High-sensitivity cardiac troponin T: risk stratification tool in patients with symptoms of chest discomfort

Alma M Mingels, Ivo A Joosen, Mathijs O Versteylen, Eduard M Laufer, Mark H Winkens, Joachim E Wildberger, Marja P Van Dieijen-Visser, Leonard Hofstra, Alma M Mingels, Ivo A Joosen, Mathijs O Versteylen, Eduard M Laufer, Mark H Winkens, Joachim E Wildberger, Marja P Van Dieijen-Visser, Leonard Hofstra

Abstract

Background: Recent studies have demonstrated the association between increased concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and the incidence of myocardial infarction, heart failure, and mortality. However, most prognostic studies to date focus on the value of hs-cTnT in the elderly or general population. The value of hs-cTnT in symptomatic patients visiting the outpatient department remains unclear. The aim of this study was to investigate the prognostic value of hs-cTnT as a biomarker in patients with symptoms of chest discomfort suspected for coronary artery disease and to assess its additional value in combination with other risk stratification tools in predicting cardiac events.

Methods: We studied 1,088 patients (follow-up 2.2 ± 0.8 years) with chest discomfort who underwent coronary calcium scoring and coronary CT-angiography. Traditional cardiovascular risk factors and concentrations of hs-cTnT, N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hsCRP) were assessed. Study endpoint was the occurrence of late coronary revascularization (>90 days), acute coronary syndrome, and cardiac mortality.

Results: Hs-cTnT was a significant predictor for the composite endpoint (highest quartile [Q4]>6.7 ng/L, HR 3.55; 95%CI 1.88-6.70; P<0.001). Survival analysis showed that hs-cTnT had significant predictive value on top of current risk stratification tools (Chi-square change P<0.01). In patients with hs-cTnT in Q4 versus <Q4, a 2- to 3-fold increase in cardiovascular risk was noticed, either when corrected for high or low Framingham risk score, coronary calcium scoring, or CT-angiography assessment (HR 3.11; 2.73; 2.47; respectively; all P<0.01). This was not the case for hsCRP and NT-proBNP.

Conclusions: Hs-cTnT is a useful prognostic biomarker in patients with chest discomfort suspected for coronary artery disease. In addition, hs-cTnT was an independent predictor for cardiac events when corrected for cardiovascular risk profiling, calcium score and CT-angiography results.

Conflict of interest statement

Competing Interests: The hs-cTnT kits were provided by Roche Diagnostics. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.

Figures

Figure 1. Flowchart of the study design.
Figure 1. Flowchart of the study design.
* Early revascularizations within 90 days after CCTA were censored at the time of PCI or CABG.
Figure 2. Kaplan-Meier analyses illustrating improved classification…
Figure 2. Kaplan-Meier analyses illustrating improved classification by including hs-cTnT to current risk stratification tools.
Figures on the left shows Kaplan-Meier curves for FRS (A), CCS (C) and CCTA assessment (E). Figures on the right shows Kaplan-Meier curves when hs-cTnT was added to FRS (B), CCS (D) and CCTA assessment (F). Q4 = fourth quartile of hs-cTnT concentrations.

References

    1. Kaptoge S, Di Angelantonio E, Lowe G, Pepys MB, Thompson MG, et al. C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis. Lancet. 2010;375:132–140.
    1. Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, et al. Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med. 2006;355:2631–2639.
    1. Ridker PM. C-reactive protein and the prediction of cardiovascular events among those at intermediate risk: moving an inflammatory hypothesis toward consensus. J Am Coll Cardiol. 2007;49:2129–2138.
    1. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med. 2004;350:655–663.
    1. Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009;361:858–867.
    1. Keller T, Zeller T, Peetz D, Tzikas S, Roth A, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med. 2009;361:868–877.
    1. Lindahl B, Venge P, James S. The new high-sensitivity cardiac troponin T assay improves risk assessment in acute coronary syndromes. Am Heart J. 2010;160:224–229.
    1. Laufer EM, Mingels AM, Winkens MH, Joosen IA, Schellings MW, et al. The extent of coronary atherosclerosis is associated with increasing circulating levels of high sensitive cardiac troponin T. Arterioscler Thromb Vasc Biol. 2010;30:1269–1275.
    1. Korosoglou G, Lehrke S, Mueller D, Hosch W, Kauczor HU, et al. Determinants of troponin release in patients with stable coronary artery disease: insights from CT angiography characteristics of atherosclerotic plaque. Heart. 2011;97:823–831.
    1. de Lemos JA, Drazner MH, Omland T, Ayers CR, Khera A, et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA. 2010;304:2503–2512.
    1. deFilippi CR, de Lemos JA, Christenson RH, Gottdiener JS, Kop WJ, et al. Association of serial measures of cardiac troponin T using a sensitive assay with incident heart failure and cardiovascular mortality in older adults. JAMA. 2010;304:2494–2502.
    1. Otsuka T, Kawada T, Ibuki C, Seino Y. Association between high-sensitivity cardiac troponin T levels and the predicted cardiovascular risk in middle-aged men without overt cardiovascular disease. Am Heart J. 2010;159:972–978.
    1. Alehagen U, Dahlstrom U, Rehfeld JF, Goetze JP. Prognostic assessment of elderly patients with symptoms of heart failure by combining high-sensitivity troponin T and N-terminal pro B-type natriuretic peptide measurements. Clin Chem. 2010;56:1718–1724.
    1. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 48:1475–1497.
    1. D'Agostino RB, Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117:743–753.
    1. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Jr, et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–832.
    1. Austen WG, Edwards JE, Frye RL, Gensini GG, Gott VL, et al. A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation. 1975;51:5–40.
    1. Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, et al. SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr. 2009;3:122–136.
    1. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18:499–502.
    1. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction–summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366–1374.
    1. Omland T, de Lemos JA, Sabatine MS, Christophi CA, Rice MM, et al. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med. 2009;361:2538–2547.
    1. Kavsak PA, Wang X, Ko DT, MacRae AR, Jaffe AS. Short- and long-term risk stratification using a next-generation, high-sensitivity research cardiac troponin I (hs-cTnI) assay in an emergency department chest pain population. Clin Chem. 2009;55:1809–1815.
    1. Vasile VC, Saenger AK, Kroning JM, Jaffe AS. Biological and analytical variability of a novel high-sensitivity cardiac troponin T assay. Clin Chem. 2010;56:1086–1090.
    1. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. J Am Coll Cardiol. 2007;50:2173–2195.
    1. Fox KF, Cowie MR, Wood DA, Coats AJ, Gibbs JS, et al. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J. 2001;22:228–236.
    1. Virmani R, Burke AP, Farb A, Kolodgie FD. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006;47:C13–18.
    1. Hadamitzky M, Freissmuth B, Meyer T, Hein F, Kastrati A, et al. Prognostic value of coronary computed tomographic angiography for prediction of cardiac events in patients with suspected coronary artery disease. JACC Cardiovasc Imaging. 2009;2:404–411.

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