Diagnosis of MI after CABG with high-sensitivity troponin T and new ECG or echocardiogram changes: relationship with mortality and validation of the universal definition of MI

Abstract

Aims: Criteria for diagnosing myocardial infarction (MI) after coronary artery bypass grafting (CABG) are controversial. Uncertainties remain around the optimal threshold for biomarker elevation and the need for associated criteria. There are no studies of high-sensitivity troponin (hs-TnT) after CABG. We assessed whether using hs-TnT to define MI after CABG was associated with 30-day and medium-term mortality and evaluated the utility of adding to the troponin criteria new Q-waves or imaging evidence of new wall motion abnormality as suggested in the Universal Definition of MI.

Methods: Isolated CABG was performed in 818 patients from July 2010 to June 2012 and hs-TnT was measured 12-24 hours after CABG. Patients with rising baseline or missing troponins (n=258) were excluded. Thresholds of 140 ng/l (10-times 99th percentile upper reference limit) and 500 ng/l (10-times coefficient of variation of 10% for fourth-generation troponin T applied to hs-TnT) were prespecified.

Results: Mean follow up was 1.8±0.6 years. On multivariate analyses, isolated hs-TnT rise >140 ng/l (n=360) or >500 ng/l (n=162) were not associated with mortality. Additional ECG and/or echocardiographic criteria plus hs-TnT >140 ng/l was associated with 30-day mortality (hazard ratio, HR, 4.92, 95% CI 1.34-18.1; p=0.017) and medium-term mortality (HR 3.44, 95% CI 1.13-10.5; p=0.030), whereas ECG and/or echocardiographic abnormalities with hs-TnT >500 ng/l was not (p=0.281 and p=0.123 for 30-day and medium-term mortality, respectively).

Conclusions: A definition for MI following CABG using hs-TnT with a cut point of 10-times 99th percentile upper reference limit and ECG and/or echocardiographic criteria predicts 30-day and medium-term mortality. These findings validate the Third Universal Definition of type 5 MI.

Keywords: Coronary artery bypass surgery; Universal Definition; high-sensitivity troponin; myocardial infarction.

Conflict of interest statement

Conflict of interest: HW has received research grants from Sanofi Aventis, Eli Lilly, Medicines Company, Pfizer, Roche, Johnson & Johnson, Schering Plough, Merck Sharpe & Dohme, Astra Zeneca, GlaxoSmithKline, Daiichi Sankyo Pharma Development, and Bristol-Myers Squibb and has served on advisory boards for Merck Sharpe & Dohme, Roche, and Regado Biosciences. TW, RS, TR, NK and GG declare that they have no conflicts of interest.

Figures

Figure 1.

Study population.

Figure 2.

Kaplan–Meier survival curves for five MI criteria: (a) hs-TnT >140 ng/l; (b) hs-TnT >500 ng/l; (c) ECG and/or echocardiographic criteria; (d) hs-TnT >140 ng/l and ECG and/or echocardiographic criteria; (e) hs-TnT >500 ng/l and ECG and/or echocardiographic criteria. Results of log-rank test are shown.