Outcomes and Care of Patients With Acute Heart Failure Syndromes and Cardiac Troponin Elevation

Study Questions:

What are the presenting features, processes of care, and outcomes of patients presenting with and without elevation of cardiac troponin (cTn+ vs. cTn-) among patients with acute heart failure syndromes (AHFS)?

Methods:

This was a retrospective analysis of 13,656 AHFS patients seeking care in the emergency department (ED) in Ontario, Canada. Clinical data were abstracted from three complementary data sets. cTn was considered elevated if a test drawn within the first 24 hours of the emergency department visit exceeded the upper limit of the normal range according to the assay in use at each institution. The primary outcome of the study was all-cause mortality. Secondary outcomes included hospitalizations for ischemic heart (most responsible diagnosis of angina pectoris, acute myocardial infarction, other acute ischemic heart diseases, and chronic ischemic heart diseases) or cardiovascular disease (all admissions for ischemic heart disease, heart failure, or other cardiovascular conditions). In an exploratory 2:1 propensity-matched analysis, the authors examined whether early coronary revascularization (within 14 days of ED visit) was associated with survival, stratified by cTn status.

Results:

Among those with peak troponin values that exceeded the upper limit of the normal range, median values were 0.30 (0.09-1.40). Instantaneous 30-day adjusted hazard ratios (HRs) for cTn+ versus cTn- patients were 9.17 (95% confidence interval [CI], 8.31-10.12; p < 0.001) for death, 5.14 (95% CI, 4.66-5.67; p < 0.001) for cardiovascular readmission, and 13.08 (95% CI, 10.95-15.62; p < 0.001) for ischemic heart disease hospitalization. In propensity-matched analysis of 143 individuals with cTn+ AHFS, early coronary revascularization (within 14 days of the ED visit) was associated with reduced mortality (adjusted HR, 0.29; 95% CI, 0.09-0.92; p = 0.036) compared to those who did not undergo revascularization.

Conclusions:

Modestly elevated levels of cTn are associated with increased risk of death and cardiovascular hospitalizations. Select patients with AHFS and elevated cTn who undergo early coronary revascularization may experience improved survival.

Perspective:

This analysis adds to the literature that supports the prognostic value of even modestly elevated cTn levels among patients with AHFS. The limitations of this retrospective analysis aside (including the low rates of procedures performed within 14 days of presentation to the ED), this study does suggest that there may be a subset of AHFS patients with elevated cTn in whom early coronary revascularization may be a consideration. There may be under-utilization of invasive and noninvasive testing for ischemia, and management strategies in this vulnerable population with AHFS should be better defined with future studies.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Prognosis, Myocardial Infarction, Myocardial Ischemia, Biological Markers, Canada, Heart Failure, Ontario, Troponin


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