Low risk patients with acute atrial fibrillation and elevated high-sensitivity troponin do not have increased incidence of pathological stress tests

Abstract

Objectives: Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Design: We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results: None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint (p ¼ .49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusion: Patients with paroxysmal AF/ AFL, without a history of CAD and heart failure, who present with a RVR and minor hsTnT elevations were not found to have an increased incidence of pathological stress tests compared to patients with hsTnT values below the 99th percentile.

Predictive value of high-sensitivity troponin for significant coronary artery disease in new-onset atrial fibrillation with rapid ventricular response

“…The optimal cutoff HS-cTnT value (30 ng/l) was determined to be above the 99th percentile upper reference limit value (14 ng/l), suggesting that minor HS-cTnT elevations in new-onset AF may not necessarily reflect underlying clinically significant CAD, but rather may be precipitated by common confounders such as tachycardia, renal impairment, acute heart failure, and infection. This is consistent with a study by Thelin et al [11], who found that low-risk patients with rapid paroxysmal AF/ AFL but minor HS-cTnT elevations (median, 25; IQR, 18-35 ng/l) did not have an increased incidence of pathological stress tests compared with those with a normal troponin.…”

“…This is consistent with a study by Thelin et al . [11], who found that low-risk patients with rapid paroxysmal AF/AFL but minor HS-cTnT elevations (median, 25; IQR, 18–35 ng/l) did not have an increased incidence of pathological stress tests compared with those with a normal troponin.…”

“…Limited data are currently available examining the association between troponin elevations at index presentation in new-onset AF with obstructive CAD, an association which may have important long-term prognostic implications as outlined. Previous attempts to clarify the relationship of HS-cTn with significant CAD in patients presenting with AF have yielded mixed results [10][11][12], with many of these studies being small and underpowered. Furthermore, comparison is made difficult by widely varying study designs and troponin assays.…”