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Cardiac Troponin Measurement in the Critically Ill: Potential for Guiding Clinical Management
Stacy Poe1, Robin H Vandivier-Pletsch, Michael Clay
1From the *Department of Veterans Affairs, Office of Informatics and Analytics, Office of Productivity, Efficiency and Staffing; †Cardiology Division, Department of Internal Medicine, Cincinnati Veterans Administration Medical Center; ‡Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati; §Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center; and ∥Department of Environmental Health, University of Cincinnati, Cincinnati, OH.
Insights
Elevated cardiac troponin (cTn) in critically ill patients without acute coronary syndromes (ACS) is linked to higher mortality. Statins, beta-blockers, and aspirin may reduce this risk in a troponin-dependent manner.
Area of Science:
- Critical Care Medicine
- Cardiology
- Pharmacology
Background:
- Elevated cardiac troponin (cTn) in critically ill patients without acute coronary syndromes (ACS) is associated with increased mortality.
- No current evidence-based interventions exist to reduce mortality in this patient group.
Purpose of the Study:
- To investigate the association between ACS medications (beta-blockers, aspirin, statins) and mortality in critically ill patients with elevated cTn but no ACS.
- To determine if these medications act as outcome modifiers in a cTn-dependent manner.
Main Methods:
- Retrospective analysis of the Veterans Administration Inpatient Evaluation Center database (October 2007 - September 2008).
- Inclusion of non-ACS patients admitted to Veterans Administration Intensive Care Units.
- Thirty-day mortality was analyzed, adjusted for illness severity, with normalized troponin assay values.
Main Results:
- Elevated cTn (intermediate and high) was associated with increased 30-day mortality in critically ill patients without ACS.
- Statins were associated with reduced mortality in patients with no or intermediate cTn elevation.
- Beta-blockers and aspirin were associated with reduced mortality in patients with high cTn elevation.
Conclusions:
- This study confirms the association between elevated troponin and adverse outcomes in critically ill patients without ACS.
- Statins, beta-blockers, and aspirin show potential as outcome modifiers, with their effect dependent on troponin levels.
Background:
Elevated cardiac troponin (cTn) in the absence of acute coronary syndromes (ACS) is associated with increased mortality in critically ill patients. There are no evidence-based interventions that reduce mortality in this group.
Objectives:
We performed a retrospective investigation of the Veterans Administration Inpatient Evaluation Center database to determine whether drugs used in ACS (β-blockers, aspirin, and statins) are associated with reduced mortality in critically ill patients.
Methods:
Thirty-day mortality was determined for non-ACS patients admitted to any Veterans Administration Intensive Care Unit between October 1, 2007, and September 30, 2008, adjusted for severity of illness. Troponin assay values were normalized across institutions.
Results:
Multivariate analyses for 30-day mortality showed an odds ratio (OR) of 1.82 for patients with high cTn (P < 0.0001, cTn > 10% coefficient of variation) and 1.18 for intermediate cTn (P = 0.0021, cTn between lowest limit detectable and 10% coefficient of variation) compared with patients with no elevation, adjusting for severity of illness (n = 19,979). Logistic regression models showed that patients with no or intermediate elevations of cTn taking statins within 24 hours of cTn measurement had a lower mortality than patients not taking statins (OR, 0.66; 95% confidence interval [95% CI], 0.53-0.82; P = 0.0003), whereas patients with high cTn had a lower mortality if they were taking β-blockers or aspirin within 24 hours of cTn measurement compared to patients not taking β-blockers or aspirin (β-blockers: OR, 0.80; 95% CI, 0.68-0.94; P = 0.0077; aspirin: OR, 0.81;95% CI, 0.69-0.96; P = 0.0134).
Conclusions:
This retrospective study confirms an association between elevated troponin and outcomes in critically ill patients without ACS and identifies statins, β-blockers, and aspirin as potential outcome modifiers in a cTn-dependent manner.
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