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Aims  Fibroblast growth factor 23 (FGF‐23) is known to be elevated in patients with congestive heart failure (CHF). As FGF‐23 is expressed in the bone but can also be expressed in the myocardium, the origin of serum FGF‐23 in CHF remains unclear. It is also unclear if FGF‐23 expressed in the bone is associated with outcome in CHF. The aim of the present study was to investigate FGF‐23 levels measured in bone marrow plasma (FGF‐23‐BM) and in peripheral blood (FGF‐23‐P) in CHF patients to gain further insights into the heart–bone axis of FGF‐23 expression. We also investigated possible associations between FGF‐23‐BM as well as FGF‐23‐P and outcome in CHF patients.    Methods and results  We determined FGF‐23‐P and FGF‐23‐BM levels in 203 CHF patients (85% male, mean age 61.3 years) with a left ventricular ejection fraction (LVEF) ≤45% and compared them with those of 48 healthy controls (48% male, mean age 39.2 years). We investigated the association between FGF‐23‐BM and FGF‐23‐P with all‐cause mortality in CHF patients, 32 events, median follow‐up 1673 days, interquartile range [923, 1828]. FGF‐23‐P (median 60.3 vs. 22.0 RU/mL,  P  < 0.001) and FGF‐23‐BM (median 130.7 vs. 93.1 RU/mL,  P  < 0.001) levels were higher in CHF patients compared with healthy controls. FGF‐23‐BM levels were significantly higher than FGF‐23‐P levels in both CHF patients and in healthy controls ( P  < 0.001). FGF‐23‐P and FGF‐23‐BM correlated significantly with LVEF ( r  = −0.37 and  r  = −0.33, respectively), N terminal pro brain natriuretic peptide levels ( r  = 0.57 and  r  = 0.6, respectively), New York Heart Association status ( r  = 0.28 and  r  = 0.25, respectively), and estimated glomerular filtration rate ( r  = −0.43 and  r  = −0.41, respectively) ( P  for all <0.001) and were independently associated with all‐cause mortality in CHF patients after adjustment for LVEF, estimated glomerular filtration rate, New York Heart Association status, and N terminal pro brain natriuretic peptide, hazard ratio 2.71 [confidence interval: 1.18–6.20],  P  = 0.018, and hazard ratio 2.80 [confidence interval: 1.19–6.57],  P  = 0.018, respectively.    Conclusions  In CHF patients, FGF‐23 is elevated in bone marrow plasma and is independently associated with heart failure severity and all‐cause mortality. The failing heart seems to interact via FGF‐23 within a heart–bone axis.

Bone marrow and plasma FGF‐23 in heart failure patients: novel insights into the heart–bone axis