BackgroundThe impact of cardiac troponin (cTn) testing on the downstream use of cardiovascular services is not well understood. We conducted this large-scale single centre cohort study to investigate the patterns of testing that result from the use of cTn.MethodsWe conducted this investigation using data collected between 1 January 2013 and 18 December 2015 from an academically affiliated tertiary care centre. Data from all hospitalised patients evaluated with cTn (Roche Elecsys cTn-T) assay were collected from our integrated data repository and divided into two cohorts: all cTn assays negative (<0.03 µg/L) versus at least one elevated (≥0.03 µg/L). The main outcomes were the frequency of use cardiovascular services and mortality.ResultsAmong 26 663 subjects, 18.6% had at least one elevated cTn assay; acute myocardial infarction was diagnosed in 3.9% overall. More men received cardiac catheterisation and cardiology consultation (OR 1.29, 95% CI 1.20 to 1.39 and OR 1.45, 95% CI 1.31 to 1.61) while African-American patients were less likely to have either catheterisation (OR 0.85, 95% CI 0.77 to 0.93) or consultation (OR 0.72, 95% CI 0.63 to 0.82) performed. Mortality was associated with detectable cTn (HR 2.05, P<0.0001).ConclusionsAmong hospitalised patients evaluated with cTn, we observed patterns of underuse and overuse of cardiovascular services. These patterns may have further relevance when high-sensitivity cTn assays are available in the USA. Sex and race-based disparities in cardiovascular services persist.

Cardiovascular disease (CVD) is the number one cause of mortality world-wide and places a high medical and socioeconomic burden on developing countries. Our understanding of CVD and its evolution over the last 100 years has altered considerably. Reasons for the increased rate of CVD in the developing world include rapid urbanization and the demographic shift known as the modern epidemiologic transition. The case for intervention is based on both major human and economic impacts of CVD. It has been estimated that cost-effective interventions in developing countries with a high burden of CVD could result in a projected 24 million lives saved. This reduction in CVD mortality could reduce economic costs by $8 billion. Approaches to intervention include: 1) cardiovascular health promotion and CVD prevention and 2) action plans advocated by the World Health Organization.

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Introduction: Serum troponin (Tn) is a highly sensitive test useful in diagnosing acute myocardial infarction. Elevated Tn is associated with higher mortality and greater use of cardiovascular services. The effect of sex and race on these observations has not been well characterized. We hypothesize that sex and race will be independent predictors of cardiology consultation and cardiac catheterization. Methods: We analyzed adult patients hospitalized between 2012 and 2015 who had Tn testing. Patients were compared in 2 cohorts: those with and those without elevation in Tn. We extracted data on demographics, self-reported race, medical history, new inpatient diagnoses, Charlson comorbidity index (CCI), and mortality (up to 3 years). We developed a Cox proportional hazard model for mortality and used logistic regression to determine associations with cardiology consultation and cardiac catheterization. Results: Of the 26,663 included, 22.0% were black, 50.1% were women, 9.8% had diabetes, and 6.4% had pre-existing coronary disease. Cardiac catheterization was performed on 1,800 (6.8%), 3,672 (13.8%) had a cardiology consult, and 4,962 (18.6%) had elevated Tn. Among the variables associated with cardiology consultation were elevated Tn (odds ratio [OR] =3.44, 95% confidence interval [CI] 3.19-3.72, p<0.0001), male sex (OR=1.29, 95% CI 1.20-1.39, p<0.0001) and black race (OR=0.85, 95% CI 0.77-0.93, p=0.0006). Cardiac catheterization was associated with elevated Tn (OR=8.16, 95% CI 7.34-9.06, p<0.0001), male sex (OR=1.45, 95% CI 1.31-1.61, p<0.0001), CCI >4 (OR=0.44, 95% CI 0.35-0.54, p<0.0001), and black race (OR=0.72, 95% CI 0.63-0.82, p<0.0001). A total of 4,697 patients died during follow-up. Elevated Tn (hazard ratio [HR] =2.05, p<0.0001), male sex (HR=1.14, p<0.0001), and CCI >4 (HR=3.33, p<0.0001) were associated with a higher risk of death, while risk among black patients was lower (HR=0.86, p<0.0001). Conclusion: As observed in other investigations, elevated Tn is associated with a higher risk of mortality, cardiac catheterization, and cardiology consultation. We observed that men were more likely to undergo catheterization and consultation, while black patients were less likely to have either. Further investigation into reasons for the observed disparities is warranted.

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