Association of Hypertension Severity with 30-Day Major Adverse Cardiovascular Events in Patients with Intermediate...

Hypertension is a recognized risk factor for acute coronary syndrome and major adverse cardiovascular events, yet its influence on high sensitivity cardiac troponin (hscTn) concentrations and on the prognostic value of intermediate hscTnI results remains uncertain. We assessed whether blood pressure category confounds the relationship between intermediate hscTnI values (4-18 nanograms per liter [ng/L]) and 30-day major adverse cardiovascular events.

We performed a secondary analysis of the Rapid Acute Coronary Syndrome Evaluation-Implementation Trial (steppedwedge randomized trial across nine Michigan emergency departments [ED] (July 2020-April 2021). From 32,609 patients in the primary trial, we analyzed only those with available hs-cTnI values reported to be in the intermediate range (4-18 ng/L). The first recorded ED blood pressure-determined category: normotensive (< 140/< 90 millimeters of mercury [mm Hg] moderate [140-179/90-109 mm Hg]; or severe [≥ 180/≥ 110 mm Hg]. Generalized linear models and penalized logistic regression examined associations with hscTnI and 30-day major adverse cardiovascular events (allcause death, myocardial infarction, or urgent revascularization), respectively, adjusting for confounders.

Analysis included 23,803 patients. Mean age was 57.5 ± 17.9 years; 57.5% were women and 32.7% Black. Blood pressure categories were normotensive 40.9%, moderate 46.5%, and severe 12.6%. After adjustment, severe blood pressure was associated with a 16% higher mean hscTnI (calculated as %change= 10^β - 1; β = 0.064, 95%, CI 0.047-0.082). Major adverse cardiovascular events at 30-days occurred in 148 patients (0.6%), 47 of them normotensive (0.5%), 77 with moderate hypertension (0.7%), and 24 with severe hypertension (0.8%). Compared with normotension, moderate blood pressure independently increased 30-day major adverse cardiovascular events risk (adjusted odds ratio [AOR] 1.47, 95% CI, 1.02-2.13; absolute risk difference +0.25%, 95% CI, 0.01-0.49), whereas severe blood pressure showed no clear association (AOR 1.32, 95% CI, 0.80-2.18; absolute risk difference +0.17%, 95 % CI, -0.09 to 0.43). Estimates were similar in sensitivity analyses limited to patients without coronary artery disease.

Among ED patients with intermediate hscTnI, blood pressure ≥ 140/90 mm Hg confers modestly higher short term risk of major adverse cardiovascular events, but incremental severity beyond this threshold does not add prognostic value. Elevated hscTnI in the context of severely elevated blood pressure likely reflects myocardial stress rather than additional ischemic risk. Clinicians should interpret intermediate troponin results in hypertensive patients cautiously, integrating clinical presentation and established risk factors.