Igfbp7 for evaluating asymptomatic cerebral infarction and decline of cognitive function

Abstract

To provide a method for predicting an asymptomatic cerebral infarction and / or decline of a cognitive function, and a method for improving accuracy of predicting a clinical risk score of the asymptomatic cerebral infarction and / or decline of a cognitive function of a subject.SOLUTION: The present invention relates to a method for determining whether a subject has experienced an asymptomatic cerebral infarction at least once. The method includes the steps of: (a) determining an amount of IGFBP7 in a sample from a subject; (b) comparing the amount determined in step (a) with a reference; and (c) determining whether the subject has experienced an asymptomatic cerebral infarction at least once. The present invention further relates to a method for predicting an asymptomatic cerebral infarction and / or decline of a cognitive function and a method for evaluating and monitoring a degree of asymptomatic small and large, non-cortical and cortical infarctions in the subject. The present invention further includes a corresponding use.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] The present invention relates to a method for assessing whether a subject has experienced one or more silent infarctions, the method comprising the steps of: a) determining the amount of IGFBP7 in a sample from the subject; b) comparing the amount determined in step c) with a standard; and assessing whether the subject has experienced one or more silent infarctions.

[0002] Also encompassed are methods for predicting silent infarction and / or cognitive decline, and methods for improving the predictive accuracy of clinical risk scores for silent cerebral infarction and / or cognitive decline in a subject.

[0003] Combining the amount of IGFBP7 with the CHA2D2-VASc score improves the predictive accuracy of the clinical risk score for asymptomatic cerebral infarction and / or cognitive decline.Furthermore, the present invention relates to a method for assessing the extent of asymptomatic large non-cortical and cortical infarctions and / or white matter lesions in a subject. [Background technology]

[0004] background Stroke is second only to ischemic heart disease as a cause of disability-adjusted-life years lost in high-income countries and as a cause of death worldwide. Anticoagulation appears to be the treatment of choice to reduce the risk of stroke.

[0005] Atrial fibrillation (AF) is an important risk factor for stroke (Hart et al., Ann Intern Med 2007;146(12):857-67; Go AS et al. JAMA 2001;285(18):2370-5). AF is characterized by an irregular heartbeat that often begins with a brief period of abnormal beats, increases over time, and may become a permanent condition. An estimated 2.7 to 6.1 million people in the United States and approximately 33 million people globally have AF (Chugh SSet al., Circulation 2014;129:837-47). Because AF is an important risk factor for stroke and systemic embolism, early diagnosis of AF and risk of stroke is highly desirable (Hart et al., Ann Intern Med 2007;146(12):857-67; Go AS et al. JAMA 2001;285(18):2370-5).

[0006] Diagnosis of cardiac arrhythmias such as atrial fibrillation usually involves identifying the cause of the arrhythmia and classifying the arrhythmia. Guidelines for classifying atrial fibrillation by the American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) are primarily based on simplicity and clinical relevance. The first category is called "first detected AF." People in this category are first diagnosed with AF and may or may not have had previous undetected episodes. If the first detected episode stops naturally within one week but is followed by another episode, the category changes to "paroxysmal AF." Patients in this category have episodes that last up to seven days, but in most cases of paroxysmal AF, the episodes stop within 24 hours. If the episodes last for more than one week, they are classified as "persistent AF." If such episodes continue for more than one year, i.e., cannot be terminated by electrical or pharmacological cardioversion, the classification changes to "permanent AF."

[0007] Recent evidence suggests that patients with AF face an increased risk of cognitive impairment / decline and dementia. also suggested (Conen et al., J Am Coll Cardiol 2019;73:989-99). Part of the association between AF and dementia is explained by the higher stroke risk among AF patients. However, the risk of dementia was also increased in patients with AF but without a clinical history of stroke. Clinically unrecognized cerebral infarction (i.e., silent cerebral infarction) or other brain lesions, such as white matter lesions, may explain this association.

[0008] Asymptomatic large cortical and noncortical infarcts (LNCCI) are associated with cognitive impairments similar to those of overt stroke, corresponding to an approximately 10-year age difference in cognitive performance. Therefore, prevention of silent cerebral infarctions appears to be of major public health interest. Timely identification of these lesions is necessary so that appropriate treatment measures can be initiated. However, brain magnetic resonance imaging (MRI) in all AF patients is not feasible from a practical and economic point of view. Therefore, predictive tools are needed to identify AF patients at high risk of silent brain lesions.

[0009] Asymptomatic large cortical and noncortical infarcts (LNCCI) on magnetic resonance imaging have been associated with several adverse outcomes, such as cognitive impairment and depression. For example, white matter changes have been reported to be associated with impaired motor function in speed and fine motor coordination, as well as with many diseases, including vascular dementia, dementia with Lewy bodies, and psychiatric disorders.

[0010] There is a great need for biomarkers that allow for the assessment of stroke, silent cerebral infarction and / or cognitive decline.

[0011] The insulin-like growth factor axis has previously been found to be a predictor of outcome in HF (Watanabe et al., Insulin-like growth factor axis (insulin-like growth factor-i / insulin-like growth factor-binding protein-3) as a prognostic predictor of heart failure: Association with adiponectin, Eur J Heart Fail. 2010;12:1214-1222). IGFBP-7 (insulin-like growth factor binding protein 7) is a 30 kDa modular glycoprotein known to be secreted by endothelial cells, vascular smooth muscle cells, fibroblasts, and epithelial cells (Ono et al., Biochem Biophys Res Comm 202(1994)1490).

[0012] Insulin growth factor binding protein-7 (IGFBP-7) is also described as IGFBP-related protein 1 (IGFBP-rP1), mac25 / angiomodulin (AGM), tumor adhesion factor and prostacyclin stimulating factor (PSF) (UniProtKB-P602867). IGFBP-7 binds to IGF-1 and IGF-2 with relatively low affinity and belongs to the subfamily of low affinity IGFBPs.

[0013] The role of IGFBP-7 as a tumor suppressor has been described in several malignancies, including prostate and brain tumors.

[0014] In the brain, IGFBP-7 was observed to be exclusively associated with glioblastoma vessels, but not with vessels from non-malignant brain [Pen et al. (2007) Molecular markers of extracellular matrix remodeling in glioblastoma vessels: microarray study of laser-captured glioblastoma vessels. Glia 55(6), 559].

[0015] Furthermore, IGFBP-7 has been reported to play an important role in the growth and migration of gliomas [Jiang et al. (2008) Insulin-like Growth Factor Binding Protein 7 Mediators Glioma Cell Growth and Migration. Neoplasia 10,1335].

[0016] WO 2017 / 216387 discloses that Ang-2 and IGFB7 can be used to predict the recurrence of atrial fibrillation.

[0017] WO 2014 / 072500 discloses IGPBP7 as a biomarker for the diagnosis of atrial fibrillation.

[0018] WO 2019 / 115620 further discloses that IGFBP7 can be used to predict risk of stroke and to improve the predictive accuracy of clinical stroke risk scores.

[0019] However, so far, altered IGFBP7 levels have not been described for the assessment of asymptomatic infarction or for the assessment of the extent of asymptomatic small and large noncortical or cortical infarctions (SNCI and LNCCI) or white matter lesions in subjects.

[0020] Advantageously, in the research underlying the present invention, IGFBP7 is found to be a biomarker for the assessment of stroke and silent infarction, and for the prediction of silent infarction and / or cognitive decline.The determination of IGFBP7 further allows to improve the prediction accuracy of the clinical risk score of silent cerebral infarction.

[0021] Furthermore, the biomarker IGFBP7 was shown to positively correlate with the presence of asymptomatic small and large noncortical or cortical infarcts (SNCI and LNCCI) and with the presence of white matter lesions (WML) in patients.

[0022] The extent of SNCI, LNCCI and WML was associated with clinically silent stroke (Conen et al. al.2019;Wang Y,Liu G,Hong D,Chen F,Ji X,Cao G.White matter injury in ischemic stroke.Prog Neurobiol.2016;141:45-60), the biomarker IGFBP7 can be used to assess the extent of SNCI, LNCCI and WML, and to assess whether a subject has previously experienced one or more silent strokes, i.e. clinically silent strokes. Summary of the Invention

[0023] SUMMARY OF THE PRESENT APPLICATION In a first aspect, the present invention relates to a method for assessing whether a subject has experienced one or more silent infarctions, the method comprising: a) determining the amount of the biomarker IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) assessing whether the subject has experienced one or more silent infarctions.

[0024] In a second aspect, the present invention relates to a method for predicting silent infarction and / or cognitive decline in a subject, the method comprising: a) determining the amount of the biomarker IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) predicting silent infarction and / or cognitive decline in a subject.

[0025] In a third aspect, the present invention provides a method for improving the predictive accuracy of a clinical risk score for silent cerebral infarction and / or cognitive decline in a subject, comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) improving the prediction accuracy of the clinical risk score for asymptomatic cerebral infarction by combining the value of the amount of IGFBP7 with the clinical risk score for asymptomatic cerebral infarction.

[0026] In a fourth aspect, the present invention relates to a method for assessing the extent of asymptomatic small and large non-cortical and cortical infarcts in a subject, the method comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) assessing the extent of asymptomatic large non-cortical or cortical infarction in the subject based on the amount determined in step a).

[0027] In a fifth aspect, the present invention relates to a method for assessing the extent of white matter pathology in a subject, the method comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) assessing the extent of white matter lesions in the subject based on the amount determined in step a).

[0028] In a sixth aspect, the present invention provides a method for monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions and / or cognitive function in a subject, comprising: a) determining the amount of IGFBP7 in a sample from a subject; b) determining the amount of IGFBP7 in a second sample from the subject obtained after the first sample; c) comparing the amount of IGFBP7 in the first sample with the amount of IGFBP7 in the second sample; and d) monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or cognitive function of the subject based on the results of step c).

[0029] In a seventh aspect, the present invention relates to a computer implemented method for predicting stroke and / or silent infarction and / or cognitive decline in a subject, the method comprising: a) receiving in a processing unit a value of the amount of IGFBP7 in a sample from a subject; b) processing the value received in step (a) with a processing unit, the processing step comprising retrieving one or more thresholds for the amount of IGFBP7 from a memory and comparing the value received in step (a) with the one or more thresholds; and c) providing via an output device a prediction of silent infarction and / or cognitive decline, the prediction being based on the results of step (b).

[0030] In an eighth aspect, the present invention provides an in vitro use of IGFBP7 or an agent that binds to IGFBP7, comprising: a) to predict silent infarction and / or cognitive decline in a subject; b) Use for assessing the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions in a subject, or for improving the predictive accuracy of a subject's clinical stroke risk score. [Brief description of the drawings]

[0031] [Figure 1] Measurement of circulating IGFBP7 in EDTA plasma samples from the SWISS AF study in Fazekas score <2 (absent) versus Fazekas score ≥2 (present): detection of WML / prediction of risk of silent stroke: Circulating IGFBP7 levels were assessed. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0032] Detailed Description of the Invention Before the present invention is described in detail below, it should be understood that the present invention is not limited to the specific methods, protocols, and reagents described herein, which may vary. It should also be understood that the terms used herein are for the purpose of describing specific embodiments only, and are not intended to limit the scope of the present invention, which is limited only by the appended claims. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art.

[0033] Several documents are cited herein. Each document cited herein (including all patents, patent applications, scientific publications, manufacturer's specifications, instructions, etc.), whether supra or infra, is hereby incorporated by reference in its entirety. In the event of a discrepancy between a definition or teaching of such an incorporated reference and a definition or teaching cited herein, the body of the present specification shall control.

[0034] Each element of the present invention will be described below. Although these elements are listed with specific embodiments, it should be understood that they can be combined in any manner and in any number to create additional embodiments. The various described examples and preferred embodiments should not be construed to limit the present invention to only the embodiments explicitly described. This description should be understood to support and encompass embodiments that combine the explicitly described embodiments with any number of disclosed and / or preferred elements. Furthermore, any permutation and combination of all elements described in this application should be considered to be disclosed by the description of this application unless the context indicates otherwise.

[0035] The method of the present invention is preferably an ex vivo or in vitro method. Moreover, the method may comprise several steps in addition to those explicitly mentioned above. For example, further steps may concern taking a pre-treatment sample or evaluating the results obtained by said method. The method may be performed manually or may be supported by automation. Preferably, steps (a), (b) and / or (c) may be fully or partially supported by automation, for example by suitable robots and sensory equipment for computer-implemented comparison and / or prediction based on the decision in step (a) or said comparison in step (b).

[0036] definition The word "comprise", and variations such as "comprises" and "comprising", will be understood to imply the inclusion of a stated integer or step or group of integers or steps, but not the exclusion of any other integers or steps or group of integers or steps.

[0037] As used in this specification and the appended claims, the singular forms "a," "an," and "the" include plural referents unless the content clearly dictates otherwise.

[0038] Levels, concentrations, amounts, and other numerical data may be expressed or presented herein in a "range" format. It is understood that such range formats are used merely for convenience and brevity, and thus, include not only the numerical values ​​expressly recited as boundaries of the ranges, but also each numerical value and subrange is treated as if it were expressly recited. In particular, ranges should be interpreted flexibly to include all individual values ​​or subranges subsumed within the range. By way of example, a numerical range of "150 mg to 600 mg" should be interpreted to include not only the explicitly recited value of 150 mg to 600 mg, but also the individual values ​​and subranges within the indicated range. Thus, this numerical range includes individual values ​​such as 150, 160, 170, 180, 190, ... 580, 590, 600 mg, etc., and subranges such as 150 to 200, 150 to 250, 250 to 300, 350 to 600, etc. This same principle also applies to ranges reciting only one numerical value. Moreover, such an interpretation should be applied regardless of the breadth of the range or the characteristics being described.

[0039] The term "about," when used in connection with a numerical value, is meant to encompass numerical values ​​in a range having a lower limit of 5% less than the stated numerical value and an upper limit of 5% greater than the stated numerical value.

[0040] As will be understood by one of skill in the art, the assessments described herein, such as assessing stroke and / or asymptomatic infarcts, assessing the extent of asymptomatic large non-cortical or small non-cortical or cortical infarcts, assessing white matter pathology, predicting asymptomatic infarcts and / or cognitive decline, improving the predictive accuracy of clinical risk scores for asymptomatic cerebral infarction, the extent of asymptomatic large non-cortical or cortical infarcts and / or monitoring cognitive function, are typically not intended to be correct for 100% of subjects.

[0041] In some embodiments, the prediction can be made in a suitable and accurate manner in a statistically significant portion of the subject. Whether a portion is statistically significant can be determined without further ado by those skilled in the art using various well-known statistical evaluation tools, such as, for example, determining confidence intervals, determining p-values, Student's t-test, Mann-Whitney test, etc. For more details, see Dowdy and Wearden, Statistics for Research, John Wiley & Sons, New York 1983. Preferred confidence intervals are at least 90%, at least 95%, at least 97%, at least 98%, or at least 99%. The p-value is preferably 0.1, 0.05, 0.01, 0.005, or 0.0001.

[0042] The term "atrial fibrillation" is well known in the art. As used herein, the term preferably refers to supraventricular tachyarrhythmia characterized by uncoordinated atrial activity with the resultant deterioration of the mechanical function of the atria. In particular, the term refers to an abnormal heart rhythm characterized by rapid and irregular heartbeats. The term involves the two atria of the heart. In normal heart rhythm, excitation generated by the sinoatrial node spreads throughout the heart, causing myocardial contraction and blood ejection. In atrial fibrillation, the regular electrical impulses of the sinoatrial node are replaced by chaotic and rapid electrical impulses that cause irregular heartbeats. Symptoms of atrial fibrillation are heart palpitations, fainting, shortness of breath, or chest pain. However, most episodes are asymptomatic. On an electrocardiogram, atrial fibrillation is characterized by the replacement of uniform P waves by rapid oscillations or fibrillation waves that vary in amplitude, shape, and timing, and is associated with irregular and frequent rapid ventricular responses when atrioventricular conduction is normal.

[0043] The American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) propose the following classification system (see Fuster (2006) Circulation 114(7):e257-354, which is hereby incorporated by reference in its entirety, see e.g., Figure 3 therein): initially detected AF, paroxysmal AF, persistent AF, and permanent AF.

[0044] All people with AF initially belong to a category called first detected AF. However, subjects may or may not have previously undetected episodes. If AF has lasted for more than one year, the subject suffers from permanent AF. In particular, conversion back to sinus rhythm is not made (or only by medical intervention). If AF lasts for more than 7 days, the subject suffers from persistent AF. The subject may require pharmacological or electrical intervention to stop the atrial fibrillation. Thus, persistent AF occurs in episodes, but the arrhythmia typically does not spontaneously (i.e., without medical intervention) convert back to sinus rhythm. Paroxysmal atrial fibrillation preferably refers to intermittent episodes of atrial fibrillation that do not last more than 7 days and that terminate spontaneously (i.e., without medical intervention). In most cases of paroxysmal AF, the episodes do not last for more than 24 hours. Thus, while paroxysmal atrial fibrillation terminates spontaneously, persistent atrial fibrillation does not and requires electrical or pharmacological cardioversion, or other procedures such as ablation procedures (Fuster (2006) Circulation 114(7):e257-354) to terminate. The term "paroxysmal atrial fibrillation" is defined as an episode of AF that terminates spontaneously in less than 48 hours, more preferably less than 24 hours, and most preferably less than 12 hours. Both persistent and paroxysmal AF can recur.

[0045] As mentioned above, the subject to be tested preferably suffers from paroxysmal, persistent or permanent atrial fibrillation.

[0046] Further, atrial fibrillation is considered to have been previously diagnosed in the subject, and thus is diagnosed, i.e., detected, atrial fibrillation.

[0047] It is further envisaged that subjects tested in accordance with the methods and uses of the present invention may not have a known history of stroke and / or TIA (transient ischemic attack).

[0048] In some embodiments, the subject has no known history of stroke. In other embodiments, the subject has no known history of both stroke and TIA. Thus, the subject being tested shall not have suffered from clinically recognized stroke and / or TIA.

[0049] The term "evaluate silent infarction" as used herein refers to a subject having silent stroke or undergoing silent infarct stroke. According to the present invention, a subject with silent stroke is at risk of developing clinical stroke. The term "evaluate silent infarction" as used herein also refers to a subject diagnosing silent infarction, determining disease severity, guiding treatment (for the purpose of treatment intensification / reduction), predicting disease outcome (risk prediction, e.g. stroke), monitoring treatment (e.g., the effect of anticoagulant on IGFBP7 level), and stratifying treatment of subjects (selection of treatment options; e.g., long-term and selection from SWISS AF).

[0050] The term "predict risk" as used herein preferably refers to assessing the probability that a subject will suffer from silent infarction and / or cognitive decline. Typically, it is predicted whether a subject is at risk (hence high risk) or not at risk (hence low risk) of silent infarction and / or cognitive decline. Thus, the method of the present invention allows to distinguish between subjects at risk and subjects not at risk of silent infarction and / or cognitive decline. Furthermore, it is envisaged that the method of the present invention allows to distinguish between subjects with reduced, average and elevated risk.

[0051] As stated above, the risk (and probability) of suffering from silent infarction and / or cognitive decline within a particular time frame shall be predicted.

[0052] In some embodiments of the invention, the prediction of silent infarction and / or cognitive decline is determined after the sample to be tested is obtained.

[0053] In another embodiment of the invention, the prediction window is preferably at least 1 month, at least 3 months, at least 6 months, at least 9 months, at least 1 year, at least 2 years, at least 3 years, at least 4 years, at least 5 years, at least 10 years, at least 15 years, or at least 20 years intervals, or any intermittent time range.

[0054] In a preferred embodiment, the prediction window is a period of 1 month to 5 years. Thus, the risk of suffering from silent infarction and / or cognitive decline within 1 month to 5 years is predicted. In a preferred embodiment, the prediction window is a period of 1 month to 2 years. Preferably, the prediction window is a period of about 1 year. Most preferably, the prediction window may be a period of about 2 years. Thus, the risk of suffering from silent infarction and / or cognitive decline within 2 years is predicted.

[0055] Preferably, the prediction window is calculated from the completion of the method of the invention. More preferably, the prediction window is calculated from the time the sample to be tested is obtained.

[0056] In a preferred embodiment, the expression "predict the risk of silent infarction and / or cognitive decline" means that the subject analyzed by the method of the present invention is assigned to either a group of subjects at risk of silent infarction and / or cognitive decline, or a group of subjects that are not at risk of silent infarction and / or cognitive decline.Therefore, whether a subject is at risk of silent infarction and / or cognitive decline is predicted.As used herein, "subject at risk of silent infarction and / or cognitive decline" is preferably at high risk (preferably within a prediction window) of silent infarction and / or cognitive decline.Preferably, the risk is elevated compared to the average risk in a cohort of subjects.

[0057] As used herein, a "subject not at risk of suffering from silent infarction and / or cognitive decline" preferably has a low risk (preferably within a predictive window) of suffering from silent infarction and / or cognitive decline. Preferably, the risk is reduced compared to the average risk in a cohort of subjects. A subject at risk of suffering from silent infarction and / or cognitive decline has a risk of suffering from silent infarction and / or cognitive decline of preferably at least 20% or more preferably at least 30%, preferably within a predictive window of about 3 years. A subject at risk of suffering from silent infarction and / or cognitive decline has a risk of suffering from said adverse event of preferably less than 12%, more preferably less than 10%, preferably within a predictive window of 2 years.

[0058] The term "stroke" is well known in the art. The term preferably refers to ischemic stroke, especially cerebral ischemic stroke. The stroke predicted by the method of the present invention shall be caused by a reduction in blood flow to the brain or parts thereof, which results in an insufficient supply of oxygen to brain cells. In particular, stroke results in irreversible tissue damage due to brain cell death. Symptoms of stroke are well known in the art. Ischemic stroke may be caused by atherothrombosis or embolism of major cerebral arteries, by coagulation disorders or non-atheromatous vascular diseases, or by cardiac ischemia leading to a reduction in overall blood flow. The ischemic stroke is preferably selected from the group consisting of atherothrombotic stroke, cardioembolic stroke and foveolar stroke. The term "stroke" preferably does not include hemorrhagic stroke.

[0059] Whether a subject has suffered a stroke, particularly an ischemic stroke, can be determined by well-known methods. Furthermore, symptoms of stroke are well-known in the art. For example, Symptoms of a stroke may include sudden numbness or weakness in the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding, sudden loss of vision in one or both eyes, sudden difficulty walking, dizziness, or loss of balance or coordination.

[0060] The term "silent infarction", i.e., "silent cerebral infarction" or "silent cerebral infarction" is known in the art and described, for example, in Conen et al. (Conen et al., J Am Coll Cardiol 2019;73:989-99), which is incorporated herein by reference in its entirety. Silent infarction is a clinically silent infarction in a patient without a clinical history of stroke or transient ischemic attack. Thus, the subject to be tested shall have no known history of stroke and / or TIA (transient ischemic attack).

[0061] In a preferred embodiment, the risk of silent infarction is predicted. This term preferably refers to silent cerebral infarction or silent cerebral infarction (Krisai et al.).

[0062] Silent infarction is a stroke that does not have any outward symptoms associated with stroke, and patients typically do not realize that they have suffered a stroke. Despite not causing identifiable symptoms, silent strokes still cause damage to the brain and expose patients to an increased risk of both future transient ischemic attacks and major strokes. Silent infarction is associated with subtle deficits in physical and cognitive functions that generally go unnoticed. Silent strokes often affect areas of the brain associated with various thought processes, mood regulation, and cognitive functions, and are a major cause of cognitive decline or vascular cognitive impairment, and may also lead to loss of bladder control. Silent infarction typically causes lesions that are detected by the use of neuroimaging such as MRI.

[0063] The term "silent cerebral infarction" is further defined as cerebral infarction (LNCCI and / or SNCI) on brain MRI in patients without a history of stroke or TIA (Conen et al., 2019).

[0064] The term "LNCCI" is defined as a large non-cortical or cortical infarct, and the term "SNCI" is defined as a small non-cortical infarct.

[0065] In a preferred embodiment, subjects with "large noncortical or cortical infarctions (LNCCI)" are evaluated. The term "asymptomatic large noncortical or cortical infarctions (LNCCI)" is defined as a hyperintense lesion on FLAIR that does not involve the cortex and is >20 mm in diameter on axial sections. FLAIR = fluid attenuated inversion recovery. These lesions are consistent with ischemic infarction in the white matter, internal or external capsule, deep brain nuclei, thalamus, or in the territory of perforating arterioles located in the brainstem (Conen et al. 2019).

[0066] Asymptomatic large and small noncortical or cortical infarcts (SNCI and LNCCI) on magnetic resonance imaging have been associated with several adverse outcomes, such as cognitive impairment and depression. For example, white matter changes have been reported to be associated with impaired motor function in speed and fine motor coordination, as well as with many diseases, including vascular dementia, dementia with Lewy bodies, and psychiatric disorders.

[0067] The term "white matter lesion" is well known in the art. White matter refers to regions of the central nervous system (CNS) that are primarily composed of myelinated axons. White matter lesions (also called "white matter disease") are commonly detected as white matter hyperintensities (WMH) or "leukodystrophy" on brain MRI in aging individuals. The presence and extent of WMH have been described as radiological markers of small cerebrovascular disease and an important predictor of lifetime risk of stroke, cognitive impairment, and functional disability (Chutinet A, Rost NS. White matter disease as a marker of small cerebrovascular disease in aging individuals). IGFBP7 is a biomarker for long-term cerebrovascular disease and dementia.Curr Treat Options Cardiovasc Med.2014;16(3):292.doi:10.1007 / s11936-013-0292-z). Determination of IGFBP7 makes it possible to assess the degree of WML, i.e. the burden of WML. The biomarker therefore allows for the quantification of WML in a subject, i.e. it is a marker of loss of volume of functional brain tissue.

[0068] The extent of white matter lesions can be expressed by the Fazekas score (Fazekas, JB Chawluk, A Alavi, HI Hurtig, and RA Zimmerman American Journal of Roentgenology 1987 149:2,351-356). The Fazekas score ranges from 0 to 3, with 0 indicating no WML, 1 indicating mild WML, 2 indicating moderate WML, and 3 indicating severe WML.

[0069] The term "cognitive decline" as used herein is defined as a disruption of memory, attention, and cognitive function. Instead of the term cognitive decline, the term cognitive impairment, cognitive disorder, or dementia may be used.

[0070] The term preferably refers to symptoms that can be characterized as a usually progressive loss of cognitive and intellectual function that does not involve impairment of perception or consciousness caused by various disorders, but is most commonly associated with structural brain disease. Cognitive testing can be performed using the Montreal Cognitive Assessment (MoCA), as described in Conen et al. 2019. The term "cognitive function" refers to symptoms that can be characterized as a usually progressive loss of cognitive and intellectual function that does not involve impairment of perception or consciousness caused by various disorders, but is most commonly associated with structural brain disease. Cognitive function was assessed using scores as described in the Montreal Cognitive Assessment (MoCA) which evaluates visuospatial and executive functions, confrontation naming, memory, attention, language, and abstraction. Patients could receive a maximum score of 30, with higher scores indicating better cognitive function. One point was added to the total test score if the patient had 12 years or less of formal education.

[0071] The most common type of dementia is Alzheimer's disease, which accounts for 50% to 70% of cases. Other common types include vascular dementia (25%), Lewy body dementia, and frontotemporal dementia. The term "dementia" includes, but is not limited to, AIDS dementia, Alzheimer's dementia, presenile dementia, senile dementia, atonic dementia, Lewy body dementia (diffuse Lewy body disease), multi-infarct dementia (vascular dementia), paralytic dementia, post-traumatic dementia, praecox dementia, and vascular dementia.

[0072] In some embodiments, the term dementia refers to vascular dementia, Alzheimer's disease, dementia with Lewy bodies, and / or frontotemporal dementia, and thus the risk of suffering from vascular dementia, Alzheimer's disease, dementia with Lewy bodies, and / or frontotemporal dementia is predicted.

[0073] In some embodiments, the risk of suffering from "Alzheimer's disease" is predicted. The term "Alzheimer's disease" is well known in the art. Alzheimer's disease is a chronic neurodegenerative disease that usually begins slowly and gradually worsens over time. As the disease progresses, symptoms include language problems, disorientation, mood swings, loss of motivation, failure to manage self-care, and behavioral problems.

[0074] In one embodiment, the risk of developing "vascular dementia" is predicted. The term "dementia" preferably refers to the progressive loss of memory and other cognitive functions caused by vascular damage or disease in the brain. The term is therefore intended to refer to dementia symptoms caused by problems with blood circulation to the brain. This can occur after silent cerebral infarction or after strokes accumulate over time.

[0075] The method of the present invention can also be used to screen a larger population of subjects.Therefore, it is envisaged that at least 100 subjects, particularly at least 1000 subjects, are evaluated, for example, for the risk of silent infarction.Therefore, the amount of biomarker IGFBP7 is determined in samples from at least 100 subjects, or particularly at least 1000 subjects.Furthermore, it is envisaged that at least 10.000 subjects are evaluated.

[0076] The term "anticoagulant therapy" is preferably a treatment aimed at reducing the risk of anticoagulation in the subject. The administration of at least one anticoagulant aims at reducing or preventing blood clotting and associated stroke. In a preferred embodiment, the at least one anticoagulant is selected from the group consisting of heparin, coumarin derivatives (i.e. vitamin K antagonists), in particular warfarin or dicoumarol, oral anticoagulants, in particular dabigatran, rivaroxaban or apixaban, tissue factor pathway inhibitor (TFPI), antithrombin III, factor IXa inhibitors, factor Xa inhibitors, inhibitors of factors Va and VIIIa, and thrombin inhibitors (anti-type IIa).

[0077] In a particularly preferred embodiment, the anticoagulant is a vitamin K antagonist, such as warfarin or dicoumarol. Vitamin K antagonists, such as warfarin or dicoumarol, are inexpensive but inconvenient, cumbersome, and often unreliable treatments with time variability in the therapeutic range, which requires improved patient compliance. NOACs (new oral anticoagulants) include direct factor Xa inhibitors (apixaban, rivaroxaban, darexaban, edoxaban), direct thrombin inhibitors (dabigatran), and PAR-1 antagonists (vorapaxar, atopaxar).

[0078] If the test subject is on anticoagulant therapy, and if the subject is identified (by the method of the present invention) as not at risk of suffering from silent infarction, the dose of anticoagulant therapy can be reduced. Thus, a reduction in the dose may be recommended. By reducing the dose, the risk of suffering from side effects (such as bleeding) may be reduced.

[0079] The term "clinical stroke risk score" is well known in the art. For example, such scores are described in Kirchhof P. et al (European Heart Journal 2016;37:2893-2962). In one embodiment, the score is the CHA2DS2-VASc score. In another embodiment, the score is the CHADS2Score (Gage BF.Et al., JAMA,285(22)(2001),pp.2864-2870) and the ABC score, i.e., the ABC (age,biomarkers,clinical history) stroke risk score (Hijazi Z.et al.,Lancet 2016;387(10035):2302-2311). All publications in this paragraph are incorporated herein by reference for their entire disclosure.

[0080] Thus, in one embodiment, the clinical stroke risk score is the CHA2DS2-VASc score. In an alternative embodiment of the invention, the clinical stroke risk score is the CHADS2 score.

[0081] As used herein, the term "recommend" means to establish a suggested treatment regimen applicable to a subject. However, administering the actual treatment, whatever it may be, is not. It should be understood that the term does not include the term "predictive measures." The recommended treatment depends on the results of, for example, a prediction, by the methods of the present invention.

[0082] The term "monitoring" as used herein preferably relates to the assessment of disease progression as referred to elsewhere in this specification. Furthermore, the effectiveness of treatment for the patient can be monitored.

[0083] The "subject" to be tested according to the method and use of the present invention is preferably a mammal. Mammals include, but are not limited to, livestock animals (e.g., cows, sheep, cats, dogs and horses), primates (e.g., humans and non-human primates such as monkeys), rabbits, rodents (e.g., mice and rats). Preferably, the subject is a human subject. The terms "subject" and "patient" are used interchangeably herein.

[0084] In certain embodiments, the subject is a human patient. In some embodiments, the patient is of any age. In some embodiments, the patient is 50 years old or older, particularly 60 years old or older, particularly 65 years old or older. It is further envisaged that the patient to be examined is 70 years old or older.

[0085] In a preferred embodiment of the methods and uses of the present invention, the subject is aged 65 years or older. In another preferred embodiment, the subject is aged 70 years or older. In another embodiment, the subject is aged 75 years or older.

[0086] The term "sample" refers to a sample of bodily fluids, a sample of separated cells, or a sample from a tissue or organ. Bodily fluid samples can be collected by well-known techniques and include samples of blood, plasma, serum, urine, lymph, sputum, ascites, saliva, tears, cerebrospinal fluid, or other bodily secretions or derivatives thereof. Tissue or organ samples may be obtained from any tissue or organ, for example, by biopsy. Separated cells may be obtained from bodily fluids or tissues or organs by separation techniques such as centrifugation or cell sorting. For example, cell, tissue, or organ samples may be taken from cells, tissues, or organs that express or produce a biomarker. For example, the sample may be a myocardial tissue sample. Additionally, the sample may be a neural tissue sample or an intestinal tissue sample. In some embodiments, the sample is a bone marrow sample. The sample may be frozen, fresh, fixed (e.g., formalin fixed), centrifuged, and / or embedded (e.g., paraffin embedded), and the like. The cell sample may, of course, be subjected to a variety of well-known post-collection preparation and storage techniques (e.g., nucleic acid and / or protein extraction, fixation, storage, freezing, ultrafiltration, concentration, evaporation, centrifugation, etc.) prior to assessing the amount of marker in the sample.

[0087] Thus, the sample may be a tissue sample. In a preferred embodiment, the tissue sample is a cardiac tissue sample, such as a myocardial tissue sample. In particular, the sample is a tissue sample from the right atrial appendage. In another preferred embodiment, the sample is a neural tissue sample, such as a brain tissue sample or a spinal cord sample.

[0088] In other preferred embodiments, the sample is a blood (i.e., whole blood), serum, or plasma sample. For example, the sample can be a venous blood, serum, or plasma sample. Alternatively, the sample can be a capillary blood sample (e.g., obtained from a finger). In some embodiments, the sample is a peripheral blood sample. Serum is the liquid fraction of whole blood obtained after the blood is allowed to clot. To obtain serum, the clot is removed by centrifugation and the supernatant is then collected. Plasma is the cell-free fluid part of blood. To obtain a plasma sample, whole blood is collected in an anticoagulant-treated tube (e.g., a citrate-treated or EDTA-treated tube). Cells are removed from the sample by centrifugation to obtain the supernatant (i.e., the plasma sample).

[0089] Additionally, the sample may contain stem cells such as bone marrow or peripheral blood derived stem cells, lymphocytes, cardiomyocytes, neuronal cells or intestinal cells.

[0090] In some embodiments, the sample is a cerebrospinal fluid sample.

[0091] Biomarker detection: Biomarkers as referred to herein can be detected using methods generally known in the art. Detection methods generally include methods that quantify the amount of biomarker in a sample (quantitative methods). It is generally known to those skilled in the art which of the following methods are suitable for qualitative and / or quantitative detection of biomarkers. Samples can be conveniently assayed for proteins using, for example, Western blots and immunoassays such as ELISA, RIA, fluorescence and luminescence based immunoassays, as well as commercially available proximity extension methods. Further suitable methods for detecting biomarkers include measuring physical or chemical properties specific to a peptide or polypeptide, such as its exact molecular weight or NMR spectrum. Such methods include, for example, analytical devices such as biosensors, optical devices linked to immunoassays, biochips, mass spectrometers, NMR analyzers, or chromatography devices. Further methods include microplate ELISA-based methods, fully automated or robotic immunoassays (available on Elecsys™ analyzers), CBA (enzymatic Cobalt Binding Assay, e.g. available on Roche-Hitachi™ analyzers), and latex agglutination assays (available on Roche-Hitachi™ analyzers).

[0092] For detection of biomarker proteins as used herein, a wide range of immunoassay techniques are available using such assay formats, see, for example, U.S. Patent Nos. 4,016,043, 4,424,279, and 4,018,653. These include both traditional competitive binding assays as well as one-site and two-site or "sandwich" assays of the non-competitive type. These assays also include direct binding of labeled antibodies to the target biomarker.

[0093] Methods using electrochemiluminescent labels are well known. Such methods exploit the ability of special metal complexes to undergo oxidation to an excited state, which relaxes from the excited state to the ground state and emits electrochemiluminescence. For a review, see Richter, MM, Chem. Rev. 2004;104:3003-3036.

[0094] In some embodiments, the detection antibody (or antigen-binding fragment thereof) used to measure the amount of the biomarker is ruthenylated or iridinylated. Thus, the antibody (or antigen-binding fragment thereof) comprises a ruthenium label. In some embodiments, the ruthenium label is a bipyridine-ruthenium(II) complex. Alternatively, the antibody (or antigen-binding fragment thereof) comprises an iridium label. In some embodiments, the iridium label is a complex as disclosed in WO 2012 / 107419.

[0095] In an embodiment of a sandwich assay for the determination of IGFBP7, the assay comprises a biotinylated first monoclonal antibody that specifically binds to IGFBP7 (as a capture antibody) and a rutheniumylated F(ab')2-fragment of a second monoclonal that specifically binds to IGFBP7 as a detection antibody. The two antibodies form a sandwich immunoassay complex with IGFBP7 in the sample.

[0096] Measuring the amount of the polypeptide may preferably comprise the steps of: (a) contacting the polypeptide with an agent that specifically binds to the polypeptide; (b) (optionally) removing unbound agent; and (c) measuring the amount of bound binding agent, i.e., the agent complex formed in step (a). According to a preferred embodiment, the contacting step The steps of contacting and removing and measuring may be performed by an analyzer unit. According to some embodiments, the steps may be performed by a single analyzer unit of the system or by multiple analyzer units in operable communication with each other. For example, according to specific embodiments, the system disclosed herein may comprise a first analyzer unit for performing the contacting and removing steps, and a second analyzer unit operably connected to the first analyzer unit by a transport unit (e.g., a robotic arm) for performing the measuring step.

[0097] Agents that specifically bind biomarkers (also referred to herein as "binders") may be covalently or non-covalently bound to a label that allows for detection and measurement of the bound agent. Labeling may be by direct or indirect methods. Direct labeling is achieved by binding a label directly (covalently or non-covalently) to the binder. Indirect labeling is achieved by binding (covalently or non-covalently) a second binder to the first binder. The second binder shall specifically bind to the first binder. The second binder may be bound to a suitable label and / or may be a target (receptor) for a third binder that binds to the second binder. Suitable secondary and higher order binders may include antibodies, secondary antibodies, and the well-known streptavidin-biotin system (Vector Laboratories, Inc.). Binders or substrates may also be "tagged" with one or more tags known in the art. Such tags may then be targets for higher order binders. Suitable tags include biotin, digoxygenin, His-tag, glutathione-S-transferase, FLAG, GFP, myc-tag, influenza A virus hemagglutinin (HA), maltose binding protein, etc. In the case of peptides or polypeptides, the tag is preferably at the N-terminus and / or C-terminus. Suitable labels are any labels detectable by suitable detection methods. Exemplary labels include gold particles, latex beads, acridan esters, luminol, ruthenium complexes, iridium complexes, enzymatically active labels, radioactive labels, magnetic labels (including "e.g. magnetic beads", paramagnetic and superparamagnetic labels), and fluorescent labels. Enzymatically active labels include, for example, horseradish peroxidase, alkaline phosphatase, β-galactosidase, luciferase, and derivatives thereof.Suitable substrates for detection include diaminobenzidine (DAB), 3,3'-5,5'-tetramethylbenzidine, NBT-BCIP (4-nitro blue tetrazolium chloride and 5-bromo-4-chloro-3-indolyl-phosphate available as ready-made stock solutions from Roche Diagnostics), CDP-Star™ (Amersham Bio-sciences), ECF™ (Amersham Biosciences). The appropriate enzyme-substrate combination may produce a colored reaction product, fluorescence or chemiluminescence, which can be determined by methods known in the art (e.g., using a light-sensitive film or a suitable camera system). For measuring enzyme reactions, the above criteria apply as well. Exemplary fluorescent labels include fluorescent proteins (e.g., GFP and its derivatives), Cy3, Cy5, Texas Red, fluorescein, and Alexa dyes (e.g., Alexa568). Further fluorescent labels are available, for example, from Molecular Probes (Oregon). The use of quantum dots as fluorescent labels is also contemplated.Radioactive labels can be detected by any method known and appropriate, such as a light-sensitive film or a phosphor imager.

[0098] The amount of a polypeptide may also preferably be determined by: (a) contacting a solid support comprising a binding agent for the polypeptide as described elsewhere herein with a sample comprising the peptide or polypeptide, and (b) measuring the amount of peptide or polypeptide bound to the support. Materials for manufacturing supports are well known in the art and include, inter alia, commercially available column materials, polystyrene beads, latex beads, magnetic beads, etc. , colloidal metal particles, glass and / or silicon chips and surfaces, nitrocellulose strips, membranes, sheets, duracyte, wells and walls of reaction trays, plastic tubes, and the like.

[0099] In yet another embodiment, the sample is removed from the complex formed between the binding agent and the at least one marker prior to measuring the amount of complex formed. Thus, in one embodiment, the binding agent may be immobilized on a solid support.

[0100] In yet other embodiments, the sample may be removed from the complexes formed on the solid support by applying a wash solution.

[0101] "Sandwich assays" are among the most useful and commonly used assays and encompass several variations of the sandwich assay technique. Briefly, in a typical assay, an unlabeled (capture) binding agent is immobilized or can be immobilized on a solid substrate, and the sample to be tested is contacted with the capture binding agent. After an appropriate incubation period sufficient to allow for the formation of a binding agent-biomarker complex, a second (detection) binding agent labeled with a reporter molecule capable of producing a detectable signal is added and incubated for a sufficient time to allow for the formation of another binding agent-biomarker-labeled binding agent complex. Any unreacted material can be washed away, and the presence of the biomarker is determined by observation of the signal produced by the reporter molecule bound to the detection binding agent. The results can be either qualitative, by simple observation of the visible signal, or quantified by comparison with a control sample containing known amounts of biomarker.

[0102] The incubation step of typical sandwich assay can be modified as necessary and appropriate. Such modifications include, for example, simultaneous incubation, in which two or more binding agents and biomarkers are co-incubated. For example, both the sample to be analyzed and the labeled binding agent are added to the immobilized capture binding agent at the same time. Also, the sample to be analyzed and the labeled binding agent can be first incubated, and then the antibody that is bound to the solid phase or can be bound to the solid phase is added.

[0103] The complex formed between the specific binding agent and the biomarker shall be proportional to the amount of biomarker present in the sample. It will be understood that the specificity and / or sensitivity of the applied binding agent defines the extent of the proportion of at least one marker contained in the sample that can be specifically bound. Details of how to perform the measurement are also described elsewhere in this specification. The amount of complex formed shall be converted into the amount of biomarker that reflects the amount actually present in the sample.

[0104] The terms "binding agent", "specific binding agent", "analyte specific binding agent", "detection agent", "agent that binds to a biomarker" and "agent that specifically binds to a biomarker" are used interchangeably herein. Preferably, it relates to an agent that comprises a binding moiety that specifically binds to the corresponding biomarker. Examples of "binding agent", "detection agent" and "agent" are nucleic acid probes, nucleic acid primers, DNA molecules, RNA molecules, aptamers, antibodies, antibody fragments, peptides, peptide nucleic acids (PNAs) or chemical compounds. A preferred agent is an antibody that specifically binds to the biomarker to be determined. The term "antibody" is used herein in the broadest sense and encompasses a variety of antibody structures, including, but not limited to, monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g. bispecific antibodies), and antibody fragments (i.e. antigen-binding fragments thereof) so long as they exhibit the desired antigen-binding activity. Preferably, the antibody is a polyclonal antibody (or an antigen-binding fragment thereof). More preferably, the antibody is a monoclonal antibody (or an antigen-binding fragment thereof). In addition, as described elsewhere herein, it is contemplated that two monoclonal antibodies that bind to different positions of the IGFBP7 polypeptide (in a sandwich immunoassay) are used. Thus, at least one antibody is used to determine the amount of IGFBP7.

[0105] The agent or detection agent shall specifically bind to the biomarker IGFBP7. The term "specific binding" or "specifically binds" refers to a binding reaction in which the molecules of the binding pair exhibit binding to each other under conditions in which they do not significantly bind to another molecule. The term "specific binding" or "specifically binds" when referring to a protein or peptide as a biomarker preferably means that the binding agent binds to the corresponding biomarker with at least 10% specificity. 7 M -1 The affinity of the a The term "specific binding" or "specifically binding" preferably refers to a binding reaction in which the target molecule is bound to the target molecule at a specific binding site. 8 M -1 or even more preferably at least 10 9 M -1 The terms "specific" or "specifically" are used to indicate that other molecules present in a sample do not significantly bind to a binding agent specific for a target molecule.

[0106] The term "amount" as used herein includes the absolute amount of a biomarker (e.g., IGFBP7) as used herein, the relative amount or concentration of the biomarker, and any value or parameter that correlates therewith or can be derived therefrom. Such values ​​or parameters include intensity signal values ​​derived from any specific physical or chemical property obtained from the peptide by direct measurement, such as intensity values ​​in mass or NMR spectra. In addition, all values ​​or parameters obtained by indirect measurement as specified elsewhere in this specification are included, such as the response amount determined by a biological readout system in response to the peptide or intensity signal obtained from a specifically bound ligand. It should be understood that values ​​that correlate with the above amounts or parameters can also be obtained by all standard mathematical operations.

[0107] The term "comparing" as used herein refers to comparing the amount of a biomarker (IGFBP7) in a sample from a subject with a reference amount of the biomarker as specified elsewhere in this specification. It should be understood that comparing as used herein generally refers to a comparison of corresponding parameters or values, e.g., an absolute amount is compared to an absolute amount of a reference, whereas a concentration is compared to a concentration of a reference, or an intensity signal obtained from a biomarker in a sample is compared to an intensity signal of the same type obtained from a reference sample. The comparison may be performed manually or computer-assisted. Thus, the comparison may be performed by a computing device. The determined or detected amount of a biomarker in a sample from a subject and the value for the reference amount may, for example, be compared to each other, and the comparison may be performed automatically by a computer program that executes an algorithm for the comparison. The computer program that performs the evaluation provides the desired evaluation in a suitable output format. For computer-assisted comparison, the value of the determined amount may be compared by the computer program with a value corresponding to a suitable reference stored in a database. The computer program may further evaluate the result of the comparison, i.e., automatically provide the desired evaluation in a suitable output format. For computer-aided comparison, the determined quantity values ​​may be compared by a computer program with values ​​corresponding to suitable standards stored in a database, which may further evaluate the comparison results, i.e. automatically provide the desired prediction in a suitable output format.

[0108] According to the present invention, the amount of the biomarker IGFBP7 is to be compared to a standard, i.e. a reference amount (or a number of reference amounts). The standard is therefore preferably a reference amount. The terms "reference amount" or "reference" are well understood by those skilled in the art.

[0109] It will be appreciated that the reference amount enables prediction of asymptomatic infarction and / or cognitive decline, improving the accuracy of prediction of a subject's clinical risk score for asymptomatic cerebral infarction, assessing the extent of asymptomatic large non-cortical or cortical infarctions, assessing whether a subject has experienced one or more asymptomatic infarctions, monitoring the extent of asymptomatic large non-cortical or cortical infarctions and / or cognitive function, and diagnosing atrial fibrillation in a subject as described elsewhere herein.

[0110] For example, in the context of a method for predicting the risk of asymptomatic infarction and / or cognitive decline, the reference amount preferably refers to an amount that allows the subject to be assigned to either (i) a group of subjects at risk of asymptomatic infarction and / or cognitive decline, or (ii) a group of subjects at risk of asymptomatic infarction and / or cognitive decline.For example, in the context of a method for diagnosing asymptomatic infarction, the reference amount preferably refers to an amount that allows the subject to be assigned to either (i) a group of subjects that suffer from asymptomatic infarction, or (ii) a group of subjects that do not suffer from asymptomatic infarction.A suitable reference amount may be determined from a reference sample that is analyzed together with the test sample, i.e., simultaneously or subsequently.

[0111] Reference amounts can in principle be calculated for a cohort of subjects as specified above, based on the mean or average value of a given biomarker, by applying standard methods of statistics. The accuracy of a test, particularly one aimed at diagnosing an event, is best described by its receiver operating characteristic (ROC) (see, in particular, Zweig MH.et al., Clin.Chem.1993;39:561-577). The ROC graph is a plot of all sensitivity vs. specificity pairs resulting from continuously varying the decision threshold over the entire range of observed data. The clinical performance of a diagnostic method depends on its accuracy, i.e., its ability to correctly assign subjects to a certain prognosis or diagnosis. The ROC plot shows the overlap between the two distributions by plotting sensitivity vs. 1-specificity for the entire range of thresholds suitable for making the distinction. The y-axis is the sensitivity, or true positive rate, defined as the ratio of the number of true positive test results to the product of the number of true positive test results and the number of false negative test results. The y-axis is calculated only from the affected subgroup. On the x-axis is the false positive rate, or 1-specificity, which is defined as the ratio of the number of false positive results to the product of the number of true negative and false positive results. The x-axis is a measure of specificity, calculated only from the unaffected subgroup. The true positive rate and the false positive rate are calculated completely separately by using the test results from the two different subgroups, so the ROC plot is independent of the prevalence of the event in the cohort. Each point on the ROC plot represents a sensitivity / 1-specificity pair that corresponds to a particular decision threshold. A test with perfect discrimination (no overlap between the two distributions of results) would have an ROC plot that passes through the upper left corner, with a true positive rate of 1.0, or 100% (perfect sensitivity) and a false positive rate of 0 (perfect specificity). The theoretical plot for a test with no discrimination (the distribution of results for the two groups is identical) would be a 45° diagonal line from the lower left corner to the upper right corner. Most plots fall between these two extremes. If the ROC plot falls entirely below the 45° diagonal, this is easily corrected by swapping the criteria for "positive rate" from "higher" to "lower" and vice versa.Qualitatively, the closer the plot is to the upper left corner, the greater the overall accuracy of the test. Depending on the desired confidence interval, a threshold can be derived from the ROC curve, which allows a diagnosis for a given event with an appropriate balance of sensitivity and specificity, respectively.

[0112] Therefore, the criteria used in the methods of the present invention, i.e. threshold values ​​that allow assessment of each of the following: prediction of asymptomatic infarction and / or cognitive decline, prediction of asymptomatic infarction and / or cognitive decline, improving the accuracy of prediction of the subject's clinical risk score for asymptomatic cerebral infarction, assessment of the extent of asymptomatic large non-cortical or cortical infarctions, assessment of whether the subject has experienced one or more asymptomatic infarctions, monitoring the extent of asymptomatic large non-cortical or cortical infarctions and / or cognitive function, etc., are preferred. Alternatively, it can be generated by establishing the ROC for the cohort as described above and deriving a threshold amount therefrom.

[0113] Depending on the desired sensitivity and specificity of the assessment, the ROC plot can derive suitable thresholds, for example, an optimal sensitivity is desired for excluding subjects at risk of silent infarction and / or cognitive decline (i.e., excluding them), while it will be understood that an optimal specificity is assumed for subjects at risk of silent infarction and / or predicted to have silent infarction (i.e., excluding them).

[0114] As used herein, the term "reference amount" refers to a predetermined value that allows for the assessments referred to herein, such as predicting asymptomatic infarction and / or cognitive decline, improving the accuracy of predicting a subject's clinical risk score for asymptomatic cerebral infarction, assessing the extent of asymptomatic large noncortical or cortical infarctions, assessing whether a subject has experienced one or more asymptomatic infarctions, monitoring the extent of asymptomatic large noncortical or cortical infarctions, and / or the subject's cognitive function.

[0115] In a method for predicting the risk of silent infarction and / or cognitive decline, for example, the reference, i.e. the reference amount, makes it possible to distinguish between subjects at risk of suffering from silent infarction and / or cognitive decline and subjects not at risk of suffering from silent infarction and / or cognitive decline.

[0116] The biomarker "IGFBP7" is well known in the art. According to the present invention, the amount of insulin-like growth factor binding protein 7 (=IGFBP-7) shall be determined. Preferably, the amount of IGFBP-7 polypeptide is determined. IGFBP-7 is a modular glycoprotein of 30 kDa known to be secreted by endothelial cells, vascular smooth muscle cells, fibroblasts and epithelial cells (Ono, Y., et al., Biochem. Biophys Res Comm 202(1994)1490-1496).

[0117] Preferably, the term "IGFBP-7" refers to human IGFBP-7. The protein sequence is well known in the art and can be accessed, for example, through Uni-Prot (Q16270, IBP7_HUMAN) or GenBank (NP_001240764.1). A detailed definition of the biomarker IGFBP-7 is provided, for example, in WO 2008 / 089994, which is incorporated herein by reference in its entirety. IGFBP-7 has two isoforms, isoforms 1 and 2, which are generated by alternative splicing. In an embodiment of the invention, the total amount of both isoforms is determined (for sequences, see UniProt database entries (Q16270-1 and Q16270-2)).

[0118] In the literature, this molecule is also called FSTL2; IBP7; IGF-binding protein-related protein I; IGFBP7; IGFBP7v; IGFBP rPl; IGFBP7; IGFBPRP1; insulin-like growth factor binding protein 7; insulin-like growth factor binding protein 7 precursor; MAC25; MAC25 protein; PGI2 stimulating factor; PSF or prostacyclin stimulating factor. Northern blot studies have revealed widespread expression of this gene in human tissues, including heart, brain, placenta, liver, skeletal muscle, and pancreas (Oh, Y., et al., J. Biol. Chem. 271 (1996) 30322-30325).

[0119] IGFBP7 was initially identified as a gene differentially expressed in normal leptomeningeal and mammary epithelial cells compared to their corresponding tumor cells and was named meningioma-associated cDNA (MAC25) (Burger, A. M., et al., Oncogene. 16(1998)2459-2467). The expressed protein was analyzed by the tumor-derived adhesion factor ( It was independently purified as angiomodulin (later renamed angiomodulin) (Sprenger, CC, et al., Cancer Res 59 (1999) 2370-2375) and prostacyclin stimulating factor (Akaogi, K., et al., Proc Natl Acad Sci USA 93 (1996) 8384-8389), which was further reported as T1A12, a gene downregulated in breast cancer (StCroix, B., et al., Science 289 (2000) 1197-1202).

[0120] Preferably, the term "IGFBP7" refers to human IGFBP7. The protein sequence is well known in the art and can be accessed, for example, through GenBank (NP_001240764.1). As used herein, IGFBP7 preferably also encompasses variants of specific IGFBP7 polypeptides.

[0121] In a preferred embodiment of the methods and uses of the invention, the biomarker IGFBP7 is an IGFBP7 polypeptide. Thus, the amount of the IGFBP7 polypeptide is determined.

[0122] In a preferred embodiment of the methods and uses of the invention, the biomarker IGFBP7 is IGFBP7 mRNA. Thus, the amount of IGFBP7 mRNA is determined (which can be done directly or indirectly).

[0123] As used herein, the term "determining" the amount of a biomarker (such as IGFBP7) refers to quantification of the biomarker, e.g., measuring the level of the biomarker in a sample using a suitable detection method as described elsewhere herein. The terms "measuring" and "determining" are used interchangeably herein.

[0124] In some embodiments, the amount of a biomarker is determined by contacting the sample with an agent that specifically binds to the biomarker, thereby forming a complex between the agent and the biomarker, detecting the amount of complex formed, and then measuring the amount of the biomarker.

[0125] In an embodiment, the level of IGFBP7 is determined using an antibody, in particular a monoclonal antibody. In an embodiment, step a) of measuring the level of IGFBP7 in a patient sample comprises performing an immunoassay. In an embodiment, the immunoassay is performed in either a direct or indirect format. In an embodiment, such an immunoassay is selected from the group consisting of an enzyme-linked immunosorbent assay (ELISA), an enzyme immunoassay (EIA), a radioimmunoassay (RIA), or an immunoassay based on luminescence, fluorescence, chemiluminescence or electrochemiluminescence detection.

[0126] In certain embodiments, step a) of measuring the level of IGFBP7 in a patient sample comprises: i) incubating a patient sample with one or more antibodies that specifically bind to IGFBP7, thereby generating a complex between the antibody and IGFBP7; and ii) quantitating the complex formed in step i), thereby quantifying the level of IGFBP7 in the patient sample.

[0127] In a particular embodiment, in step i), the sample is incubated with two antibodies that specifically bind to IGFBP7. As will be apparent to those skilled in the art, the sample may be contacted in any desired order, i.e., first with the first antibody and then with the second antibody, or first with the second antibody and then with the first antibody, or simultaneously with the first and second antibodies, for a time and under conditions sufficient to form a first anti-IGFBP7 antibody / IGFBP7 / second anti-IGFBP7 antibody complex. As will be readily apparent to those skilled in the art, the specific anti-IGFBP7 antibody and IGFBP7 / second anti-IGFBP7 antibody complex may be contacted in any desired order, i.e., first with the first antibody and then with the second antibody, or first with the second antibody and then with the first antibody, or simultaneously with the first and second antibodies. It is merely a matter of routine experimentation to establish appropriate or sufficient times and conditions for the formation of a complex between P7 antigen / analyte (=anti-IGFBP7 complex), or a secondary or sandwich complex comprising a first antibody against IGFBP7, IGFBP7 (analyte) and a second anti-IGFBP7 antibody (=anti-IGFBP7 antibody / IGFBP7 / second anti-IGFBP7 antibody complex).

[0128] Detection of anti-IGFBP7 antibody / IGFBP7 complex can be carried out by any suitable means. Detection of first anti-IGFBP7 antibody / IGFBP7 / second anti-IGFBP7 antibody complex can be carried out by any suitable means. Those skilled in the art are fully familiar with such means / methods.

[0129] In certain embodiments, a sandwich is formed comprising a first antibody to IGFBP7, IGFBP7 (the analyte) and a second antibody to IGFBP7, where the second antibody is detectably labeled.

[0130] In one embodiment, a sandwich is formed comprising a first antibody against GDF-15, IGFBP7 (analyte) and a second antibody against IGFBP7, where the second antibody is detectably labeled and the first anti-IGFBP7 antibody is capable of binding to a solid phase or is bound to a solid phase.

[0131] In embodiments, the second antibody is detectably labeled, either directly or indirectly. In a particular embodiment, the second antibody is detectably labeled with a luminescent dye, in particular a chemiluminescent dye or an electrochemiluminescent dye.

[0132] In a specific embodiment, the antigen in the sample, the biotinylated monoclonal IGFBP7-specific antibody, and the monoclonal IGFBP7-specific antibody labeled with a ruthenium complex form a sandwich complex. After the addition of streptavidin-coated microparticles, the complex binds to the solid phase via the interaction between biotin and streptavidin.

[0133] Detailed Description of the Invention The method referred to by the present invention includes a method consisting essentially of the above-mentioned steps or a method comprising additional steps. Moreover, the method of the present invention is preferably an ex vivo, more preferably an in vitro method. Moreover, it may comprise steps in addition to those explicitly mentioned above. For example, the additional steps may relate to determining further markers and / or taking pre-treatment samples or evaluating the results obtained by the above-mentioned method. The method may be performed manually or assisted by automation. Preferably, steps (a), (b) and / or (c) may be assisted, in whole or in part, by automation, for example by suitable robots and sensory equipment for the determination in step (a) or the computer-implemented calculation in step (b).

[0134] In a preferred embodiment of the method of the present invention, the subject to be tested suffers from atrial fibrillation. The atrial fibrillation may be paroxysmal, persistent or permanent atrial fibrillation. Thus, the subject may suffer from paroxysmal, persistent or permanent atrial fibrillation. In particular, it is assumed that the subject suffers from paroxysmal, persistent or permanent atrial fibrillation. The best performance has been observed in patients with persistent atrial fibrillation.

[0135] Thus, in one embodiment of the method of the present invention, the subject suffers from paroxysmal atrial fibrillation. In another embodiment of the present invention, the subject suffers from persistent atrial fibrillation. In another embodiment of the present invention, the subject suffers from permanent atrial fibrillation.

[0136] In a first aspect, the present invention provides a method for assessing stroke in a subject, comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) comparing the amount of IGFBP7 with a reference amount, thereby assessing stroke.

[0137] In a preferred embodiment, an amount of IGFBP7 higher than the reference is indicative of a subject having suffered a stroke, and an amount of IGFBP7 lower than the reference is indicative of a subject not having suffered a stroke.

[0138] In a preferred embodiment, an amount of IGFBP7 higher than the reference is indicative of a subject having suffered a stroke, and an amount of IGFBP7 lower than the reference is indicative of a subject not having suffered a stroke.

[0139] In a further preferred embodiment, the subject may be suffering from atrial fibrillation.

[0140] In a preferred embodiment, the subject is a human. Furthermore, the subject sample is preferably a blood, serum, plasma or tissue sample.

[0141] In a second aspect, the present invention relates to a method for assessing whether a subject has experienced one or more silent infarctions, the method comprising: a) determining the amount of IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) assessing whether the subject has experienced one or more silent infarctions.

[0142] In a preferred embodiment, an amount of IGFBP7 higher than the baseline is indicative of a subject that has suffered from one or more silent infarctions, and an amount of IGFBP7 lower than the baseline is indicative of a subject that has not suffered from one or more silent infarctions.

[0143] In a further preferred embodiment, the subject may be suffering from atrial fibrillation.

[0144] In a preferred embodiment, the subject is a human. Furthermore, the subject sample is preferably a blood, serum, plasma or tissue sample.

[0145] In a third aspect, the present invention provides a method for predicting silent infarction and / or cognitive decline in a subject, comprising the steps of: a) determining the amount of IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) predicting silent infarction and / or cognitive decline in a subject.

[0146] In a preferred embodiment, the risk of silent infarction is predicted. This term preferably refers to silent cerebral infarction or silent cerebral infarction (Krisai et al.).

[0147] In a further preferred embodiment, the prediction accuracy of the clinical risk score for silent cerebral infarction is improved by combining the value of the amount of IGFBP7 with the CHA2D2-VASc score.

[0148] In a preferred embodiment, cognitive decline is predicted. Alternatively, it can be predicted whether a subject is at risk of cognitive decline / dementia. The risk of cognitive decline and dementia can be assessed by cognitive testing.

[0149] Preferably, an amount of IGFBP7 higher than the baseline predicts silent infarction and / or cognitive decline in the subject, and an amount of IGFBP7 lower than the baseline does not predict silent infarction and / or cognitive decline in the subject.

[0150] In a preferred embodiment, the value of the amount of IGFBP7 is combined with the CHA2D2-VASc score to improve the predictive accuracy of the clinical risk score for silent cerebral infarction and / or cognitive decline.

[0151] Further, the risk of the subject suffering from silent infarction and / or cognitive decline is predicted within one month to five years, such as within one year or within two years.

[0152] In a further preferred embodiment, the subject may be suffering from atrial fibrillation.

[0153] Furthermore, the subject sample is preferably a blood, serum, plasma or tissue sample. In a preferred embodiment, the subject is a human.

[0154] In a fourth aspect, the present invention provides a method for improving the predictive accuracy of a clinical stroke risk score for silent infarction and / or cognitive decline in a subject, comprising: a) determining the amount of the biomarker IGFBP7 in a sample from a subject; and b) combining the value of the amount of the biomarker IGFBP7 with a clinical stroke risk score, thereby improving the predictive accuracy of said clinical stroke risk score for silent infarction and / or cognitive decline.

[0155] The study underlying the present invention shows that the determination of IGFBP7 allows for improved prediction accuracy of clinical stroke risk score for asymptomatic infarction and / or cognitive decline of subjects.Therefore, the combined determination of the clinical stroke risk score for asymptomatic infarction and / or cognitive decline and the amount of IGFBP7 allows for a more reliable prediction of clinical stroke compared to the determination of IGFBP7 alone or the determination of clinical stroke risk score alone.In addition, the risk score recommended by the ESC guidelines is not sensitive enough and misses patients due to anticoagulant therapy.The present invention detects patients on anticoagulant therapy with a higher probability than the current stroke risk score recommended by the ESC guidelines.

[0156] Thus, the method for predicting the risk of silent infarction and / or cognitive decline may further comprise combining the amount of IGFBP7 with a clinical stroke risk score. Based on the combination of the amount of IGFBP7 and the clinical risk score, the subject's risk of silent infarction is predicted.

[0157] Alternatively, the method may include obtaining or providing a value of a clinical stroke risk score. Preferably, the value is a numerical value. In an embodiment, the clinical stroke risk score is generated by one of the clinically based tools available to a physician. Preferably, the value is provided by determining a value for a clinical stroke risk score for the subject. More preferably, the value for the subject is obtained from a patient record database and medical history of the subject. Thus, the value of the score may also be determined using the subject's medical history or public data.

[0158] According to the present invention, the amount of IGFBP7 can be combined with the clinical stroke risk score of silent infarction and / or cognitive decline.This preferably means that the value for the amount of IGFBP7 is combined with the clinical stroke risk score.Thus, these values ​​are functionally combined to predict the risk that a subject suffers from silent infarction and / or cognitive decline.By combining the values, a single value can be calculated, which can be used for prediction itself.

[0159] Clinical stroke risk scores are well known in the art. For example, such scores include , Kirchhof P. et al(European Heart Journal 2016;37:2893-2962). In one embodiment, the score is the CHA2DS2-VASc score. In another embodiment, the score is the CHADS2Score (Gage BF.Et al.,JAMA,285(22)(2001),pp.2864-2870) and the ABC score, i.e., the ABC (age,biomarkers,clinical history) stroke risk score (Hijazi Z.et al.,Lancet 2016;387(10035):2302-2311). All publications in this paragraph are incorporated herein by reference for their entire disclosure.

[0160] Thus, in one embodiment, the clinical stroke risk score is the CHA2DS2-VASc score. In an alternative embodiment of the invention, the clinical stroke risk score is the CHADS2 score.

[0161] In a preferred embodiment, the value of the amount of IGFBP7 is combined with the CHA2D2-VASc score to improve the predictive accuracy of the clinical risk score for silent cerebral infarction and / or cognitive decline.

[0162] In a further preferred embodiment, the above method for predicting the risk of silent infarction and / or cognitive decline in a subject (as described elsewhere herein) further comprises the step of recommending anticoagulant therapy, or recommending intensification of anticoagulant therapy, if the subject is identified as being at risk of suffering from a stroke.

[0163] The method may comprise the further step of c) improving the predictive accuracy of said clinical stroke risk score based on the results of step b).

[0164] The definitions and explanations herein above in relation to the method of predicting the risk of silent infarction and / or cognitive decline preferably also apply to the above method.For example, it is assumed that the subject is a subject with a known clinical stroke risk score for silent infarction and / or cognitive decline.Alternatively, the method may include obtaining or providing the value of the clinical stroke risk score for silent infarction and / or cognitive decline.

[0165] Further, the risk of the subject suffering from silent infarction and / or cognitive decline is predicted within one month to five years, such as within one year or within two years.

[0166] In some embodiments, the subject may be suffering from atrial fibrillation. Furthermore, the subject sample is preferably a blood, serum, plasma or tissue sample. In a preferred embodiment, the subject is a human.

[0167] In a fifth aspect of the invention, the method relates to the assessment of the extent of asymptomatic small and large non-cortical and cortical infarcts in a subject, the method comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) assessing the extent of asymptomatic large non-cortical or cortical infarction in the subject based on the amount determined in step a).

[0168] The definitions given herein above preferably apply mutatis mutandis to the following method for the assessment of the extent of white matter lesions.

[0169] Interestingly, in the study underlying the present invention, the biomarker IGFBP7 was shown to be a predictor of the risk, presence and / or absence of cerebrovascular damage as a cause of cognitive decline and cognitive impairment in patients with atrial fibrillation. It has been shown that IGFBP7 can be used to estimate the severity of cerebral infarction. Specifically, IGFBP7 has been shown to correlate with the presence of asymptomatic small and large noncortical or cortical infarctions (LNCCI or SNCI) and white matter lesions (WML) in patients. The term "LNCCI" is defined as a large noncortical or cortical infarction, and the term "SNCI" is defined as a small noncortical infarction.

[0170] In a preferred embodiment, "subjects with asymptomatic large non-cortical or cortical infarcts (LNCCI)" are evaluated.

[0171] In some embodiments of the aforementioned method, the subject may be suffering from atrial fibrillation. Furthermore, the subject sample is preferably a blood, serum, plasma or tissue sample. In a preferred embodiment, the subject is a human.

[0172] In a sixth aspect of the invention, the method relates to assessing the extent of white matter pathology in a subject, the method comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) assessing the extent of white matter pathology in the subject based on the amount determined in step a).

[0173] The higher the amount of IGFBP7, the higher the degree of LNCCI or SNCI or WML (and vice versa).Therefore, IGFBP7 can be used as a marker to assess the degree of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions and / or cognitive function in a subject.

[0174] The above definitions provided herein preferably apply mutatis mutandis to the following methods.

[0175] The extent of white matter lesions or asymptomatic large non-cortical or cortical infarcts may be caused by clinically silent infarcts. Therefore, the biomarker IGFBP7 can further be used to assess whether a subject has experienced one or more silent infarcts in the past, i.e., before the sample was obtained.

[0176] In a preferred embodiment, the test subject suffers from atrial fibrillation. Furthermore, the risk of suffering from silent infarction and / or cognitive decline in the subject within one month to five years, for example within one year or within two years, is predicted.

[0177] In a seventh aspect of the invention, the method comprises a method for monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions and / or cognitive function in a subject, comprising the steps of: a) determining the amount of IGFBP7 in a first sample from a subject; b) determining the amount of IGFBP7 in a second sample from the subject obtained after the first sample; c) comparing the amount of IGFBP7 in the first sample with the amount of IGFBP7 in the second sample; and d) monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or cognitive function of the subject based on the results of step c).

[0178] In one embodiment of the invention, the method comprises: a) recommending anticoagulant therapy; b) recommending intensification of anticoagulant therapy; c) strengthening risk factor management; and d) providing care at a specialized clinic.

[0179] The method of the present invention can aid in personalized medicine. In a preferred embodiment, the method for predicting a subject's risk of silent infarction further comprises the step of i) recommending anticoagulant therapy, or ii) recommending intensification of anticoagulant therapy, if the subject is identified as being at risk of silent infarction. In another preferred embodiment, the method for predicting a subject's risk of silent infarction further comprises the step of i) initiating anticoagulant therapy, or ii) intensifying anticoagulant therapy, if the subject is identified (by the method of the present invention) as being at risk of silent infarction.

[0180] In particular, the following applies:

[0181] If the subject being tested is not on anticoagulant therapy, initiation of anticoagulant therapy is recommended if the subject is identified as being at risk for suffering from silent infarction, and therefore anticoagulant therapy should be initiated.

[0182] If the subject being tested is already on anticoagulant therapy, intensification of anticoagulant therapy is recommended if the subject has been identified as being at risk for suffering from silent infarction, and therefore anticoagulant therapy shall be intensified.

[0183] In a preferred embodiment, anticoagulant therapy is intensified by increasing the dose of anticoagulant, ie, the dose of coagulant currently being administered.

[0184] In a particularly preferred embodiment, anticoagulant therapy is intensified by replacing a currently administered anticoagulant with a more effective anticoagulant. Accordingly, replacement of the anticoagulant is recommended.

[0185] As shown in Hijazi at al., The Lancet 2016 387, 2302-2311 (Figure 4), it has been described that better prophylaxis in high-risk patients is achieved with the oral anticoagulant apixaban compared to the vitamin K antagonist warfarin.

[0186] It is therefore envisaged that the subject to be tested is a subject treated with a vitamin K antagonist, such as warfarin or dicoumarol. If the subject is identified (by the method of the present invention) as being at risk of suffering from silent infarction, replacement of the vitamin K antagonist with an oral anticoagulant, in particular dabigatran, rivaroxaban or apixaban, is recommended. Thus, treatment with the vitamin K antagonist is discontinued and treatment with an oral anticoagulant is initiated.

[0187] The terms "subject" and "sample" are defined above. The above definitions apply where appropriate. In particular, it is envisaged that the subject does not suffer from atrial fibrillation. Furthermore, the sample may be, for example, a blood, serum or plasma sample, or a tissue sample.

[0188] Preferably, the following diagnostic algorithm is applied:

[0189] An amount of IGFBP7 higher than the baseline is indicative of a subject that has experienced one or more silent infarctions, and / or an amount of IGFBP7 lower than the baseline is indicative of a subject that has not experienced a silent infarction.

[0190] The above definitions in this specification preferably apply mutatis mutandis hereinafter.

[0191] The research carried out in the present invention shows that it is possible to monitor a subject based on the change in IGFBP7 amount.For example, it can monitor whether the degree of asymptomatic large and small non-cortical or cortical infarction and the degree of white matter lesion, i.e. the degree of large and small non-cortical infarction or cortical infarction, increases.Since the increase in the degree of asymptomatic small and large non-cortical or cortical infarction and white matter lesion can be related to cognitive function decline, the determination of biomarker IGFBP7 also allows the cognitive function of a subject to be monitored.

[0192] Accordingly, the present invention further provides a method for monitoring a subject, comprising the steps of: a) determining the amount of the biomarker IGFBP7 in a first sample from a subject; b) determining the amount of the biomarker IGFBP7 in a second sample from the subject obtained after the first sample; c) comparing the amount of biomarker IGFBP7 in the first sample with the amount of biomarker IGFBP7 in the second sample; and d) monitoring the subject based on the result of step c).

[0193] The present invention further relates to an in vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 for monitoring a subject. In some embodiments, the biomarker IGFBP7 or the agent is used in a first and a second sample from the subject.

[0194] The subject being monitored may be a subject defined in connection with a method for predicting risk of silent infarction and / or cognitive decline, for example, the subject may suffer from atrial fibrillation.

[0195] Preferably, the extent of white matter lesions and / or asymptomatic small and / or large non-cortical or cortical infarctions and / or cognitive function of the subject is monitored.However, it is also envisaged to monitor the morphological changes of the myocardial atrium, cerebral infarction, cerebral microbleeds, the progression of arrhythmias, the progression of comorbidities (hypertension or diabetes) and / or the progression of depression symptoms.Alternatively, the amount of functional brain tissue may be monitored.

[0196] The monitoring is based on a comparison of the amount of the biomarker IGFBP7 in the first sample with the amount of the biomarker IGFBP7 in the second sample. A "second sample" is understood to be a sample obtained to reflect changes in the amount of the biomarker IGFBP7 compared to the amount of IGFBP7 in the first sample. The second sample is therefore intended to be obtained after the first sample. Preferably, the second sample is not obtained immediately after the first sample (to observe changes significant enough to allow monitoring). In one embodiment, the second sample is obtained at least one month after the first sample. In another embodiment, the second sample is obtained one month after the first sample. In other embodiments, the second sample is obtained at least one or two years after the first sample. Furthermore, it is envisaged that the second sample is obtained within 15 years, within 10 years, or in particular within 5 years from the first sample. Thus, the second sample can be obtained, for example, at least one month but not more than 5 years after the first sample.

[0197] It is further envisaged that the subject exhibited a silent infarction between the first and second samples, the term "silent infarction" being defined herein above.

[0198] Preferably, an increase, particularly a significant increase, in the amount of the biomarker IGFBP7 in the second sample compared to the first sample is indicative of an increase in the extent of silent infarction LNCCI in the subject and / or a decrease in the severity of the disease. The results indicate a decline in cognitive function of the elephant. Thus, between the first sample and the second sample, the degree of LNCCI has increased and / or cognitive function has declined. A significantly increased amount of the biomarker IGFBP7 should be understood to be an increase that is greater than the average decrease in a group of control subjects. In some embodiments, an increase of at least 0.5% (e.g., per year), such as an increase of at least 1% (e.g., per year) of the amount of the biomarker IGFBP7 indicates an increase in the degree of silent infarction LNCCI and / or a decline in cognitive function.

[0199] The above definitions in this specification preferably apply mutatis mutandis hereinafter.

[0200] The present invention further relates to a method for diagnosing the severity of cognitive decline in a subject suffering from cognitive decline, the method comprising: a) determining the amount of the biomarker IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) preferably comprising a step of diagnosing the severity of the subject's cognitive decline based on the results of step c).

[0201] The terms "subject" and "sample" are defined above. The previous definitions apply where appropriate. For example, it is envisioned that the subject was in sinus rhythm at the time the sample was obtained.

[0202] Diagnosis of cerebrovascular injury such as white matter lesions, asymptomatic large noncortical or cortical infarcts and / or clinically silent infarcts (including lesion size, location and type) is typically performed today using lengthy and costly magnetic resonance imaging (MRI). However, determination of IGFBP7 allows for rapid and cost-effective pre-selection for brain MRI.

[0203] The methods of the invention may further comprise the step of subjecting patients identified as being at risk of silent infarctions and / or cognitive decline, patients identified as having high-grade silent small and / or large non-cortical or cortical infarcts and / or white matter lesions, patients identified as having previously experienced one or more silent infarcts, and / or patients diagnosed as suffering from AF to magnetic resonance imaging (MRI) of the brain, in particular MRI to assess cerebrovascular damage.

[0204] In an eighth aspect of the invention, the method relates to the in vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 for the prediction of silent infarction and / or cognitive decline in a subject.

[0205] The present invention further relates to the in vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 for assessing the extent of asymptomatic small and / or large non-cortical or cortical infarcts in a subject.

[0206] The present invention further relates to the in vitro use of the biomarker IGFBP7, or an agent that binds to the biomarker IGFBP7, to aid in the assessment of the extent of white matter pathology in a subject.

[0207] The present invention further provides an in vivo assay for the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 to aid in the assessment of whether a subject has experienced one or more silent infarctions. Regarding in vitro use.

[0208] The present invention further relates to the in vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 for improving the predictive accuracy of a subject's clinical stroke risk score.

[0209] Preferably, the above uses are in vitro uses. Thus, they are preferably carried out in a sample obtained from a subject. Furthermore, the detection agent is preferably an antibody, such as a monoclonal antibody (or an antigen-binding fragment thereof) that specifically binds to the biomarker IGFBP7.

[0210] The methods of the present invention may also be practiced as computer-implemented methods.

[0211] In a ninth aspect of the invention, the present invention relates to a computer implemented method for predicting stroke and / or silent infarction and / or cognitive decline in a subject, the method comprising: a) receiving in a processing unit a value of the amount of the biomarker IGFBP7 in a sample from a subject; b) processing the value received in step (a) with a processing unit, the processing step comprising retrieving from a memory one or more threshold values ​​for the amount of biomarker IGFBP7 and comparing the value received in step (a) with the one or more threshold values; c) providing via an output device a prediction of silent infarction and / or cognitive decline, the prediction being based on the results of step (b).

[0212] The present invention further relates to a computer-implemented method for assessing the extent of an asymptomatic large non-cortical or cortical infarct in a subject, the method comprising: a) receiving in a processing unit a value of the amount of the biomarker IGFBP7 in a sample from a subject; b) processing the value received in step (a) with a processing unit, the processing step comprising retrieving from a memory one or more threshold values ​​for the amount of biomarker IGFBP7 and comparing the value received in step (a) with the one or more threshold values; e) providing via an output device an assessment of the extent of white matter pathology in the subject, said assessment being based on the results of step b).

[0213] The present invention further relates to a computer-implemented method for assessing whether a subject has experienced one or more silent infarctions, the method comprising: a) receiving in a processing unit a value of the amount of the biomarker IGFBP7 in a sample from a subject; b) processing the value received in step (a) with a processing unit, the processing step comprising retrieving from a memory one or more threshold values ​​for the amount of biomarker IGFBP7 and comparing the value received in step (a) with the one or more threshold values; c) providing via an output device an assessment of whether the subject has experienced one or more silent infarctions, said assessment being based on the results of step (b).

[0214] In some embodiments of the method of the present invention, information regarding the prediction, assessment or diagnosis (by the final step of the computer-implemented method of the present invention) is provided via a display configured to present the prediction, assessment or diagnosis. For example, information may be provided whether the subject is at risk of silent infarction and / or cognitive decline. Furthermore, a recommendation for an appropriate treatment may be displayed.

[0215] In an embodiment of the aforementioned computer-implemented method of the invention, the method may comprise the further step of transferring information regarding the determination made in step c) to the subject's electronic medical record.

[0216] Alternatively, the assessment performed in the last step of the method of the present invention can be printed by a printer, the printout containing information on whether the patient is at risk, not at risk, and / or a recommendation for appropriate therapeutic action.

[0217] The present invention further relates to a computer program comprising computer executable instructions for carrying out the steps of the method according to the invention when the program is executed on a computer or a computer network. Typically, the computer program may comprise computer executable instructions in particular for carrying out the steps of the method disclosed herein. In particular, the computer program may be stored on a computer readable data medium.

[0218] The present invention further relates to a computer program product having program code means stored on a machine-readable carrier for executing a computer-implemented method according to the invention, such as a computer-implemented method for prediction of stroke and / or cognitive decline, when the program is executed on a computer or computer network, e.g. one or more of the above steps discussed in the context of a computer program. As used herein, a computer program product refers to a program as a tradeable product. The product is generally present in any format, such as a paper format or on a computer-readable data carrier. In particular, the computer program product may be distributed over a data network.

[0219] The invention further relates to a computer or a computer network comprising at least one processing unit, the processing unit being adapted to carry out all the steps of the computer-implemented method according to the invention.

[0220] Additionally, the present invention also contemplates the following. a computer or a computer network comprising at least one processing unit, the processing unit being adapted to carry out the method according to one of the embodiments described in this description, a computer-loadable data structure adapted to carry out a method according to one of the embodiments described in this specification while said data structure is executed on a computer, a computer script adapted to carry out a method according to one of the embodiments described in this specification while the program is running on a computer, a computer program comprising program means for carrying out a method according to one of the embodiments described in this specification while said computer program is being run on a computer or on a computer network, a computer program comprising program means according to any preceding embodiment, the program means being stored on a computer readable storage medium; a storage medium on which a data structure is stored and adapted to carry out a method according to one of the embodiments described herein after the data structure has been loaded into a primary and / or working storage device of a computer or a computer network, a computer program product comprising program code means in which the program code means can be stored or can be stored on a storage medium for performing a method according to one of the embodiments described in this specification when the program code means is executed on a computer or a computer network, a data stream signal, typically encrypted, comprising glucose data measurements obtained from an individual as specified herein above, and - A data stream signal, typically encrypted, containing information aiding in the evaluation of the guidance obtained by the method of the present invention.

[0221] In further embodiments, the present invention relates to the following: In the following, embodiments of the present invention are summarized. The definitions given herein above preferably apply to the following embodiments.

[0222] 1. A method for assessing stroke in a subject, comprising: a) determining the amount of IGFBP7 in a sample from said subject; and b) comparing the amount of IGFBP7 with a reference amount, thereby assessing stroke.

[0223] 2. A method for assessing whether a subject has experienced one or more silent infarctions, comprising: a) determining the amount of IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) assessing whether the subject has experienced one or more silent infarctions.

[0224] 3. The method according to any one of claims 1 to 2, wherein an amount of IGFBP7 higher than the reference level indicates a subject suffering from stroke and / or silent infarction, and / or an amount of IGFBP7 lower than the reference level indicates a subject not suffering from stroke and / or silent infarction.

[0225] 4. A method for predicting silent infarction and / or cognitive decline in a subject, comprising: a) determining the amount of IGFBP7 in a sample from a subject; b) comparing the amount determined in step a) with a standard; and c) predicting silent infarction and / or cognitive decline in a subject.

[0226] 5. The method according to any one of claims 2 to 4, wherein the combination of the IGFBP7 quantity value with the CHA2D2-VASc score improves the predictive accuracy of the clinical risk score for silent cerebral infarction and / or cognitive decline.

[0227] 6. A method for improving the predictive accuracy of a clinical risk score for silent infarction and / or cognitive decline in a subject, comprising: a) determining the amount of IGFBP7 in a sample from a subject; and b) improving the prediction accuracy of the clinical risk score for asymptomatic cerebral infarction by combining the value of the amount of IGFBP7 with the clinical risk score for asymptomatic cerebral infarction.

[0228] 7. The method of claim 6, wherein the risk of the subject to suffer from silent infarction and / or cognitive decline in a subject within 1 month to 5 years, such as within 1 year or within 2 years, is predicted.

[0229] 8. A method for assessing the extent of asymptomatic small and large non-cortical and cortical infarcts in a subject, comprising: a) determining the amount of said IGFBP7 in a sample from a subject; and b) assessing the extent of asymptomatic large non-cortical or cortical infarction in said subject based on the amount determined in step a).

[0230] 9. A method for assessing the extent of white matter pathology in a subject, comprising: a) determining the amount of said IGFBP7 in a sample from a subject; and b) assessing the extent of white matter pathology in the subject based on the amount determined in step a). The method comprises the step of:

[0231] 10. The method of any one of embodiments 1 or 9, wherein the subject is suffering from atrial fibrillation.

[0232] 11. The method of any one of embodiments 1 or 10, wherein said atrial fibrillation is paroxysmal or persistent atrial fibrillation.

[0233] 12. The method of any one of embodiments 1 or 11, wherein said subject is a human and / or said sample is preferably blood, serum or plasma, or said sample is a tissue sample.

[0234] 13. The method of any one of embodiments 1 to 12, wherein the biomarker IGFBP7 is an IGFBP7 polypeptide.

[0235] 14. The method of any one of embodiments 1-13, wherein the subject is 65 years of age or older.

[0236] 15. The method of any one of embodiments 1 to 14, wherein the subject has a history of stroke and / or TIA (transient ischemic attack).

[0237] 16. The method of any preceding embodiment, wherein the subject was in sinus rhythm at the time the sample was obtained.

[0238] 17. A method for monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions and / or cognitive function in a subject, comprising: a) determining the amount of IGFBP7 in a first sample from a subject; b) determining the amount of IGFBP7 in a second sample from the subject obtained subsequent to the first sample; c) comparing the amount of IGFBP7 in the first sample with the amount of IGFBP7 in the second sample; and d) monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or cognitive function of the subject based on the results of step c).

[0239] 18.a) recommending anticoagulant therapy; b) recommending intensification of anticoagulant therapy; c) strengthening risk factor management; and d) Care at a specialized clinic 18. The method of any one of claims 1 to 17, further comprising:

[0240] 19. A computer-implemented method for predicting stroke and / or silent infarction and / or cognitive decline in a subject, comprising: a) receiving in a processing unit a value of the amount of IGFBP7 in a sample from a subject; b) processing the value received in step (a) with the processing unit, the processing step comprising retrieving from a memory one or more thresholds for the amount of IGFBP7 and comparing the value received in step (a) with the one or more thresholds; and c) providing a prediction of silent infarction and / or cognitive decline via an output device. providing, wherein the prediction is based on the result of step (b).

[0241] 20. A computer-implemented method according to any one of claims 19, wherein the method further comprises receiving in the processing unit of step a) a further CHA2D2-VASc score value.

[0242] 21.a) To predict silent infarction and / or cognitive decline in a subject; b) to assess the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions in a subject; or c) In vitro use of IGFBP7 or an agent that binds to IGFBP7 to improve the predictive accuracy of a subject's clinical stroke risk score.

[0243] 22. I. IGFBP7 is an IGFBP7 polypeptide, II. The subject is a human; III. The subject is 65 years of age or older; and / or IV. The method of any one of claims 1 to 14, or the in vitro use of claim 14, wherein the subject has no known history of stroke and / or TIA (transient ischemic attack).

[0244] 23. In vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 to assess whether a subject has experienced one or more silent strokes.

[0245] 24. In vitro use of the biomarker IGFBP7 or an agent that binds to the biomarker IGFBP7 to improve the predictive accuracy of a subject's clinical stroke risk score.

[0246] All references cited herein are hereby incorporated by reference with respect to their entire disclosure content and the disclosure content specifically mentioned in this specification. EXAMPLES

[0247] result Example 1: Prediction of silent cerebral infarction (LNCCI and SNCI) based on circulating IGFBP-7 levels IGFBP7 in assessing silent cerebral infarction: 1. Methods for predicting the risk of silent cerebral infarction in patients with atrial fibrillation based on circulating IGFBP7 levels in serum / plasma (SWISSAF study, Tables 1 and 2) 2. To provide a method to improve the prediction of clinical accuracy of clinical stroke risk scores for silent cerebral infarction based on circulating IGFBP7 levels in serum / plasma (e.g., CHA2DS2-VASc, CHADS2 score) (SWISS AF study, Table 3).

[0248] The ability of circulating IGFBP7 to predict the risk of developing silent infarction was assessed in the SWISS AF study (Conen D., Forum Med Suisse 2012;12:860-862; Conen et al., Swiss Med Wkly. 2017;147). Patients in the SWISS AF cohort had a median age of 74 years, a rate of previous clinical stroke or TIA of 20%, a rate of vascular disease of 34% and a history of diabetes mellitus in 17%.

[0249] IGFBP7 was measured in the complete SWISS AF study using a pre-commercial assay, Insulin-like growth factor binding protein 7 (IGFBP-7) (high-throughput Elecsys® immunoassay; Roche Diagnostics, Mannheim, Germany). For detection of IGFBP-7, A sandwich immunoassay was developed for the obas Elecsys® ECLIA platform.

[0250] Because estimates from a naive proportional hazards model in the case-control cohort are biased (because the ratio of cases to controls changes), we used a weighted proportional hazards model. Weights are based on the inverse probability of each patient being selected into the case-control cohort. To obtain estimates for absolute survival in the two groups based on dichotomized baseline IGFBP7 measurements (≦median vs. >median), we created a weighted version of the Kaplan-Meier plot.

[0251] To assess the ability of IGFBP7 to improve existing risk scores for stroke prognosis, CHADS2, CHA2DS2-VASc and ABC scores were extended with IGFBP7 (log2 transformed). Extensions were performed by creating partial hazard models including IGFBP7 and the respective risk scores as independent variables.

[0252] The c-indices of the CHADS2 and CHA2DS2-VASc and ABC scores were compared with the c-indices of these extended models. For the calculation of the c-indices in the case-cohort setting, we used a weighted version of the c-index as proposed in Ganna (2011).

[0253] result [Table 1]

[0254] Patients with LNCCI or SNCI on bMRI were older (75.0 vs. 68.1 years, p<0.0001), had more frequent persistent AF (28.4 vs. 17.8%, p=0.0002), had higher systolic BP levels (136.7 vs. 131.3 mmHg, p<0.0001) and higher CHA2DS2-VASc scores (3.2 vs. 2.1 points, p<0.0001), but showed no difference in the rate of oral anticoagulation therapy (90.3 vs. 88.5%, p=0.32). As shown in Table 1, IGFBP-7 has significantly higher levels in patients with brain lesions.

[0255] As shown in Table 1, the risk of silent cerebral infarction in patients with atrial fibrillation can be assessed based on circulating IGFBP7 levels in serum / plasma.

[0256] [Table 2]

[0257] As shown in Table 2 , IGFBP-7 was significantly associated with LNCCI after multivariate adjustment for age and sex (model 1) or age, sex, systolic blood pressure, previous major bleeding, arterial hypertension, diabetes mellitus, coronary artery disease, peripheral vascular disease, BMI, smoking status, oral anticoagulant use, and antiplatelet drug use.

[0258] Therefore, the risk of silent cerebral infarction in patients with atrial fibrillation can be assessed based on circulating IGFBP-7 levels in serum / plasma.

[0259] [Table 3]

[0260] When we added individual biomarkers to the CHA2DS2-VASc score, the AUC (95% CI) was improved by IGFBP-7 (0.639 (0.593; 0.685) p = 0.03), as shown in Table 3.

[0261] The combination of clinical parameters IGFBP-7 and the CHA2DS2-VASc score predicted clinically silent cerebral infarction well and outperformed the CHA2DS2-VASc score.Early clinical identification of patients at risk of cognitive decline may allow for better

[0262] Example 2: Prediction of White Matter Lesions (WML) Based on Circulating IGFBP7 Levels Data in the SWISS-AF data show that IGFBP7 correlates with the presence of white matter lesions (WMLs) in patients.

[0263] The extent of material lesions was evaluated using the Fazekas score (Fazekas, J.B. Chawluk, A Alavi, HI Hurtig, and RA Zimmerman American Journal of Roentgenology 1987 149:2,351-356). Fazekas score ranges from 0 to 3, with 0 indicating no WML, 1 indicating mild WML, 2 indicating moderate WML, and 3 indicating severe WML. To compare the association between IGFBP7 and WML patients, they were classified into two groups: Fazekas score <2 (absent) vs. Fazekas score ≥2 (present). Figure 1 shows that IGFBP7 is increased in patients with moderate or severe WML compared to patients with mild or no WML.

[0264] The extent of WML may be caused by clinically silent stroke (Wang Y, Liu G, Hong D, Chen F, Ji X, Cao G. White matter injury in ischemic stroke. Prog Neurobiol. 2016;141:45-60. doi:10.1016 / j.pneurobio.2016.04.005), which further argues for the utility of IGFBP7 for predicting risk of clinical stroke.

[0265] The ability of circulating IGFBP7 to discriminate patients with Fazekas score <2 (absent) versus Fazekas score ≥2 (present) is shown by an AUC of 0.60. Brain white matter changes in patients with dementia. Aging and changes in WML score have been described to be associated with the severity of dementia in patients with Alzheimer's disease (Kao et al., 2019).

[0266] Age is also a significant predictor of clinical stroke, so data showing significantly increased circulating IGFBP7 levels may indicate not only moderate or severe WML, but also age-related brain diseases, such as vascular dementia.

Claims

1. 1. A method for assessing whether a subject has experienced one or more silent infarctions, comprising: a) determining the amount of IGFBP7 in a sample from said subject; b) comparing the amount determined in step a) with a standard; and c) assessing whether the subject has experienced one or more silent infarctions A method comprising:

2. 2. The method of claim 1, wherein an amount of IGFBP7 higher than the baseline indicates a subject that has suffered from one or more silent infarctions, and an amount of IGFBP7 lower than the baseline indicates a subject that has not suffered from one or more silent infarctions.

3. 1. A method for predicting silent infarction and / or cognitive decline in a subject, comprising: a) determining the amount of IGFBP7 in a sample from said subject; b) comparing the amount determined in step a) with a standard; and c) predicting silent infarction and / or cognitive decline in said subject A method comprising:

4. 1. A method for improving the predictive accuracy of a clinical risk score for silent infarction and / or cognitive decline in a subject, comprising: a) determining the amount of IGFBP7 in a sample from said subject; and b) improving the prediction accuracy of the clinical risk score for silent cerebral infarction by combining the value of the amount of IGFBP7 with the clinical risk score for silent cerebral infarction; A method comprising:

5. The amount of IGFBP7 was calculated using CHA ２ D ２ The method according to any one of claims 1 to 4, wherein the predictive accuracy of the clinical risk score for silent cerebral infarction and / or cognitive decline is improved by combining with the VASc score.

6. 6. The method of any one of claims 3 to 5, wherein the risk of the subject to suffer from silent infarction and / or cognitive decline in a subject within 1 month to 5 years, such as within 1 year or within 2 years, is predicted.

7. 1. A method for assessing the extent of asymptomatic small and large non-cortical and cortical infarcts in a subject, comprising: a) determining the amount of IGFBP7 in a sample from said subject; and b) assessing the extent of asymptomatic large non-cortical or cortical infarction in said subject based on the amount determined in step a). A method comprising:

8. 1. A method for assessing the extent of white matter pathology in a subject, comprising: a) determining the amount of IGFBP7 in a sample from said subject; and b) assessing the extent of white matter pathology in the subject based on the amount determined in step a). A method comprising:

9. 1. A method for monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions and / or cognitive function in a subject, comprising: a) determining the amount of IGFBP7 in a first sample from said subject; b) determining the amount of IGFBP7 in a second sample from the subject obtained after the first sample; determining c) comparing the amount of IGFBP7 in the first sample with the amount of IGFBP7 in the second sample; and d) monitoring the extent of asymptomatic small and large non-cortical or cortical infarcts and / or cognitive function of the subject based on the results of step c). A method comprising:

10. a) recommending anticoagulant therapy; b) recommending intensification of anticoagulant therapy; c) strengthening risk factor management; and d) Care at a specialized clinic The method of claim 1 , further comprising:

11. 11. The method of claim 1 or 10, wherein the subject is suffering from atrial fibrillation.

12. 12. The method according to claim 1 or 11, wherein the subject is a human and / or the sample is preferably blood, serum or plasma, or the sample is a tissue sample.

13. 1. A computer-implemented method for predicting silent infarction and / or cognitive decline in a subject, comprising: a) receiving in a processing unit a value of the amount of IGFBP7 in a sample from said subject; b) processing the value received in step (a) with the processing unit, the processing unit comprising retrieving from a memory one or more thresholds for the amount of IGFBP7 and comparing the value received in step (a) with the one or more thresholds; and c) providing a prediction of silent infarction and / or cognitive decline via an output device, said prediction being based on the results of step (b); 4. A computer-implemented method comprising:

14. More CHA ２ D ２ 14. The computer-implemented method of claim 13, wherein the method further comprises the step of receiving in the processing unit of step a) a value of the -VASc score.

15. a) predicting silent infarction and / or cognitive decline in a subject; b) to assess the extent of asymptomatic small and large non-cortical or cortical infarcts and / or white matter lesions in a subject; or c) To improve the predictive accuracy of a subject's clinical stroke risk score In vitro use of IGFBP7 or agents that bind to IGFBP7.

16. I. IGFBP7 is an IGFBP7 polypeptide; II. The subject is a human; III. The subject is 65 years of age or older, and / or IV. The subject has no known history of stroke and / or TIA (transient ischemic attack); 16. The method according to any one of claims 1 to 14, or the in vitro use according to claim 15.

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