Prognostic Value of Serial Changes in High-Sensitivity Cardiac Troponin I and T over 3 Months Using Reference Change
Yader Sandoval1, Charles A Herzog2, Sara A Love3
1Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN;
Insights
Serial changes in high-sensitivity cardiac troponin I (hs-cTnI) and troponin T (hs-cTnT) exceeding the reference change value (RCV) predict adverse outcomes in hemodialysis patients. hs-cTnI changes >RCV are particularly predictive of sudden cardiac death (SCD).
Area of Science:
- Cardiology
- Nephrology
- Clinical Chemistry
Background:
- Serial changes in cardiac troponin assays in hemodialysis (HD) patients lack clear clinical significance.
- High-sensitivity assays for cardiac troponin I (hs-cTnI) and troponin T (hs-cTnT) are increasingly used.
Purpose of the Study:
- To evaluate the association of reference change value (RCV) and tertile concentrations of hs-cTnI and hs-cTnT with adverse outcomes in stable HD patients.
- To determine the prognostic value of serial troponin changes for all-cause mortality and sudden cardiac death (SCD).
Main Methods:
- Serial plasma samples were collected 3 months apart from 677 stable outpatient HD patients.
- Reference change values (RCVs) and tertiles for hs-cTnI and hs-cTnT were established.
- Adjusted Cox models assessed associations between troponin changes and primary outcomes: all-cause mortality and SCD.
Main Results:
- During a median 23-month follow-up, 18.6% of patients died.
- Serial hs-cTnI and hs-cTnT changes exceeding RCV were associated with significantly higher all-cause mortality (aHRs 1.9 and 1.7, respectively).
- Only hs-cTnI changes >RCV predicted SCD (aHR 2.6). In the middle tertile, hs-cTnI changes >RCV provided additive prognostic value for both SCD and all-cause mortality.
Conclusions:
- Serial changes in hs-cTnI and hs-cTnT exceeding RCV identify HD patients at increased risk for all-cause mortality.
- Serial hs-cTnI changes >RCV are also predictive of SCD.
- In patients with middle tertile troponin levels, hs-cTnI changes >RCV offer significant additive prognostic information for both SCD and mortality.
Introduction:
Serial changes in cardiac troponin in hemodialysis (HD) patients have uncertain clinical implications. We evaluated associations of adverse outcomes in HD patients with reference change value (RCV) data and tertile concentrations for cardiac troponin I (cTnI) and cTnT measured by high-sensitivity (hs) assays.
Methods:
RCV data and tertiles for hs-cTnI and hs-cTnT were determined from plasma samples collected 3 months apart in 677 stable outpatient HD patients and assessed for their associations with adverse outcomes using adjusted Cox models. Primary outcomes were all-cause mortality and sudden cardiac death (SCD).
Results:
During a median follow-up of 23 months, 18.6% of patients died. RCVs were: hs-cTnI +37% and -30%; hs-cTnT +25% and -20%. Patients with serial hs-cTnI and hs-cTnT changes >RCV (increase or decrease) had all-cause mortality of 25.2% and 23.8% respectively, compared to 15.0% and 16.5% with changes ≤RCV [adjusted hazard ratios (aHRs): 1.9, P = 0.0003 and 1.7, P = 0.0066), respectively]. Only hs-cTnI changes >RCV were predictive of SCD (aHR 2.6, P = 0.005). hs-Cardiac troponin changes >RCV improved all-cause mortality prognostication compared to changes ≤RCV in tertile 2: hs-cTnI aHR, 2.70 (P = 0.003); hs-cTnT aHR, 1.98 (P = 0.043). The aHR of changes in hs-cTnI in tertile 2 >RCV for SCD was 5.62 (P = 0.039).
Conclusions:
Changes over 3 months in hs-cTnI and hs-cTnT of >RCV identified patients at greater risk of all-cause mortality, and for hs-cTnI were also predictive of SCD. Among patients with middle tertile cardiac troponin concentrations, hs-cTnI changes >RCV provided additive prognostic value for both SCD and all-cause mortality, whereas those for hs-cTnT provided additive prognostic value only for all-cause mortality.
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