Cardiac Troponin and Recurrent Major Vascular Events after Minor Stroke or Transient Ischemic Attack
Simon Hellwig1,2, Thomas Ihl1, Ramanan Ganeshan1
1Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Insights
High-sensitivity cardiac troponin T (hs-cTnT) predicts major adverse cardiovascular events (MACE) in minor stroke or transient ischemic attack (TIA) patients. Elevated hs-cTnT identifies high-risk individuals missed by the ABCD² score, suggesting intensified care.
Area of Science:
- Cardiology
- Neurology
- Biomarkers
Background:
- Minor stroke and transient ischemic attack (TIA) patients face risks of major adverse cardiovascular events (MACE).
- Current risk stratification tools, like the ABCD² score, may not fully capture all high-risk individuals.
- High-sensitivity cardiac troponin T (hs-cTnT) is a sensitive biomarker for cardiac injury.
Purpose of the Study:
- To investigate the association between hs-cTnT levels and MACE in patients with minor stroke or TIA.
- To determine if this association is modified by risk stratification using the ABCD² score.
Main Methods:
- Post hoc analysis of the INSPiRE-TMS randomized controlled trial.
- Categorization of patients based on hs-cTnT levels (above or below the 99th percentile URL).
- Risk stratification using the ABCD² score (lower vs. higher risk).
- Cox proportional hazard regression with covariate adjustment and propensity score matching to assess MACE risk.
Main Results:
- Elevated hs-cTnT (> URL) was significantly associated with a higher incidence of MACE compared to levels ≤ URL (9.3%/yr vs. 4.4%/yr).
- The association between hs-cTnT and MACE remained significant after propensity score matching.
- A significant interaction was observed between hs-cTnT levels and ABCD² score category for MACE occurrence (p=0.04).
- In the lower-risk ABCD² category, elevated hs-cTnT identified patients with a MACE rate similar to the overall higher-risk group.
Conclusions:
- hs-cTnT levels are independently associated with incident MACE within 3 years following minor stroke or TIA.
- Elevated hs-cTnT can identify high-risk patients who might be underestimated by the ABCD² score alone.
- These findings suggest that hs-cTnT measurement may aid in guiding secondary prevention strategies and cardiac diagnostics in stroke patients.
Objective:
This study was undertaken to investigate whether high-sensitivity cardiac troponin T (hs-cTnT) is associated with major adverse cardiovascular events (MACE) in patients with minor stroke or transient ischemic attack (TIA), and whether this association differs after risk stratification based on the Age, Blood Pressure, Clinical Features, Duration of Symptoms, Diabetes (ABCD2 ) score.
Methods:
INSPiRE-TMS was a randomized controlled trial allocating patients with minor stroke or TIA to an intensified support program or conventional care. In this post hoc analysis, participants were categorized using hs-cTnT levels (5th generation; Roche Diagnostics, Manheim, Germany; 99th percentile upper reference limit [URL] = 14ng/l). Vascular risk was stratified using the ABCD2 score (lower risk = 0-5 vs higher risk = 6-7). Cox proportional hazard regression was performed using covariate adjustment and propensity score matching (PSM) for the association between hs-cTnT and MACE (stroke/nonfatal coronary event/vascular death).
Results:
Among 889 patients (mean age = 70 years, 37% female), MACE occurred in 153 patients (17.2%) during a mean follow-up of 3.2 years. hs-cTnT was associated with MACE (9.3%/yr, >URL vs 4.4%/yr, ≤URL, adjusted hazard ratio [HR] = 1.63 [95% confidence interval (CI) = 1.13-2.35], adjusted HR [Q4 vs Q1 ] = 2.57 [95% CI = 1.35-4.97], adjusted HR [log-transformed] = 2.31 [95% CI = 1.37-3.89]). This association remained after PSM (adjusted HR = 1.76 [95% CI = 1.14-2.72]). There was a significant interaction between hs-cTnT and ABCD2 category for MACE occurrence (pinteraction = 0.04). In the lower risk category, MACE rate was 9.5%/yr in patients with hs-cTnT > URL, which was higher than in those ≤URL (3.8%/yr) and similar to the overall rate in the higher risk category.
Interpretation:
hs-cTnT levels are associated with incident MACE within 3 years after minor stroke or TIA and may help to identify high-risk individuals otherwise deemed at lower risk based on the ABCD2 score. If confirmed in independent validation studies, this might warrant intensified secondary prevention measures and cardiac diagnostics in stroke patients with elevated hs-cTnT. ANN NEUROL 2021;90:901-912.
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