Do High-sensitivity Troponin and Natriuretic Peptide Predict Death or Serious Cardiac Outcomes After Syncope?
Carol L Clark1, Thomas A Gibson2, Robert E Weiss2
1Department of Emergency Medicine, William Beaumont Hospital-Royal Oak, Royal Oak, MI.
Insights
High-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) predict 30-day serious outcomes in older adults with syncope. These cardiac biomarkers are valuable tools for risk stratification in emergency department evaluations.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Research
Background:
- Syncope leads to 1.2 million US emergency department visits annually.
- Prognostic value of cardiac biomarkers like high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) in syncope is not well-defined.
- Older adults presenting with syncope require accurate risk assessment for adverse outcomes.
Purpose of the Study:
- To determine if hscTnT and NT-proBNP measured in the emergency department (ED) independently predict 30-day mortality or serious cardiac outcomes.
- To assess the association between varying levels of these biomarkers and short-term adverse events in syncope patients.
Main Methods:
- Secondary analysis of a prospective observational trial (N=3,392) of patients aged 60+ presenting with syncope.
- Collected hscTnT and NT-proBNP within 3 hours of consent; analyzed centrally.
- Used multivariate logistic regression and Bayesian Markov Chain Monte Carlo methods to adjust for covariates and estimate absolute risk.
Main Results:
- The primary outcome (30-day death/serious cardiac events) occurred in 10.8% of patients.
- Elevated hscTnT and NT-proBNP levels were independently associated with increased risk.
- For hscTnT > 50 ng/L, risk was 29%; for NT-proBNP > 2,000 ng/L, risk was 29%.
Conclusions:
- hscTnT and NT-proBNP are independent predictors of 30-day adverse outcomes in older ED patients with syncope.
- These biomarkers aid in risk stratification for syncope patients.
- Findings support the routine use of these biomarkers in the ED evaluation of syncope.
Objectives:
An estimated 1.2 million annual emergency department (ED) visits for syncope/near syncope occur in the United States. Cardiac biomarkers are frequently obtained during the ED evaluation, but the prognostic value of index high-sensitivity troponin (hscTnT) and natriuretic peptide (NT-proBNP) are unclear. The objective of this study was to determine if hscTnT and NT-proBNP drawn in the ED are independently associated with 30-day death/serious cardiac outcomes in adult patients presenting with syncope.
Methods:
A prespecified secondary analysis of a prospective, observational trial enrolling participants ≥ age 60 presenting with syncope, at 11 United States hospitals, was conducted between April 2013 and September 2016. Exclusions included seizure, stroke, transient ischemic attack, trauma, intoxication, hypoglycemia, persistent confusion, mechanical/electrical invention, prior enrollment, or predicted poor follow-up. Within 3 hours of consent, hscTnT and NT-proBNP were collected and later analyzed centrally using Roche Elecsys Gen 5 STAT and 2010 Cobas, respectively. Primary outcome was combined 30-day all-cause mortality and serious cardiac events. Adjusting for illness severity, using multivariate logistic regression analysis, variations between primary outcome and biomarkers were estimated, adjusting absolute risk associated with ranges of biomarkers using Bayesian Markov Chain Monte Carlo methods.
Results:
The cohort included 3,392 patients; 367 (10.8%) experienced the primary outcome. Adjusted absolute risk for the primary outcome increased with hscTnT and NT-proBNP levels. HscTnT levels ≤ 5 ng/L were associated with a 4% (95% confidence interval [CI] = 3%-5%) outcome risk, and hscTnT > 50 ng/L, a 29% (95% CI = 26%-33%) risk. NT-proBNP levels ≤ 125 ng/L were associated with a 4% (95% CI = 4%-5%) risk, and NT-proBNP > 2,000 ng/L a 29% (95% CI = 25%-32%) risk. Likelihood ratios and predictive values demonstrated similar results. Sensitivity analyses excluding ED index serious outcomes demonstrated similar findings.
Conclusions:
hscTnT and NT-proBNP are independent predictors of 30-day death and serious outcomes in older ED patients presenting with syncope.
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