Multimarker approach to risk stratification in non-ST elevation acute coronary syndromes: simultaneous assessment of troponin I, C-reactive protein, and B-type natriuretic peptide.
BACKGROUND
In patients with acute coronary syndromes (ACS), troponin I (TnI), C-reactive protein (CRP), and B-type natriuretic peptide (BNP) each predict adverse cardiac events. Little is known, however, about the utility of these biomarkers in combination.


RESULTS
Baseline measurements of TnI, CRP, and BNP were performed in 450 patients in OPUS-TIMI 16. Elevations in TnI, CRP, and BNP each were independent predictors of the composite of death, myocardial infarction (MI), or congestive heart failure (CHF). When patients were categorized on the basis of the number of elevated biomarkers at presentation, there was a near doubling of the mortality risk for each additional biomarker that was elevated (P=0.01). Similar relationships existed for the endpoints of MI, CHF, and the composite, both at 30 days and through 10 months. In a validation cohort of 1635 patients in TACTICS-TIMI 18, the number of elevated biomarkers remained a significant predictor of the composite endpoint after adjustment for known clinical predictors: patients with one, two, and three elevated biomarkers had a 2.1- (P=0.006), 3.1- (P<0.001), and 3.7- (P=0.001) fold increase in the risk of death, MI, or CHF by 6 months.


CONCLUSIONS
Troponin, CRP, and BNP each provide unique prognostic information in patients with ACS. A simple multimarker strategy that categorizes patients based on the number of elevated biomarkers at presentation allows risk stratification over a broad range of short- and long-term major cardiac events.
Sabatine
Marc S
MS
TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass 02115, USA. msabatine@partners.org
Morrow
David A
DA
de Lemos
James A
JA
Gibson
C Michael
CM
Murphy
Sabina A
SA
Rifai
Nader
N
McCabe
Carolyn
C
Antman
Elliott M
EM
Cannon
Christopher P
CP
Braunwald
Eugene
E
D000208:Acute Disease; D009320:Atrial Natriuretic Factor / Q000032:analysis*; D015415:Biomarkers / Q000032:analysis; D002097:C-Reactive Protein / Q000032:analysis*; D015331:Cohort Studies; D003327:Coronary Disease / Q000175:diagnosis* / Q000401:mortality; D006333:Heart Failure / Q000175:diagnosis; D006801:Humans; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis; D020097:Natriuretic Peptide, Brain; D011379:Prognosis; D018570:Risk Assessment; D013577:Syndrome; D019210:Troponin I / Q000032:analysis*
D015415:Biomarkers; D019210:Troponin I; D020097:Natriuretic Peptide, Brain; D009320:Atrial Natriuretic Factor; D002097:C-Reactive Protein