Elevated cardiac troponin is not uncommon in patients visiting emergency department (ED) even without coronary artery disease, but its prognostic implication is not well understood in such patients.
In this retrospective single-center registry, we investigated clinical outcome of patients visiting ED without documented coronary artery disease. Patients were categorized according to the maximal value of Siemens ADVIA Centaur TnI-Ultra assay (TnI) within 24 h after visit. Primary endpoint was 180-day all-cause death that included cardiac and non-cardiac death.
A total of 35,205 patients with median age 61 years and male gender 54.7% were included. Below the lowest level of detection (LOD) (≤0.006 ng/mL), between LOD and assay-specific <99th percentile (0.007–0.039 ng/mL), below median of ≥99th percentile (0.040–0.149 ng/mL), and above median of ≥99th percentile (≥0.150 ng/mL) TnI were found in 18,502 (52.6%), 11,338 (32.2%), 3,029 (8.6%), and 2,336 (6.6%) patients. In the 180-day follow-up period, 4,341 (12.3%) all-cause death including 694 (2.0%) cardiovascular death and 3,647 (10.4%) non-cardiovascular death developed. The risks of all-cause, cardiovascular, and non-cardiovascular death increased across higher TnI strata (hazard ratio [HR]=1.3 to 2.4; 2.0 to 9.3; 1.3 to 1.7; p<0.001, all). Analyses of multivariate models showed consistent results.
In patients visiting ED, elevated TnI was associated with higher risk of 180-day cardiovascular and non-cardiovascular death. Patients with elevated TnI may need additional evaluation or careful follow-up even without primary diagnosis of coronary artery disease.
Funding source: Ministry of Trade Industry & Energy, Ministry of Science & ICT, Ministry of Health and Welfare under Technology Development Program for Ai-Bio-Robot-Medicine Convergence
Award Identifier / Grant number: 20001704
Funding source: National Research Foundation of Korea
Award Identifier / Grant number: 2017R1A2B310918
Research funding: This study was supported by National Research Foundation of Korea (#2017R1A2B310918) and Ministry of Trade Industry & Energy, Ministry of Science & ICT, Ministry of Health and Welfare under Technology Development Program for Ai-Bio-Robot-Medicine Convergence (20001704).
Author contributions: All authors had access to the data and a role in writing the manuscript. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was waived given the retrospective design, the use of anonymized big database, and the reporting of aggregated results.
Ethical approval: The Samsung Medical Center Institutional Review Board approved this study.
1. Hsia, RY, Hale, Z, Tabas, JA. A national study of the prevalence of life-threatening diagnoses in patients with chest pain. JAMA Intern Med 2016;176:1029–32. https://doi.org/10.1001/jamainternmed.2016.2498.Search in Google Scholar PubMed
2. Giannitsis, E, Katus, HA. Cardiac troponin level elevations not related to acute coronary syndromes. Nat Rev Cardiol 2013;10:623–34. https://doi.org/10.1038/nrcardio.2013.129.Search in Google Scholar PubMed
3. Thygesen, K, Alpert, JS, Jaffe, AS, Chaitman, BR, Bax, JJ, Morrow, DA, et al.. Fourth universal definition of myocardial infarction (2018). Circulation 2018;138:e618–51. https://doi.org/10.1161/CIR.0000000000000617.Search in Google Scholar PubMed
4. Shah, ASV, Sandoval, Y, Noaman, A, Sexter, A, Vaswani, A, Smith, SW, et al.. Patient selection for high sensitivity cardiac troponin testing and diagnosis of myocardial infarction: prospective cohort study. BMJ 2017;359:j4788. https://doi.org/10.1136/bmj.j4788.Search in Google Scholar PubMed PubMed Central
5. Eggers, KM, Jernberg, T, Lindahl, B. Cardiac troponin elevation in patients without a specific diagnosis. J Am Coll Cardiol 2019;73:1–9. https://doi.org/10.1016/j.jacc.2018.09.082.Search in Google Scholar PubMed
6. Bardají, A, Cediel, G, Carrasquer, A, de Castro, R, Sánchez, R, Boqué, C. Troponin elevation in patients without acute coronary syndrome. Rev Española Cardiol 2015;68:469–76. https://doi.org/10.1016/j.rec.2014.10.018.Search in Google Scholar PubMed
7. Jaffe, AS, Ordonez-Llanos, J. High sensitivity troponin in chest pain and acute coronary syndromes. A step forward? Rev Española Cardiol 2010;63:763–9. https://doi.org/10.1016/s1885-5857(10)70160-2.Search in Google Scholar PubMed
8. Ferencik, M, Hoffmann, U, Bamberg, F, Januzzi, JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. Eur Heart J 2016;37:2397–405. https://doi.org/10.1093/eurheartj/ehw005.Search in Google Scholar PubMed PubMed Central
9. Shah, ASV, Anand, A, Sandoval, Y, Lee, KK, Smith, SW, Adamson, PD, et al.. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015;386:2481–8. https://doi.org/10.1016/s0140-6736(15)00391-8.Search in Google Scholar
10. Peacock, WF, Baumann, BM, Bruton, D, Davis, TE, Handy, B, Jones, CW, et al.. Efficacy of high-sensitivity troponin T in identifying very-low-risk patients with possible acute coronary syndrome. JAMA Cardiol 2018;3:104–12. https://doi.org/10.1001/jamacardio.2017.4625.Search in Google Scholar PubMed PubMed Central
11. Cediel, G, Rueda, F, García, C, Oliveras, T, Labata, C, Serra, J, et al.. Prognostic value of new‐generation troponins in ST‐segment–elevation myocardial infarction in the modern era: the RUTI‐STEMI study. J Am Heart Assoc 2017;6:e007252.10.1161/JAHA.117.007252Search in Google Scholar PubMed PubMed Central
12. Shah, ASV, Anand, A, Strachan, FE, Ferry, AV, Lee, KK, Chapman, AR, et al.. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet 2018;392:919–28. https://doi.org/10.1016/S0140-6736(18)31923-8.Search in Google Scholar PubMed PubMed Central
13. Blankenberg, S, Salomaa, V, Makarova, N, Ojeda, F, Wild, P, Lackner, KJ, et al.. Troponin I and cardiovascular risk prediction in the general population: the BiomarCaRE consortium. Eur Heart J 2016;37:2428–37. https://doi.org/10.1093/eurheartj/ehw172.Search in Google Scholar PubMed PubMed Central
14. Shah, AS, Griffiths, M, Lee, KK, McAllister, DA, Hunter, AL, Ferry, AV, et al.. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. BMJ 2015;350:g7873.10.1136/bmj.g7873Search in Google Scholar PubMed PubMed Central
15. Pokharel, Y, Sun, W, Villareal, DT, Selvin, E, Virani, SS, Ndumele, CE, et al.. Association between high-sensitivity troponin T and cardiovascular risk in individuals with and without metabolic syndrome: the ARIC study. Eur J Prev Cardiol 2017;24:628–38. https://doi.org/10.1177/2047487316683071.Search in Google Scholar PubMed PubMed Central
16. Bardají, A, Bonet, G, Carrasquer, A, González-Del Hoyo, M, Domínguez, F, Sánchez, R, et al.. Prognostic implications of detectable cardiac troponin i below the 99th percentile in patients admitted to an emergency department without acute coronary syndrome. Clin Chem Lab Med 2018;56:1954–61.10.1515/cclm-2017-1140Search in Google Scholar PubMed
17. Myhre, PL, Claggett, B, Ballantyne, CM, Selvin, E, Røsjø, H, Omland, T, et al.. Association between circulating troponin concentrations, left ventricular systolic and diastolic functions, and incident heart failure in older adults. JAMA Cardiol 2019;4:997. https://doi.org/10.1001/jamacardio.2019.3113.Search in Google Scholar PubMed PubMed Central
The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2020-1392).
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