title: Is a pattern of increasing biomarker concentrations important for long-term risk stratification in acute coronary syndrome patients presenting early after the onset of symptoms?
abstract: BACKGROUND
  Guidelines for treatment of acute coronary syndrome (ACS) recommend observing a rise or fall in cardiac troponin (cTn) concentrations for assessing acute injury. It is unknown whether a rising pattern presages a more adverse long-term prognosis than elevations that do not change. The present study assessed whether a rising pattern of cardiac biomarkers was more prognostic than simple elevations.
  
  
  METHODS
  We measured N-terminal pro-brain natriuretic peptide (NT-proBNP) (Roche), cTnT (Roche) and cTnI (Beckman Coulter) in 212 ACS patients. These biomarkers were measured in coincident EDTA and heparin plasma samples available from at least 2 different time points, an early first specimen obtained a median of 2 hours after onset of symptoms, interquartile range (IQR) 2-4 hours, and a later second specimen obtained at 9 hours, IQR 9-9 hours. The cTn concentration in the second specimen was used to classify myocardial necrosis (cTnI >0.04 ug/L; cTnT >0.01 ug/L). Outcomes [death, myocardial infarction (MI), heart failure (HF)] were obtained >8 years after the initial presentation. For patients with myocardial necrosis and a cTn concentration ratio (second/first measured concentrations) > or =1.00, the concentration ratios and the absolute concentrations in the second specimen were used to assess prognosis after 4 years.
  
  
  RESULTS
  In myocardial necrosis, the relative change (cTn2/cTn1) was greater for cTnI than for cTnT (P <0.01), whereas the relative change in NT-proBNP was the same regardless of which troponin was used to classify necrosis (P = 0.71). The concentration ratio for cTnI, cTnT, and NT-proBNP was not useful for risk stratification (i.e., death/MI/HF; P > or =0.15).
  
  
  CONCLUSIONS
  A rise in cardiac troponin or NT-proBNP concentration in ACS patients presenting early after onset of pain is not helpful for long-term prognosis.
authors: Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada. kavsakp@mcmaster.ca
authors: Peter A
authors: PA
authors: Kavsak
authors: Alice M
authors: AM
authors: Newman
authors: Dennis T
authors: DT
authors: Ko
authors: Glenn E
authors: GE
authors: Palomaki
authors: Viliam
authors: V
authors: Lustig
authors: Andrew R
authors: AR
authors: MacRae
authors: Allan S
authors: AS
authors: Jaffe
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D015415:Biomarkers / Q000097:blood; D006801:Humans; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood*; D011379:Prognosis; D011498:Protein Precursors / Q000097:blood*; D018570:Risk Assessment; D013997:Time Factors; D019210:Troponin I / Q000097:blood*; D020107:Troponin T / Q000097:blood*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D011498:Protein Precursors; D019210:Troponin I; D020107:Troponin T; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain