Prognostic performance of high-sensitivity cardiac troponin T kinetic changes adjusted for elevated admission values and the GRACE score in an unselected emergency department population.
OBJECTIVE
The aim of this study was to test the prognostic performance of rising and falling kinetic changes of high-sensitivity cardiac troponin T (hs-cTnT) and the GRACE score.


METHODS
Rising and falling hs-cTnT changes in an unselected emergency department population were compared.


RESULTS
635 patients with a hs-cTnT >99th percentile admission value were enrolled. Of these, 572 patients qualified for evaluation with rising patterns (n=254, 44.4%), falling patterns (n=224, 39.2%), or falling patterns following an initial rise (n=94, 16.4%). During 407days of follow-up, we observed 74 deaths, 17 recurrent AMI, and 79 subjects with a composite of death/AMI. Admission values >14ng/L were associated with a higher rate of adverse outcomes (OR, 95%CI:death:12.6, 1.8-92.1, p=0.01, death/AMI:6.7, 1.6-27.9, p=0.01). Neither rising nor falling changes increased the AUC of baseline values (AUC: rising 0.562 vs. 0.561, p=ns, falling: 0.533 vs. 0.575, p=ns). A GRACE score ≥140 points indicated a higher risk of death (OR, 95%CI: 3.14, 1.84-5.36), AMI (OR, 95%CI: 1.56, 0.59-4.17), or death/AMI (OR, 95%CI: 2.49, 1.51-4.11). Hs-cTnT changes did not improve the prognostic performance of a GRACE score ≥140 points (AUC, 95%CI: death: 0.635, 0.570-0.701 vs. 0.560, 0.470-0.649 p=ns, AMI: 0.555, 0.418-0.693 vs. 0.603, 0.424-0.782, p=ns, death/AMI: 0.610, 0.545-0.676 vs. 0.538, 0.454-0.622, p=ns). Coronary angiography was performed earlier in patients with rising than with falling kinetics (median, IQR [hours]:13.7, 5.5-28.0 vs. 20.8, 6.3-59.0, p=0.01).


CONCLUSIONS
Neither rising nor falling hs-cTnT changes improve the prognostic performance of elevated hs-cTnT admission values or the GRACE score. However, rising values are more likely associated with the decision for earlier invasive strategy.
Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany.
Moritz
M
Biener
Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany.
Matthias
M
Mueller
Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany.
Mehrshad
M
Vafaie
Mayo Clinic and Mayo College of Medicine, Rochester, MN, USA.
Allan S
AS
Jaffe
Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany.
Hugo A
HA
Katus
Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany. Electronic address: evangelos_giannitsis@med.uni-heidelberg.de.
Evangelos
E
Giannitsis
D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization; D006801:Humans; D007700:Kinetics; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000378:metabolism / Q000628:therapy; D010343:Patient Admission; D011379:Prognosis; D018570:Risk Assessment; D020107:Troponin T / Q000378:metabolism*
D020107:Troponin T
GRACE score; High-sensitivity troponin T; Kinetic changes; Prognosis