Magnitude of Troponin Elevation and Long-Term Clinical Outcomes in Acute Coronary Syndrome Patients Treated With and Without Revascularization

Abstract

Background— In patients with non–ST-segment–elevation acute coronary syndrome (NSTE ACS), elevated troponin levels identify patients at high risk for adverse outcomes; however, it is unknown whether the magnitude of troponin elevation during hospitalization remains predictive of subsequent events in patients undergoing coronary revascularization. Methods and Results— We studied 12 635 patients with NSTE ACS in the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) study with at least 1 troponin measurement during index hospitalization. Cox proportional hazards regression was used to examine the relationship between peak troponin level (standardized as the ratio of peak troponin value measured during hospitalization and local laboratory upper reference limit [URL]) and revascularization on all-cause mortality at 2 years. Revascularization (percutaneous coronary intervention or coronary artery bypass graft) was performed during index hospitalization in 8586 patients (68.0%); revascularized patients had higher peak troponin ratios (median, 23 versus 9.5× URL). Among patients that did not undergo revascularization, the mortality rate at 2 years increased in a curvilinear fashion with increasing levels of peak troponin. In contrast, the mortality rate at 2 years remained constant irrespective of peak troponin levels among revascularized patients ( P for interaction=0.004). This relationship was unchanged after multivariable adjustment. Conclusions— There is a differential relationship between the magnitude of troponin elevation and long-term mortality in ACS patients treated with and without revascularization. Although prognostically important in patients treated without revascularization, the prognostic implications of peak troponin level seem to be minimal in revascularized patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00527943.

Relationship Between Peak Troponin Values and Long‐Term Ischemic Events Among Medically Managed Patients With Acute Coronary Syndromes

“…This relationship was not observed in those who underwent revascularization (P=0.23). 10 The graded relationship of increasing peak troponin with ischemic events that we observed was consistent with this observation and prior studies evaluating troponin elevation as a prognostic indicator among patients with NSTE ACS. However, TRILOGY ACS provided the unique opportunity to establish this relationship over a long-term (30-month) followup period among patients who were medically managed with P2Y12 inhibitor therapy.…”

“…In a subset of patients included in TRACER who did not undergo revascularization, increasing levels of peak cardiac troponin were associated with increasing long‐term mortality ( P =0.001). This relationship was not observed in those who underwent revascularization ( P =0.23) …”

Beta-blockers for post-acute coronary syndrome mid-range ejection fraction: a nationwide retrospective study

“…Troponin levels were registered through the peak troponin ratio (PTR; ratio of peak troponin level divided by the local laboratory defined), since different assays for troponin were registered. 18 The primary endpoint was inhospital death during index admission. Regarding statistical analysis, categorical variables are presented as frequency values and continuous variables are presented as mean (µ) ± standard deviation (SD).…”

Does Preoperative Troponin Level Impact Outcomes After Coronary Artery Bypass Grafting?

“…In a study of patients with acute myocardial infarction operated on within 21 days, the troponin level itself failed to predict 6-month mortality, despite increased mortality in those with positive biomarkers compared to those with negative biomarkers (12). Similarly, in a subgroup of patients presenting with NSTEMI who underwent revascularization with CABG, preoperative troponin levels did not correlate with rates of 2-year mortality (20). Our population was designed to include only those who underwent urgent or emergent operations, thus excluding elective case for which incremental increase in troponin level is known to correlate with adverse outcomes.…”