Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study
Sameer Arora1, Matthew A Cavender1, Patricia P Chang1
1Division of Cardiology, University of North Carolina at Chapel Hill, USA.
Insights
Patients with decreasing cardiac troponin I levels after admission for myocardial infarction had worse outcomes. These patients received less guideline-based care and had higher mortality, often from non-cardiovascular causes.
Area of Science:
- Cardiology
- Biomarker research
- Clinical outcomes
Background:
- The fourth universal definition of myocardial infarction (MI) necessitates troponin changes for non-ST-segment elevation MI (NSTEMI) classification.
- Understanding differences in NSTEMI based on initial cardiac troponin patterns is crucial for patient management.
Purpose of the Study:
- To investigate if patient characteristics, treatment strategies, and outcomes differ based on initial cardiac troponin I (cTnI) patterns in NSTEMI.
- To analyze the clinical significance of increasing versus decreasing cTnI in patients admitted with chest pain.
Main Methods:
- Retrospective analysis of 1926 hospitalizations for chest pain and elevated cTnI within 12 hours of symptom onset.
- Patients classified as NSTEMI were analyzed based on cTnI change (≥0.02 ng/mL difference) during the first hospitalization day.
- Comparison of demographics, management (antiplatelets, lipid-lowering agents, angiography), and mortality between increasing and decreasing cTnI groups.
Main Results:
- Increasing cTnI was more common (78%).
- Decreasing cTnI patients were more often Black (45% vs. 35%), female (54% vs. 40%), and received less non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and angiography (38% vs. 64%).
- While in-hospital mortality was similar (3%), 28-day mortality was doubled in the decreasing cTnI group (12% vs. 5%; P=0.01), with more non-cardiovascular deaths (75% vs. 38%; P=0.01).
Conclusions:
- Patients with decreasing cTnI after initial elevation have poorer outcomes and less adherence to evidence-based therapies.
- Higher 28-day mortality in the decreasing cTnI group was largely due to non-cardiovascular causes.
- Further research is needed to determine if these findings relate to Type 2 MI or subacute presentations.
Background:
The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.
Methods:
We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.
Results:
A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).
Conclusion:
Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
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