What is the PULS Cardiac TestTM?

The PULS Cardiac Test is a serum blood test that identifies the asymptomatic “Vulnerable Patient” by quantifying endothelial damage, predicting Acute Coronary Syndromes (ACS), and improving patient care.

How does the PULS Cardiac Test quantify endothelial damage?

The PULS Cardiac Test quantifies 9 clinically-significant protein biomarkers that are activated by the body’s immune response to endothelial damage. These measurements are calculated into a single score that predicts ACS in a 5-year time frame. From this score, physicians can intervene to prevent disease progression and improve patient care.

How do unstable cardiac lesions form?

A cardiac lesion forms when oxidized lipids or other free radicals cause arterial damage. The arterial wall becomes “leaky”, allowing more particles to bind to the arterial surface resulting in a lesion that resembles a blister or pimple comprised of a thin cap and lipid core (plaque) that may become unstable and prone to rupture. The process releases molecules that attract white blood cells (monocytes, granulocytes, eosinophils, and T-cells) to the arterial wall.

Why test for unstable cardiac lesions?

The rupture of unstable cardiac lesions causes 75% of all heart attacks. Over 50% of individuals are “vulnerable patients”, or those who are unaware they have active formation of cardiac lesions that can eventually rupture without warning. In fact, 50% of all heart attacks are silent, meaning the patient felt no pain and was not hospitalized. Being able to detect individuals with unstable cardiac lesions that are likely to rupture prior to a cardiac event is crucial to preventive cardiology.

Is the PULS Test right for me?

The PULS Cardiac Test is optimized for patients 40 years or older who have had no previous history of a Heart Attack (myocardial infarction). The clinical situation and medical necessity can dictate use in younger patients.

Is there a Heart Disease test for patients under 40?

AHA Guidelines recommend getting a baseline CHD assessment in individuals starting at age 20. Basic and Expanded Lipid Profiles are baseline assessments appropriate for patients under 40 years old. Contact Client Services at (866) 299-8998 for more information.

How was the test developed?

The test was developed through multiple longitudinal outcomebased studies with multiple institutions over a 15-year period of collaborative research. All available biomarkers and global risk factors were evaluated statistically by three dierent software systems to determine which permutations were most indicative of endothelial damage and predictive of ACS in a 5-year time frame. From these studies, the 9 biomarkers of significance emerged and became the core of the PULS Cardiac Test.

What are the 9 proteins used to detect endothelial injury leading to unstable lesion rupture?

Since multiple pathways are involved in formation of unstable cardiac lesions, no single biomarker can adequately characterize the lesions. Multiple biomarkers are needed to achieve the necessary sensitivity and specificity. The PULS Cardiac Test uses 9 of the most clinically-significant protein biomarkers to measure the body’s immune response to coronary artery endothelial damage that leads to unstable lesion formation and rupture:


IL-16 - “Signaling Molecule” triggers repair process. Immune response begins.


MCP-3 - Macrophage attracts monocytes and converts to foam cells. Gives immune cells direction and activity.

Eotaxin - Eosinophil consumes fibrin and prevents blood clot.

Activates immune cells at areas of damage.

CTACK - Helps regulate local inflammatory response and cleans up damaged tissue.


sFas - Cell repair “prevents cell death”

Fas Ligand - Initiates cell death and recycling

HGF - Forms collagen. Stimulates tissue and repair.


HDL - Helps remove bad cholesterol and neutralizes free radicals

HbA1c - Diabetes Marker

How were PULS biomarkers selected and validated?

The original studies for the PULS Cardiac Test were initiated at Stanford University and Kaiser Permanente. Researchers analyzed gene expression profiles in the lesions of mouse models of ACS (mice do not form hard plaque) . Over 250 candidate proteins were identified in mice lesions and many of them were shown to be conserved in humans by analysis of soft lesions during CABG. The number of biomarker candidates was narrowed from 50 to 9 pathways during additional studies. Various permutations of these biomarkers with existing biomarkers like LP-PLA2 and hsCRP, and global risk factors were tested by 3 software systems (Akaike, Bayesian, and Drop-inDeviance) to predict a 5 year risk of ACS. This process resulted in all three systems identifying the same 9 biomarkers and 4 global risk factors (age, sex, diabetic status, and family history). These biomarkers and global risk factors were then incorporated into a benchmark algorithm format with performance superior to gold standard measures of risk such as Framingham, Reynolds, etc. The resulting algorithm yielded a clinical net reclassification index of 43% (this index penalizes an algorithm for falsely up-classifying and down-classifying patients; values above 10% when compared to Framingham are considered good). The algorithm (PULS) was then independently validated by the NIH NHLBI group in MESA which confirmed the findings. These clinical trials were all longitudinal outcome-based studies.

How have studies for PULS biomarkers been able to accurately measure endothelial health when other studies have failed?

Many groups have tried to utilize biomarkers to evaluate Acute Coronary Syndromes (ACS) and have been unsuccessful. In working with the NIH NHLBI MESA group, researchers for the PULS Cardiac Test were asked to evaluate why these previous, well designed studies failed to identify patients who were missed by conventional analysis. Researchers discovered the problem was in the previous analytic system used in these studies. The immunoassays used had strong cross-reactivity within the components, precluding enough analytic discrimination to be informative. Clinical researchers for the PULS Cardiac Test were able to avoid this problem by designing sensitive and specific assays with minimal or no cross-reactivity ( <1%).

Can individual biomarkers effectively measure endothelial damage leading to unstable cardiac lesion formation?

A number of pathways are responsible for free radical damage to the endothelium, resulting repair, and inflammatory response that creates an unstable cardiac lesion. If one looks at a biopsy of an unstable cardiac lesion, one will see pathways that include macrophages, T-cells, eosinophils and some neutrophils, apoptosis, fibrin, smooth muscle hypertrophy and other repair changes.

Individual biomarkers provide insucient information to adequately characterize this process. Multiple biomarkers representing multiple pathways are required to adequately define this process.

PULS protein biomarkers cover 9 of the pathways involved in the formation and progression of unstable cardiac lesions. Seven of the biomarkers are 98% sensitive and specific for diagnosing endothelial injury or dysfunction and identifying the formation of cardiac lesions.

The algorithm predicts the progression of these cardiac lesions and predicts when they might become unstable and prone to rupture (ACS) in the following 5 year period.

A key point is there are many biomarkers and global risk factors (i.e. age) that correlate with Heart Disease. However, few biomarkers indicate whether an individual has the disease. PULS biomarkers not only identify Coronary Heart Disease, they can determine disease stage. The PULS algorithm can predict the likelihood of an unstable cardiac lesion rupture (ACS) in the following 5-year period.

How does the PULS Cardiac Test complement and compare to current clinical testing for Coronary Heart Disease?

The PULS Cardiac Test is not intended to replace any current tests or diagnostic modalities. The PULS test gives a unique characterization of the patients cardiac health that is best used in context with other existing diagnostic tests like lipid studies to better characterize a patient’s cardiac health.

Diagnostic & Predictive

The PULS Cardiac Test is both a diagnostic and predictive cardiac test. While other CHD clinical tests (such as cholesterol) evaluate the risk of developing CHD, the PULS Cardiac Test detects silent damage to the coronary arteries, assesses disease stage, and predicts likelihood of ACS.

Identifies Low & High Risk “Vulnerable” Patients

Unlike traditional tests for Heart Disease, the PULS Cardiac Test can detect the early stages of endothelial or arterial injury, diagnose disease stage, and predict how likely the patient is to suer an unstable cardiac lesion rupture (myocardial infarction). This means the test is not only high-eective at identifying highrisk vulnerable patients, it can also can identify patients who are at low risk for heart attack, ensuring that interventions are focused only on those patients who actually need them. Providing the information on both ACS risk and disease stage are important when guiding physicians in formulating preventive or intervention strategies that improve patient care.

Other Key Dierentiators

The PULS Cardiac Test: • Has been independently validated in a multi-ethnic population (MESA). • Was developed based on longitudinal outcome-based clinical trials that demonstrate clinical utility in identifying patients with endothelial damage who are in danger of ACS. • Conforms to current ACC/AHA guidelines. • Has been shown to motivate patients to adhere to physician recommendations.

How do I order the PULS Test?

Contact our Client Services team at (866) 299-8998 for more information.

How is the PULS Cardiac Test performed? What are the specimen requirements?

The PULS Cardiac Test is a serum blood test that requires 1 SST and 1 Lavender tube of blood. Based on your location, we can provide a number of convenient options to perform blood draws. Contact Client Services at (866) 299-8998 for more information.

What will be included in the results?

The test results will include your complete Cardiac Profile (PULS SCORE) with individual measurements for each of the 9 protein biomarkers that contribute to your cumulative 5-year unstable cardiac lesion diagnosis and likelihood of rupture. This score will then be categorized into low, borderline, or elevated (see Question 14). In addition, you will also receive: • Your “Heart Age” which shows your Cardiac Score relative to your Age and Gender group. • Recommended lifestyle modifications that may help maintain or reduce your chances of a Heart Attack. • The PULS Cardiac Test results will allow you to then determine the most appropriate course of action for the patient based on the latest clinical guidelines.

How do I interpret test results?

PULS Cardiac Test results provide a personalized 5-year Cardiac Profile score that conforms to ACC/AHA Guidelines for Normal, Borderline, or Elevated Risk:

Normal (<3.5%): These patients are in the desired range. Reviewing good nutrition and exercise habits and identifying any areas of concern like heart age, rising BMI or family history will dictate if additional recommendations are encouraged.

Borderline (3.5-7.49%): Patients in the intermediate range are generally early in disease progression. Frequently, simple lifestyle modifications such as a healthy diet, physical activity, smoking cessation, and stress management can bring these individuals back into the normal range.

Elevated (>7.5%): These patients have an elevated risk of ACS and should be treated as such using the ACC/AHA guidelines. Further evaluation is recommended to better define the clinical picture and treatment plan. If the patient is not currently under the care of a cardiologist, referral to a cardiologist should be considered. Case studies have shown that some patients with high-risk results who have not acted on the information have experienced heart attacks within weeks or months of the test.

How has the PULS Cardiac Test demonstrated clinical utility and improved patient care?

In an independent external validation in MESA, the PULS Cardiac Test identified 61% of patients (when used in conjunction with lipid studies) who went on to have an cardiac event, and who would have been missed by established risk factors. In a prospective clinical utility study, 70% of physicians changed their treatment plan based on the PULS Cardiac Test results. Using new treatment plans, the majority of patients moved to compliance with current guidelines. The study included physicians in the areas of cardiology, internal medicine, family practice, and obstetrics/gynecology.