Prognostic value of cardiac biomarkers in the risk stratification of syncope: a systematic review

Abstract

The role of cardiac biomarkers in risk stratification of syncope is unclear. We undertook a systematic review to assess their predictive value for short-term major adverse cardiovascular events (MACE). We conducted a systematic review using MEDLINE, EMBASE, DARE and Cochrane databases from inception to July 2014. We included studies involving adult syncope patients that evaluated cardiac biomarker levels for risk stratification during acute management and excluded case reports, reviews and studies involving children. Primary outcome (MACE) included death, cardiopulmonary resuscitation, myocardial infarction (MI), structural heart disease, pulmonary embolism, significant hemorrhage or cardiac procedural interventions. Secondary outcome analysis assessed for prediction of MI, cardiac syncope and death. Two reviewers extracted patient-level data based on the cut-off reported. Pooled sensitivities and specificities were calculated using patient-level data. A total of 1862 articles were identified, and 11 studies with 4246 patients were included. Studies evaluated 3 biomarkers: contemporary troponin (2693 patients), natriuretic peptides (1353 patients) and high-sensitive troponin (819 patients). The pooled sensitivities and specificities for MACE were: contemporary troponin 0.29 (95 % CI 0.24, 0.34) and 0.88 (95 % CI 0.86, 0.89); natriuretic peptides 0.77 (95 % CI 0.69, 0.85) and 0.73 (95 % CI 0.70, 0.76); high-sensitive troponin 0.74 (95 % CI 0.65, 0.83) and 0.65 (95 % CI 0.62, 0.69), respectively. Natriuretic peptides and high-sensitive troponin showed good diagnostic characteristics for both primary and secondary outcomes. Natriuretic peptides and high-sensitive troponin might be useful in risk stratification.

2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope

“…IIb C-LD Usefulness of brain natriuretic peptide and high-sensitivity troponin measurement is uncertain in patients for whom a cardiac cause of syncope is suspected. 125,127,129,130 See Online Data Supplements 7 and 8.…”

Do High‐sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?

“…Values of cardiac biomarkers were greater in patients who experienced the primary outcome (hscTnT, median [IQR] = 22 [10-51] ng/mL vs. 11 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] ng/mL; NT-proBNP median [IQR] = 776 [244-2,175] ng/mL vs. 210 [82-620] ng/mL). Table 1 and Data Supplement S1, Figures S1 and S2 (available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1111/acem.…”

“…A systematic review of 11 studies assessing biomarker use in syncope/near syncope concluded that "there is modest predictive value for high-sensitivity troponin and natriuretic peptides for major cardiac adverse cardiovascular events." 12 However, these conclusions were tempered by limitations of prior studies, including small sample sizes, single-center populations, and nonstandardized data collection of potential confounding variables. Our study design specifically addresses these methodologic challenges and confirms the independent predictive value of these biomarkers.…”

“…Preliminary work suggests that these biomarkers may be important in syncope/near syncope risk prediction. [7][8][9][10][11][12] However, cardiac biomarkers have not been uniformly measured in these pilot studies, and this may have introduced testing bias due to illness severity. The 2017 American College of Cardiology/ American Heart Association/Heart Rhythm Society (HRS) Syncope Guidelines state: "The ability of troponin and natriuretic peptide measurement to influence clinical decision making or patient outcome is unknown."…”

Reliability of Clinical Assessments in Older Adults With Syncope or Near Syncope

“…Future syncope prediction models may preferentially include highly objective variables such as age and diagnostic testing such as hematocrit, brain natriuretic peptide, and troponin testing . Many of these diagnostic tests were not included in early clinical prediction models and more recent studies have suggested these tests may have a role in risk stratification of ED patients with syncope .…”