Relationship Between Troponin on Presentation and In-Hospital Mortality in Patients With ST-Segment-Elevation
Brett L Wanamaker1, Milan M Seth1, Devraj Sukul1
1Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI.
Insights
Admission troponin levels predict in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention. Elevated troponin indicates higher mortality risk, irrespective of clinical factors.
Area of Science:
- Cardiology
- Biomarkers
- Clinical Research
Background:
- Troponin release kinetics in ST-elevation myocardial infarction (STEMI) correlate with ischemia duration.
- Limited research exists on admission troponin's prognostic value in STEMI patients undergoing primary percutaneous coronary intervention (PCI).
Purpose of the Study:
- To investigate the association between admission troponin levels and in-hospital mortality in a large cohort of STEMI patients treated with primary PCI.
- To evaluate troponin's predictive power for mortality beyond established clinical risk factors.
Main Methods:
- Multivariable adaptive regression modeling was employed to analyze admission troponin levels and in-hospital mortality.
- A validated mortality risk model from the NCDR CathPCI database was used for risk adjustment and prediction.
- Patients were stratified into troponin groups to compare predicted versus observed mortality.
Main Results:
- Nearly half (47.2%) of STEMI patients undergoing primary PCI had undetectable or reference range troponin on admission.
- Admission troponin was an independent predictor of in-hospital mortality; any elevation above the reference range increased mortality risk (1.8% vs. 5.1%).
- Patients with the highest predicted risk and highest troponin levels experienced 19.5% observed mortality, while low troponin groups had lower-than-predicted mortality.
Conclusions:
- Normal admission troponin in STEMI patients undergoing primary PCI is associated with a relatively good prognosis.
- Elevated admission troponin levels independently predict increased in-hospital mortality, even in patients with low baseline clinical risk.
- The findings underscore the need for improved prehospital STEMI detection and care, particularly for patients presenting with markedly elevated troponin levels.
Abstract:
Background Troponin release in ST-segment-elevation myocardial infarction (STEMI) has predictable kinetics with early levels reflective of ischemia duration. Little research has examined the value of admission troponin levels in STEMI patients undergoing primary percutaneous coronary intervention. We investigated the relationship between troponin on presentation and mortality in a large, real-world cohort of STEMI patients undergoing primary percutaneous coronary intervention. Methods and Results We used multivariable adaptive regression modeling to examine the association between admission troponin levels and in-hospital mortality for patients who underwent primary percutaneous coronary intervention for STEMI. We adjusted for known clinical risk factors using a validated mortality risk model derived from the NCDR (National Cardiovascular Data Registry) CathPCI database, and this same model was used to calculate patients' predicted mortality based on clinical and demographic factors. Patients were then stratified by troponin groups to compare predicted versus observed mortality. Of the 14 061 patients included in the cohort, 47.2% had initial troponin levels that were undetectable or within the reference range. Admission troponin was an independent predictor of in-hospital mortality, and any value above the reference range was associated with increased mortality (1.8% versus 5.1%, [standardized difference, 18.2%]). Patients with the highest predicted risk for mortality (13% predicted) in the highest admission troponin grouping experienced an observed mortality of 19.5%. Patients in low troponin groupings consistently demonstrated lower than predicted mortality based on their clinical and demographic risk profile. Conclusions Nearly half of patients undergoing primary percutaneous coronary intervention had normal troponin on presentation and had a relatively good outcome. Mortality increases with elevated admission troponin levels, regardless of baseline clinical risk. The substantial number of patients who present with markedly elevated troponin and their relatively worse outcomes highlights the need for continued improvement in prehospital STEMI detection and care.
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