High Sensitivity Troponin I for Risk Assessment in Patients With Atrial Fibrillation: Insights From the ARISTOTLE Trial

Study Questions:

Do levels of high-sensitivity troponin-I (hs-TnI) correlate with major clinical outcomes in patients with atrial fibrillation (AF)?


In the ARISTOTLE trial, 18,201 patients with AF and ≥1 risk factor for stroke were randomly assigned to treatment with apixaban or warfarin. In this substudy, the relationship between hs-TnI levels and outcomes was analyzed in 14,821 patients (mean age 70 years) in whom biomarkers were measured upon study entry. The major endpoints included stroke/systemic embolism, cardiac death, all-cause mortality, and major bleeding events. The median duration of follow-up was 1.9 years.


The hs-TnI level was >5.4 ng/L in 50% of patients, >10.1 ng/L in 25%, and ≥23 ng/L in 9.2%. The annual stroke/embolism rate was significantly higher in the highest hs-TnI level quartile (2.26%) than in the lowest quartile (0.76%). The hs-TnI level was independently and significantly associated with stroke/embolism (hazard ratio [HR], 1.98), cardiac death (HR, 4.52), and major bleeding (HR, 1.44). The c-statistic (a measure of predictive accuracy) of the CHA2DS2-VASc score for stroke/embolism improved from 0.629 to 0.653 with the addition of hs-TnI levels into the scoring system.


The authors concluded that hs-TnI level is an independent predictor of stroke, cardiac death, and major bleeding in patients with AF, regardless of anticoagulation with apixaban or warfarin.


Of note is that hs-TnI levels identified patients with a CHA2DS2-VASc score ≤2 whose stroke risk was similar to that of patients with a score >3. The clinical implication is that patients who might not be anticoagulated based on the CHA2DS2-VASc score could become appropriate candidates when hs-TnI levels are taken into consideration.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, EP Basic Science

Keywords: Blood Coagulation, Stroke, Troponin I, Warfarin, Electric Countershock, Pyrazoles, Embolism, Risk Assessment, Pyridones, Hemorrhage

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