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Prognostic significance of troponin level in 3121 patients presenting with atrial fibrillation (The NIHR Health
Amit Kaura1, Ahran D Arnold1, Vasileios Panoulas1
1NIHR Imperial Biomedical Research Centre Imperial College London and Imperial College Healthcare NHS Trust London United Kingdom.
Insights
Elevated troponin levels in patients with atrial fibrillation (AF) correlate with increased mortality risk. Coronary angiography may mitigate this risk, suggesting coronary artery disease is a key factor.
Area of Science:
- Cardiology
- Clinical Medicine
- Biomarkers
Background:
- Atrial fibrillation (AF) patients often have troponin tests, but the clinical significance of results is unclear.
- Troponin elevation in AF is common, yet its association with mortality and underlying causes needs clarification.
Purpose of the Study:
- To investigate the relationship between troponin levels, coronary angiography, and all-cause mortality in AF patients.
- To determine if coronary artery disease (CAD) mediates the increased mortality risk associated with troponin elevation in AF.
Main Methods:
- Utilized National Institute of Health Research Health Informatics Collaborative data from 3121 UK tertiary center patients admitted with AF (2010-2017).
- Analyzed peak troponin levels (scaled as multiples of the upper limit of normal) and their association with all-cause mortality over a median follow-up of 1462 days.
- Examined the relationship between troponin levels, odds of undergoing coronary angiography, and mortality risk post-angiography.
Main Results:
- A positive troponin result (above the upper limit of normal) was associated with a 1.20-fold increased hazard ratio for mortality (P<0.05).
- Higher troponin levels showed an exponential relationship with mortality risk, peaking at approximately 250-fold the upper limit of normal (HR 2.6).
- Increased troponin levels correlated with higher odds of coronary angiography, which was associated with a 36% lower mortality risk (aHR 0.61, P=0.01).
Conclusions:
- Elevated troponin levels are linked to increased all-cause mortality in patients presenting with AF.
- The reduced mortality in patients undergoing coronary angiography suggests that CAD may be the underlying cause of troponin elevation and is potentially treatable with revascularization.
Abstract:
Background Patients presenting with atrial fibrillation (AF) often undergo a blood test to measure troponin, but interpretation of the result is impeded by uncertainty about its clinical importance. We investigated the relationship between troponin level, coronary angiography, and all-cause mortality in real-world patients presenting with AF. Methods and Results We used National Institute of Health Research Health Informatics Collaborative data to identify patients admitted between 2010 and 2017 at 5 tertiary centers in the United Kingdom with a primary diagnosis of AF. Peak troponin results were scaled as multiples of the upper limit of normal. A total of 3121 patients were included in the analysis. Over a median follow-up of 1462 (interquartile range, 929-1975) days, there were 586 deaths (18.8%). The adjusted hazard ratio for mortality associated with a positive troponin (value above upper limit of normal) was 1.20 (95% CI, 1.01-1.43; P<0.05). Higher troponin levels were associated with higher risk of mortality, reaching a maximum hazard ratio of 2.6 (95% CI, 1.9-3.4) at ≈250 multiples of the upper limit of normal. There was an exponential relationship between higher troponin levels and increased odds of coronary angiography. The mortality risk was 36% lower in patients undergoing coronary angiography than in those who did not (adjusted hazard ratio, 0.61; 95% CI, 0.42-0.89; P=0.01). Conclusions Increased troponin was associated with increased risk of mortality in patients presenting with AF. The lower hazard ratio in patients undergoing invasive management raises the possibility that the clinical importance of troponin release in AF may be mediated by coronary artery disease, which may be responsive to revascularization.
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