title: Magnitude of troponin elevation and long-term clinical outcomes in acute coronary syndrome patients treated with and without revascularization.
abstract: BACKGROUND
  In patients with non-ST-segment-elevation acute coronary syndrome (NSTE ACS), elevated troponin levels identify patients at high risk for adverse outcomes; however, it is unknown whether the magnitude of troponin elevation during hospitalization remains predictive of subsequent events in patients undergoing coronary revascularization.
  
  
  RESULTS
  We studied 12 635 patients with NSTE ACS in the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) study with at least 1 troponin measurement during index hospitalization. Cox proportional hazards regression was used to examine the relationship between peak troponin level (standardized as the ratio of peak troponin value measured during hospitalization and local laboratory upper reference limit [URL]) and revascularization on all-cause mortality at 2 years. Revascularization (percutaneous coronary intervention or coronary artery bypass graft) was performed during index hospitalization in 8586 patients (68.0%); revascularized patients had higher peak troponin ratios (median, 23 versus 9.5× URL). Among patients that did not undergo revascularization, the mortality rate at 2 years increased in a curvilinear fashion with increasing levels of peak troponin. In contrast, the mortality rate at 2 years remained constant irrespective of peak troponin levels among revascularized patients (P for interaction=0.004). This relationship was unchanged after multivariable adjustment.
  
  
  CONCLUSIONS
  There is a differential relationship between the magnitude of troponin elevation and long-term mortality in ACS patients treated with and without revascularization. Although prognostically important in patients treated without revascularization, the prognostic implications of peak troponin level seem to be minimal in revascularized patients.
  
  
  BACKGROUND
  URL: http://www.clinicaltrials.gov. Unique identifier: NCT00527943.
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.). bagaia@smh.ca.
authors.forename: Akshay
authors.initials: A
authors.lastname: Bagai
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Zhen
authors.initials: Z
authors.lastname: Huang
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Yuliya
authors.initials: Y
authors.lastname: Lokhnygina
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: John
authors.initials: J
authors.lastname: Strony
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Sergio
authors.initials: S
authors.lastname: Leonardi
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Claes
authors.initials: C
authors.lastname: Held
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Tricoci
authors.affiliation: From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D054058:Acute Coronary Syndrome / Q000097:blood / Q000401:mortality / Q000601:surgery; D015415:Biomarkers / Q000097:blood; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome; D014336:Troponin / Q000097:blood
chemical_list: D015415:Biomarkers; D014336:Troponin
keywords: myocardial infarction; troponin