Akshay Bagai1, Zhen Huang2, Yuliya Lokhnygina2, Robert A Harrington2, Paul W Armstrong2, John Strony2, Harvey D White2, Sergio Leonardi2, Claes Held2, Frans Van de Werf2, Lars Wallentin2, Pierluigi Tricoci2, Kenneth W Mahaffey2. 1. From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.). bagaia@smh.ca. 2. From the Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Ontario, Canada (A.B.); Department of Medicine, Duke Clinical Research Center, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (A.B., Z.H., Y.L., S.L., P.T.); Department of Medicine, Stanford University, CA (R.A.H., K.W.M.); Department of Medicine, University of Alberta, Edmonton, Canada (P.W.A.); Merck & Co, Whitehouse Station, NJ (J.S.); Department of Medicine, Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Department of Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.); Department of Medicine, Uppsala Clinical Research Center, Uppsala University, Sweden (C.H., L.W.); and Department of Medicine, University Hospitals Leuven, Leuven, Belgium (F.V.d.W.).
Abstract
BACKGROUND: In patients with non-ST-segment-elevation acute coronary syndrome (NSTE ACS), elevated troponin levels identify patients at high risk for adverse outcomes; however, it is unknown whether the magnitude of troponin elevation during hospitalization remains predictive of subsequent events in patients undergoing coronary revascularization. METHODS AND RESULTS: We studied 12 635 patients with NSTE ACS in theThrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) study with at least 1 troponin measurement during index hospitalization. Cox proportional hazards regression was used to examine the relationship between peak troponin level (standardized as the ratio of peak troponin value measured during hospitalization and local laboratory upper reference limit [URL]) and revascularization on all-cause mortality at 2 years. Revascularization (percutaneous coronary intervention or coronary artery bypass graft) was performed during index hospitalization in 8586 patients (68.0%); revascularized patients had higher peak troponin ratios (median, 23 versus 9.5× URL). Among patients that did not undergo revascularization, the mortality rate at 2 years increased in a curvilinear fashion with increasing levels of peak troponin. In contrast, the mortality rate at 2 years remained constant irrespective of peak troponin levels among revascularized patients (P for interaction=0.004). This relationship was unchanged after multivariable adjustment. CONCLUSIONS: There is a differential relationship between the magnitude of troponin elevation and long-term mortality in ACS patients treated with and without revascularization. Although prognostically important in patients treated without revascularization, the prognostic implications of peak troponin level seem to be minimal in revascularized patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00527943.
RCT Entities:
BACKGROUND: In patients with non-ST-segment-elevation acute coronary syndrome (NSTE ACS), elevated troponin levels identify patients at high risk for adverse outcomes; however, it is unknown whether the magnitude of troponin elevation during hospitalization remains predictive of subsequent events in patients undergoing coronary revascularization. METHODS AND RESULTS: We studied 12 635 patients with NSTE ACS in the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) study with at least 1 troponin measurement during index hospitalization. Cox proportional hazards regression was used to examine the relationship between peak troponin level (standardized as the ratio of peak troponin value measured during hospitalization and local laboratory upper reference limit [URL]) and revascularization on all-cause mortality at 2 years. Revascularization (percutaneous coronary intervention or coronary artery bypass graft) was performed during index hospitalization in 8586 patients (68.0%); revascularized patients had higher peak troponin ratios (median, 23 versus 9.5× URL). Among patients that did not undergo revascularization, the mortality rate at 2 years increased in a curvilinear fashion with increasing levels of peak troponin. In contrast, the mortality rate at 2 years remained constant irrespective of peak troponin levels among revascularized patients (P for interaction=0.004). This relationship was unchanged after multivariable adjustment. CONCLUSIONS: There is a differential relationship between the magnitude of troponin elevation and long-term mortality in ACSpatients treated with and without revascularization. Although prognostically important in patients treated without revascularization, the prognostic implications of peak troponin level seem to be minimal in revascularized patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00527943.
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