limited to, cilostazol, abciximab, limaprost, eptifibatide, and CT-50547. Cyclooxygenase inhibitors can include, but are not limited to, meloxicam, rofecoxib and celecoxib. B-type natriuretic peptides can include, but are not limited to, nesiritide and ularitide. NVl FGF modulators can include, but are not limited to, XRP0038. HT1B/5-HT2A antagonists, can include, but are not limited to, SL65.0472. Guanylate cyclase inhibitors can include, but are not limited to, ataciguat (HMR1766) and HMR1069. e-NOS transcription enhancers, can include, but are not limited to, AVE9488 and AVE3085. Anti-atherogenics can include, but are not limited to, AGI-1067. CPU inhibitors can include, but are not limited to, AZD9684. Renin inhibitors can include, but are not limited to, aliskirin and VNP489. Inhibitors of adenosine diphosphate ("ADP") induced platelet aggregation can include, but are not limited to, clopidogrel, ticlopidine, prasugrel, and AZD6140. HE-1 inhibitors can include, but are not limited to, AVE4454 and AVE4890. Other cardiovascular agents can also be used in methods according to the present invention.

C. Kits

[0052] In another aspect, the present invention provides kits for measuring activin A status, which kits are used to detect biomarkers described herein. In one embodiment, the kit comprises a solid support, such as a chip, a microtiter plate or a bead or resin having a capture reagent attached thereon, wherein the capture reagent binds an activin A biomarker. Thus, for example, the kits of the present invention can comprise mass spectrometry probes for SELDI, such as ProteinChip® arrays. In the case of bio-specific capture reagents, the kit can comprise a solid support with a reactive surface, and a container comprising the bio-specific capture reagent.

[0053] The kit can also comprise a washing solution or instructions for making a washing solution, in which the combination of the capture reagent and the washing solution allows capture of the biomarker or biomarkers on the solid support for subsequent detection by, e.g., mass spectrometry. The kit may include more than type of adsorbent, each present on a different solid support.

[0054] In a further embodiment, such a kit can comprise instructions for suitable operational parameters in the form of a label or separate insert. For example, the instructions may inform a consumer about how to collect the sample, how to wash the probe or the particular biomarkers to be detected.

[0055] In yet another embodiment, the kit can comprise one or more containers with biomarker samples, to be used as standard(s) for calibration.

D. Examples

[0056] The following examples as well as the figures are included to demonstrate preferred embodiments of the invention. It should be appreciated by those of skill in the art that the techniques disclosed in the examples or figures represent techniques discovered by the inventors to function well in the practice of the invention, and thus can be considered to constitute preferred modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments which are disclosed and still obtain a like or similar result without departing from the spirit and scope of the invention. EXAMPLE 1

1. Methods

[0057] Study Design and Oversight. A prospective case-control study was conducted at the University of Chicago Medical Center and Beth Israel Deaconess Medical Center (Boston, MA) in accordance with institutional policies and IRB approval. Written informed consent was obtained from all patients.

[0058] Human Subjects. 85 pregnant women who delivered at the University of Chicago or Beth Israel Deaconess Medical Center between July 2014 and November 2016 were enrolled. Inclusion criteria included women at least 18 years of age with a singleton gestation of less than 41 weeks. Exclusion criteria included preexisting cardiomyopathy, ischemic or valvular heart disease, pulmonary disease, diabetes mellitus or labor. Recruitment occurred on admission to labor and delivery, the antepartum floor, or during routine prenatal visits. Patients were classified into three separate groups for analysis using ACOG criteria (ACOG practice bulletin, Obstetrics and gynecology, 2002, 99(1): 159-67): no hypertensive disorder of pregnancy, chronic or gestational hypertension, and preeclampsia (PE). Preeclampsia was defined as blood pressure >140 mmHg systolic or >90 mmHg diastolic on two occasions at least four hours apart, and a urine protein (mg)/creatinine (mg) ratio > 0.3 or > 300 mg in 24 hours occurring after 20 weeks of gestation. In the absence of proteinuria, preeclampsia was defined as the presence of any end organ damage. Severe features were defined as severe hypertension (defined as systolic blood pressure > 160 mmHg or diastolic blood pressure > 105, measured twice) or hypertension with any of the following features: thrombocytopenia (<100,000 platelets/mL), renal insufficiency (serum creatinine concentrations >1.1 mg/dL, or a doubling of the serum creatinine concentration), impaired liver function (elevated serum liver transaminases, ALT or AST > 80 U/L), pulmonary edema, or cerebral or visual symptoms. A Maternal -Fetal Medicine specialist confirmed all clinical diagnoses. All clinical data were extracted from patient records.

[0059] Echocardiography. Transthoracic echocardiograms were performed at the time of enrollment and again twelve months after delivery by an experienced sonographer (LW) blinded to both the subjects' diagnosis and to the levels of Activin A. Echocardiographic measurements were performed as previously described (Shahul et al., Hypertension. 2016, 67(6): 1273-80) and included doppler and diastolic measurements (E/A ratio, mitral valve inflow deceleration time, and E'). Simpson' s biplane disc method was used to calculate ejection fraction (EF) and left atrial volume (LAV), and left ventricular mass index (LVMI) was calculated using the area-length method (Lang et al., J Am Soc Echocardiogr . 2015, 28(1): 1- 39.el4). Fully automated TomTec software (AutoStrain, TomTec Image-Arena 1.2, Unterschleissheim, Germany) was used for GLS measurement (Knackstedt et al., J Am Coll Cardiol. 2015;66(13): 1456-66). The researcher analyzing the echocardiographic data was blinded to patients' disease status. Global longitudinal strain (GLS) is prognostic of adverse cardiovascular outcomes in various patient populations. GLS can be assessed by 2-dimensional speckle tracking echocardiography and has emerged as a new method for assessing left ventricular (LV) function. GLS is altered despite preserved LV function as assessed by ejection fraction (LV ejection fraction [LVEF]) in conditions predisposing to cardiovascular disease, including increasing age, hypertension, diabetes mellitus, stable angina, renal dysfunction, and obesity. GLS, as an early marker of cardiac dysfunction and can identify people at risk of cardiovascular morbidity and mortality.

[0060] Measurement of Circulating Activin Levels. Venous blood samples were collected at the time of the enrollment echocardiogram and again twelve months after delivery. All samples were drawn at the same time or within 24 hours of performing the echocardiogram. Blood samples were centrifuged for eight minutes at -4 °C; the plasma was then aliquoted, labeled with a study ID, and stored at -70 °C. A single operator blinded to clinical information performed Activin A assays on each participants' plasma sample in duplicate using commercially available kits (Ansh Labs, Webster, TX). Because all assays were performed after delivery all treating physicians were unaware of the results.

[0061] Statistical Analysis. Data were assessed with the use of parametric or non-parametric t-tests, as appropriate and presented as means (± standard deviations) or median (quartile 1, quartile 3) depending on the data distribution. Normality was assessed with the use of the Shapiro-Wilk test. Categorical variables are reported as frequencies and proportions and assessed with a chi-square or Fisher's Exact test. An abnormal GLS was defined as < -18% based on previously published studies (Shahul et al., Hypertension. 2016, 67(6): 1273-80; Yang et al., JACC Cardiovasc Imaging. 2017, 10(3):217-26; Ajmi et al., Pregnancy hypertension, 2017). Antepartum Activin A levels were classified as abnormal if greater than the 99th percentile of the normal group values per American Heart Association guidelines on biomarker analyses (Vasan, Circulation. 2006, 113(19):2335-62). To assess the relationship between antepartum Activin A and postpartum GLS at twelve months, univariate and multivariable logistic regression models were constructed. GLS and Activin A levels were dichotomized as described above. Multivariable models were adjusted for clinically relevant confounders including maternal age, body mass index, gestational age at delivery and mean arterial pressure. To assess the predictive ability of antepartum Activin A levels, a receiver operating characteristic analysis was performed. Additional secondary analyses examined the correlation 5 between postpartum Activin A levels and mean arterial pressures (MAP), LVMI, and echocardiographic indices of diastolic function. Statistical analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC). Two-tailed p-values of < 0.05 were considered statistically significant.

Table 1. Participant characteristics by hypertensive status.

0 Values are presented as mean ± standard deviation or median (quartile 1, quartile 3) depending on distribution.

* Comparison of patients with non-proteinuric hypertension and normotensive normal patients

** Comparison of patients with preeclampsia and normotensive normal patients Table 2. Post-partum (1-year) cardiac systolic and diastolic function indices and cardiac morphology by hypertensive status.

Values are presented as mean ± standard deviation or median (quartile 1, quartile 3) depending on distribution. GLS=global longitudinal strain; LV=left ventricular; LA- Left atrial,DT-deceleration time

* Comparison of patients with non-proteinuric hypertension and normotensive normal patients

** Comparison of patients with preeclampsia and normotensive normal patients

Table 3. Unadjusted and adjusted models predicting abnormal GLS.

GLS: global longitudinal strain;

{Adjusted for maternal age , race,, mean arterial blood pressure, body mass index and preterm delivery status (gestational age <34 weeks) 2. Results

[0062] Demographics. A total of 85 participants were included in the analysis. Baseline characteristics are shown in Table 1. Thirty -two (38%) patients were diagnosed with PE, 28 (33%) were diagnosed with gestational or chronic hypertension and 25 (29%) did not have a hypertensive disorder of pregnancy. Preeclamptic women had higher body mass index values (p = 0.01) and mean arterial pressures (p<0.0001) than women without hypertensive disorders of pregnancy. Women with chronic or gestational hypertension also had higher body mass index values and mean arterial pressures than participants without HDP (both p<0.003).

[0063] Activm A Measurements. Women with PE had higher antepartum levels of Activin A (p = 0.003) than women without hypertensive disorders of pregnancy. Similar differences in Activin A levels were also greater in women with chronic or gestational hypertension and those without HDP (p=0.02; Table 1). Median post-partum Activin A levels did not differ among groups (all p>0.15)

[0064] Echocardiographic Measurements. Cardiac systolic and diastolic function indices for all three patient groups are compared in Table 2. At one-year postpartum, abnormal GLS (defined as GLS < -18%) was more common in women who had had preeclampsia (60%) than in women who have had chronic or gestational hypertension (44%) or women without HDP (20%)(P = 0.02). Postpartum left ventricular mass index (LVMI), septal wall thickness (SWT), and deceleration times (DT) were all higher in women who had had PE or gestational or chronic hypertension than in women without a hypertensive disorder of pregnancy (Table 2).

[0065] Correlation between Activin and Echocardiography Measurements and post-partum blood pressures. Antepartum Activin A levels correlated with worsening antepartum GLS (r = 0.70; p = 0.0001). Although postpartum Activin A levels were considerably lower than antepartum, they still correlated with increasing left ventricular mass index (p=0.02), increasing mean arterial pressures (p=0.02), and decreasing E' values (p = 0.01).

[0066] Association Between Antepartum Activin and Echocardiography Measurements. Across the entire study group, abnormal antepartum Activin A levels predicted the presence of postpartum cardiac dysfunction at one year (c-statistic 0.74, p = 0.004; Table 3). After multivariable adjustment for maternal age, race, mean arterial blood pressure, body mass index and preterm delivery status (gestational age < 34 weeks), this association persisted (c statistic 0.91, P<0.001). Based upon this model, the predicted probability of an abnormal post-partum GLS given an abnormal antepartum Activin A was 95.1%. [0067] In this prospective study of cardiac dysfunction in patients with hypertensive disorders of pregnancy and non-hypertensive controls, it was observed that subclinical cardiac dysfunction, as manifested by abnormal GLS, is present in women with HDP during pregnancy and persists 12 months after delivery. In addition, it was observed that abnormal levels of antepartum Activin A correlated with myocardial dysfunction during pregnancy and predicted cardiac dysfunction at one-year postpartum. These findings remained robust after adjustment for relevant confounders including mean arterial pressure and gestational age at delivery. It was further noted that postpartum levels of Activin A correlate with measures of cardiovascular disease including increasing mean arterial pressures, increasing LVMI, and worsening diastolic function.

[0068] There is an association between Activin A and persistent cardiac dysfunction at one- year postpartum. A correlation was identified between postpartum Activin A levels and worsening hypertension, a measure of ongoing cardiovascular dysfunction.

[0069] In certain aspects women at-risk for delayed complications of HDP may be identified pre-delivery via measurement of blood activin levels. It was found that both prehypertension and hypertension were more common in women who have had a preeclamptic delivery than in healthy participants at one-year postpartum. The higher proportion of persistent subclinical systolic and diastolic cardiac dysfunction that was observed among women with preeclampsia pre-delivery may reflect accelerated cardiovascular disease. Detecting such disease during pregnancy thus provides an opportunity for mitigating or even reversing the progression to clinically symptomatic clinical cardiovascular disease.

[0070] The biomarker Activin A correlates with cardiac dysfunction both pre-delivery and at one year postpartum in women with HDP. Activin A may be a useful tool for identifying patients at risk for post-partum development of cardiovascular disease. REFERENCES

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Claims

1. A method for identifying a propensity for postpartum cardiac dysfunction in a female subject comprising the steps of:

(a) measuring the quantity of Activin A in a biological sample from a subject antepartum and/or postpartum;

(b) identifying a subject as at risk for a postpartum cardiac dysfunction if the quantity of Activin A measured is higher than a reference value for Activin A in an antepartum and/or postpartum subject having no cardiac dysfunction or a predetermined Activin A threshold; and

(c) treating the subject for postpartum cardiac dysfunction if the subject is identified as at risk for postpartum cardiac dysfunction.

2. The method of claim 1, wherein the subject is identified as at risk for a postpartum cardiac dysfunction if Activin A levels are greater than 3 ng/mL.

3. The method of claim 1 or 2, wherein Activin A is measured by an immunoassay.

4. The method of any one of claims 1 to 3, wherein Activin A is measured by a competitive binding assay, sandwich assay, or an immunoprecipitation assay.

5. The method of claim 1, wherein Activin A is measured by enzyme-linked immunosorbent assay (ELISA).

6. The method of any one of claims 1 to 5 further comprising assessing global longitudinal strain (GLS), blood pressure (BP), or GLS and BP.

7. The method of any one of claims 1 to 6, wherein the cardiac dysfunction is cardiac hypertrophy, cardiac remodeling, septic cardiomyopathy, peripartum cardiomyopathy, or heart failure.

8. The method of any one of claims 1 to 7, wherein treatment of the subject for postpartum cardiac dysfunction comprises administering a therapeutically effective amount of aspirin or similar drug, an Activin A antagonist, a calcium channel blocker, a statin, a cholesterol absorption inhibitor, a low molecular weight heparin, an antiarrhythmic agent, an alpha adrenergic agonist, a beta adrenergic blocking agent, an aldosterone antagonist, an angiotensin- converting-enzyme ("ACE") inhibitor, an ACE/NEP inhibitor, an angiotensin II receptor blocker ("ARB"), endothelin antagonists, a neutral endopeptidase inhibitor, a phosphodiesterase inhibitor, a fibrinolytic, a GP Ilb/IIIa antagonist, a direct thrombin inhibitor, an indirect thrombin inhibitor, a lipoprotein-associated phospholipase A2 ("LpPLA2") modulator, a direct factor Xa inhibitor, an indirect factor Xa inhibitor, an indirect factor Xa/IIa inhibitor, a diuretic, a nitrate, a thromboxane antagonist, a platelet aggregations inhibitor, a cyclooxygenase inhibitor, a B-type natriuretic peptide, a NV1FGF modulator, a HT1B/5- HT2A antagonist, a guanylate cyclase activator, an e-NOS transcription enhancer, an antiatherogenic, a renin inhibitor, an inhibitor of adenosine diphosphate (" ADP")-induced platelet aggregation, a HE-1 inhibitors, or combinations thereof.

9. The method of any one of claims 1 to 8, wherein the subject has been previously diagnosed with a hypertensive disorder of pregnancy (HDP) during the current or a previous pregnancy.

10. The method of any one of claims 1 to 9, wherein the biological sample is a blood sample or a blood fraction.

11. The method of any one of claims 1 to 10, wherein the subject is at least 30 years old.

12. The method of any one of claims 1 to 11, wherein the subject is obese.

13. The method of any one of claims 1 to 12, wherein the subject has a history of cardiac disorders.

14. The method of any one of claims 1 to 13, wherein the subject is a smoker.

15. The method of any one of claims 1 to 14, wherein the subject is an alcoholic.

16. The method of any one of claims 1 to 15, wherein the subject is malnourished.

17. The method of any one of claims 1 to 16, wherein the subject is of African- American descent.

18. The method of any one of claims 1 to 17, wherein the subject has had multiple pregnancies.

19. A method for diagnosing cardiac dysfunction in a postpartum subject that has been diagnosed with a hypertensive disorder of pregnancy (HDP), comprising the steps of: (a) measuring the quantity of Activin A in one or more antepartum and/or postpartum biological sample from the subject that has previously been diagnosed with a hypertensive disorder of pregnancy (HDP); and

(b) diagnosing the subject with a postpartum cardiac dysfunction if the quantity of

Activin A measured is higher than a reference value for Activin A.

20. The method of claim 19, wherein the subject is diagnosed as having postpartum cardiac dysfunction if Activin A levels are greater than 3 ng/mL.

21. The method of claim 19 or 20, further comprising treating the subject for cardiac dysfunction.

22. A method for monitoring a subject that has given birth in the previous 6 months and has been diagnosed with a hypertensive disorder of pregnancy (HDP), comprising the steps of: a. periodically measuring the quantity of Activin A in a biological sample from the subject that has previously been diagnosed with a hypertensive disorder of pregnancy (HDP); and

b. treating the subject for postpartum cardiac dysfunction if the quantity of Activin A measured is higher than a reference value for Activin A.

23. The method of claim 22, wherein Activin A levels are measured on an hourly, daily, or weekly basis.