Hs-cTroponins for the prediction of recurrent cardiovascular events in patients with established CHD – A comparative analysis from the KAROLA study

Tackling dynamic prediction of death in patients with recurrent cardiovascular events

In the field of cardiovascular disease, recurrent events such as stroke or myocardial infarction (MI) are often encountered, leading to an increase in the risk of death. Accurately evaluating the prognosis of patients and dynamically predicting the risk of death by considering the historical recurrent events can improve medical decisions and lead to better health care outcomes. Recently proposed joint modeling approaches within the Bayesian framework have inspired the development of a dynamic prediction tool, which can be applied for subject-level prediction of death with implementation in software packages. The prediction model incorporates subject heterogeneity with subject-level random effects that account for unobserved time-invariant factors and an extra copula function capturing the part caused by unmeasured time-dependent factors. Thereafter, given the prespecified landmark timet ' $$ {t}^{\prime } $$ , the survival probability for a prediction horizon time of interestt $$ t $$ can be estimated for each individual. The prediction accuracy is assessed by time-dependent receiving operating characteristic curve and the area under the curve and the Brier score with calibration plots is compared to traditional joint frailty models. Finally, the tool is applied to patients with multiple attacks of stroke or MI in the Cardiovascular Health study and the Atherosclerosis Risk in Communities study for illustration.

Differences between high-sensitivity cardiac troponin T and I in stable populations: underlying causes and clinical implications

OBJECTIVES

Measurement of high-sensitivity (hs) cardiac troponin (cTn) T and I is widely studied for cardiac assessment of stable populations. Recent data suggest clinical and prognostic discrepancies between both hs-cTn. We aimed at reviewing published studies with respect to underlying causes and clinical implications.

CONTENT

We summarized current evidence on release and clearance mechanisms of cTnT and I, and on preanalytical and assay-related issues potentially portending to differences in measured concentrations. We also performed a systematic review of outcome studies comparing both hs-cTn in the general population, patients with congestive heart failure, stable coronary artery disease and atrial fibrillation.

SUMMARY AND OUTLOOK

For the interpretation of concentrations of hs-cTnT, stronger association with renal dysfunction compared to hs-cTnI should be considered. Hs-cTnT also appears to be a stronger indicator of general cardiovascular morbidity and all-cause mortality. Hs-cTnI concentrations tend to be more sensitive to coronary artery disease and ischemic outcomes. These findings apparently reflect variations in the mechanisms of cardiac affections resulting in cTn release. Whether these differences are of clinically relevance remains to be elucidated. However, having the option of choosing between either hs-cTn might represent an option for framing individualized cardiac assessment in the future.

The Elevated High-Sensitivity Cardiac Troponin T Pilot: Diagnoses and Outcomes

OBJECTIVE

To identify the diagnoses and outcomes associated with elevated high sensitivity cardiac troponin T (hs-cTnT) compared with the 4th-generation troponin T and to validate the Mayo Clinic hs-cTnT myocardial infarction algorithm cutoff values.

PATIENTS AND METHODS

Consecutive blood samples of patients presenting to the emergency department between July 2017 and August 2017, who had 4th-generation troponin T, were also analyzed using the hs-cTnT assay. Troponin T values, discharge diagnoses, comorbidities, and outcomes were assessed. In addition, analyses of sex-specific and hs-cTnT cutoff values were assessed.

RESULTS

Of 830 patients, 32% had an elevated 4th-generation troponin T, whereas 64% had elevated hs-cTnT. With serial sampling, 4th-generation troponin missed a chronic myocardial injury pattern and acute myocardial injury pattern in 64% and 16% of patients identified with hs-cTnT, respectively. Many of these "missed" patients had discharge diagnoses associated with cardiovascular disease, infection, or were postoperative. Five of the 6 patients with unstable angina ruled in for myocardial infarction.

CONCLUSION

There were many increases in hs-cTnT that were missed by the 4th-generation cTnT assay. Most new increases are not related to acute cardiac causes. They were more consistent with chronic myocardial injury. High-sensitivity cTnT did reclassify most patients with unstable angina as having non-ST-elevation myocardial infarction. Older age, more comorbidities, and lower hemoglobin were associated with elevated hs-cTnT. Our data also support the use of our sex-specific cutoff values.

Relationship between cardiac biomarker concentrations and long-term mortality in subjects with osteoarthritis

Osteoarthritis (OA) is associated with adverse cardio-metabolic features. N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponins T and I (hs-cTnT and hs-cTnI) are well-characterized cardiac markers and provide prognostic information. The objective was to assess the association of cardiac biomarker concentrations with long-term mortality in subjects with OA. In a cohort of 679 OA subjects, undergoing hip or knee replacement during 1995/1996, cardiac biomarkers were measured and subjects were followed over 20 years. During a median follow-up of 18.4 years, 332 (48.9%) subjects died. Median of hs-cTnT, hs-cTnI, and NT-proBNP at baseline was 3.2 ng/L, 3.9 ng/L, and 96.8 ng/L. The top quartile of NT-proBNP was associated with increased risk of mortality (Hazard Ratio (HR) 1.79, 95% confidence interval (CI) 1.17–2.73) after adjustment for covariates including troponins (hs-cTnT HR 1.30 (95% CI 0.90–1.89), hs-cTnI HR 1.32 (95% CI 0.87–2.00) for top category). When biomarker associations were evaluated as continuous variables, only NT-proBNP (HR per log-unit increment 1.34, 95% CI 1.16–1.54) and hs-cTnI (HR 1.38, 95% CI 1.11–1.72) showed robust results. Elevated cardiac biomarker concentrations predicted an increased risk of long-term mortality and strongest for NT-proBNP and hs-cTnI. These results might help to identify subjects at risk and target preventive efforts early.

Repeat Measurements of High Sensitivity Troponins for the Prediction of Recurrent Cardiovascular Events in Patients With Established Coronary Heart Disease: An Analysis From the KAROLA Study

Background

High‐sensitivity cardiac troponins T and I (hs‐cTnT and hs‐cTnI) are established biomarkers for myocardial injury and used for diagnostic and prognostic purposes. However, whether repeat measurements improve prediction of recurrent cardiovascular disease (CVD) events in patients with stable coronary heart disease (CHD) after adjustment for several other novel biomarkers remains unclear.

Methods and Results

We measured both troponins in 873 coronary heart disease patients from the KAROLA (Langzeiterfolge der Kardiologischen Anschlussheilbehandlung) study about 9 weeks after their initial acute event (baseline) and after 12 months, followed them for 12 years, assessed a combined CVD end point, and adjusted for several risk factors. As we found evidence for effect modification, results were stratified according to presence of myocardial infarction at baseline. During follow‐up, 186 fatal and non‐fatal CVD events occurred. Both baseline and 12‐months troponin concentrations were significantly associated with CVD events in patients without myocardial infarction at baseline; in tendency 12 months of troponin showed stronger hazard ratios (hs‐cTnT: hazard ratios 1.91 (95% CI 1.17–3.11) versus baseline values 1.71 (95% CI 1.08–2.70) and for hs‐cTnI: hazard ratio 1.55 (95% CI 1.05–2.30) versus baseline value 1.22 (95% CI 0.88–1.68) in the fully and simultaneously adjusted model.

Conclusions

Both troponins are consistently associated with recurrent cardiovascular events after adjustment for emerging risk factors during follow‐up in our study especially evident in patients without myocardial infarction at baseline. Troponin values at 12 months of follow‐up showed independent associations with future CVD events in addition to baseline assessments of troponins.