ASCVD Risk Stratification Based on Troponin and CAC Measurements

Jul 22, 2020
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Authors:
Sandoval Y, Bielinski SJ, Daniels LB, et al.
Citation:
Atherosclerotic Cardiovascular Disease Risk Stratification Based on Measurements of Troponin and Coronary Artery Calcium. J Am Coll Cardiol 2020;76:357-370.
Summary By:
Melvyn Rubenfire, MD, FACC

Quick Takes

  • In the middle-aged and elderly, a combination of undetectable hs-cTnT and a CAC score of ZERO is associated with a very low risk for ASCVD over 15 years: about 5 events per 1,000 person-years or 1/200 per year.
  • However, since they do not detect the same individuals and the prognostic results are complimentary, consideration should be given to using both for primary prevention risk stratification.
  • The hs-cTnT could be considered a very inexpensive negative risk predictor when doing 10-year risk-estimation of persons with self-pay or health care systems/countries for whom the CAC score is considered too expensive.

Study Questions:

What is the impact of the combination of baseline high-sensitivity cardiac troponin T (hs-cTnT) and coronary artery calcium (CAC) score on development of clinical atherosclerotic cardiovascular disease (ASCVD)?

Methods:

Baseline hs-cTnT (limit of detection [LoD] 3 ng/L) and CAC measurements were analyzed across participants ages 45-84 years without clinical CVD from the prospective MESA (Multi-Ethnic Study of Atherosclerosis). Incident ASCVD was defined as first instance of a myocardial infarction, fatal coronary heart disease, fatal and nonfatal stroke, resuscitated cardiac arrest, or other atherosclerotic or cardiovascular deaths. The posit was that undetectable CAC and hs-cTnT would be very low risk.

Results:

Among 6,749 race/ethnicity-diverse participants with mean age 62 (10) years, 53% women, 1,002 ASCVD events occurred during a median follow-up of 15 years. Participants with detectable CAC (20.1 vs. 5.0 events per 1,000 person-years; adjusted hazard ratio [HR], 2.35; 95% confidence interval [CI], 2.0 -2.76; p < 0.001) and detectable hs-cTnT (15.4 vs. 5.2 per 1,000 person-years; adjusted HR, 1.47; 95% CI, 1.21-1.77; p < 0.001) had higher rates of ASCVD than those with undetectable results. Individuals with undetectable hs-cTnT (32%) had similar risk for ASCVD as did those with a CAC of zero (50%) (5.2 vs. 5.0 per 1,000 person-years). Together, hs-cTnT and CAC (discordance 38%) resulted in the following ASCVD event rates: hs-cTnT 0: 11.1 per 1,000 person-years (HR, 2.74; 95% CI, 1.96-3.83; p < 0.00001), and hs-cTnT ≥LoD/CAC >0: 22.6 per 1,000 person-years (HR, 3.50; 95% CI, 2.60-4.70; p < 0.00001).

Conclusions:

An undetectable hs-cTnT identifies patients with a similar, low risk for ASCVD as those with a CAC score of zero. The increased risk among those with discordant results supports their conjoined use for risk prediction.

Perspective:

Considering the very low cost of hs-cTnT, for persons with borderline to intermediate 10-year risk estimate for whom the relatively low-cost CAC score is excessively expensive, the hs-cTnT is an excellent alternative for identifying those who are low risk.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Atherosclerosis, Coronary Disease, Diagnostic Imaging, Heart Arrest, Myocardial Infarction, Plaque, Atherosclerotic, Primary Prevention, Risk, Stroke, Troponin, Troponin T, Vascular Diseases


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