title: Prognostic significance of elevated baseline troponin in patients with acute coronary syndromes and chronic kidney disease treated with different antithrombotic regimens: a substudy from the ACUITY trial.
abstract: BACKGROUND
  Elevation of baseline cardiac troponin in patients presenting with acute coronary syndromes (ACS) confers an adverse prognosis. The prognostic value of troponin elevation in patients with chronic kidney disease (CKD) and ACS is less certain.
  
  
  RESULTS
  In the ACUITY (Acute Catheterization and Urgent Intervention Triage strategy) trial, 13 819 patients with moderate and high-risk ACS were assigned randomly to receive heparin plus a glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin monotherapy. Among 2179 patients with CKD (creatinine clearance <60 mL/min), baseline troponin elevation was present in 1291 patients (59.2%). Major bleeding and major adverse cardiac events (MACE), including death, myocardial infarction (MI), or unplanned revascularization, were examined according to baseline troponin status and randomization arm. Patients with CKD in whom the baseline troponin level was elevated had significantly higher rates of death, MI, and MACE at 30 days and 1 year compared with CKD patients without elevated baseline troponin. By multivariable analysis, baseline troponin elevation in patients with CKD was an independent predictor of composite death or MI at 30 days (hazard ratio [95% CI]=2.05 [1.48, 2.83], P<0.0001) and 1 year (1.72 [1.36, 2.17], P<0.0001). In CKD patients with baseline troponin elevation, bivalirudin monotherapy compared with heparin plus a GPI significantly reduced the 30-day rates of major bleeding with nonsignificantly different rates of MACE at 30 days and 1 year.
  
  
  CONCLUSIONS
  In patients with ACS and CKD, baseline troponin elevation is associated with significantly worse short- and long-term clinical outcomes. Bivalirudin monotherapy safely reduces major bleeding in ACS patients with CKD and baseline troponin elevation.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
authors.affiliation: Cardiovascular Research Foundation, New York, NY 10022, USA.
authors.forename: Subasit
authors.initials: S
authors.lastname: Acharji
authors.forename: Usman
authors.initials: U
authors.lastname: Baber
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Martin
authors.initials: M
authors.lastname: Fahy
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D005260:Female; D005343:Fibrinolytic Agents / Q000592:standards / Q000627:therapeutic use; D005500:Follow-Up Studies; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006629:Hirudins / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D010446:Peptide Fragments / Q000008:administration & dosage* / Q000009:adverse effects; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011379:Prognosis; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects; D012015:Reference Standards; D016019:Survival Analysis; D020107:Troponin T / Q000097:blood
chemical_list: D015415:Biomarkers; D005343:Fibrinolytic Agents; D006629:Hirudins; D010446:Peptide Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D020107:Troponin T; D006493:Heparin; C074619:bivalirudin