Cardiology Department Coimbra Hospital and Medical School Portugal
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1 Quantitative troponin elevation provide incremental prognostic value beyond comprehensive risk stratification in patients with acute coronary syndromes. Rui Baptista, Elisabete Jorge, Hélia Martins, Fátima Saraiva, Paulo Mendes, Rogério Teixeira, Carolina Lourenço, Natália António, Francisco Gonçalves, Pedro Monteiro, Mário Freitas, Luís A. Providência Cardiology Department Coimbra Hospital and Medical School Portugal
2 Background Risk stratification systems are paramount in clinical decision in patients with acute coronary syndromes GRACE risk score is valid across the ACS spectrum (1) creatine kinase MB fraction >2 times upper limit of the hospital's normal range OR if no creatine kinase MB fraction available. then total creatine phosphokinase >2 times upper limit of the hospital's normal range and/or (2) positive troponin I or T results (if performed).
3 Background Cardiac enzyme elevation not present as a continuous variable
4 Background TIMI IIIB It is not clear whether the quantitative assessment of troponin can add prognostic value to the GRACE risk score
5 Aim To determine: 1. The impact of peak troponin I on in-hospital and 30-day mortality in patients admitted with ACS 2. The incremental predictive value of peak troponin I to established risk scores
6 Methods Study population Retrospective study of 2202 consecutive patients admitted to an intensive coronary care unit with a presumptive diagnosis of ACS GRACE score Was calculated using the avaliable data. obtained on admission by the assistant physician
7 Methods Endpoints In-hospital mortality Combined in-hospital and 30-day mortality GRACE strata: Low-risk (<109) Intermediate-risk ( ) High-risk (>140) Troponin I tertiles (μg/ml) T 1-2 T T 3 - > 8.80 Statistics Kolmogorov-Smirnov Mean ± SD Log(troponin I) Student s T test Qui-Squared/Fischer C-statistic Hosmer-Lemeshow Pearson correlation
8 Results Demographics TNI T1 TNI T2 TNI T3 P value Gender (% male) Age, years 64.7± ± ±12.6 < Prior history (%) Hypertension Dyslipidemia Smoking Diabetes mellitus type Prior MI Stroke/TIA Periferal artery disease CABG Coronary angiogram < 0.001
9 Results Clinical data TNI T1 TNI T2 TNI T3 P value Systolic BP, mmhg 142.4± ± ±25.8 < Diastolic BP, mmhg 75.3± ± ±15.2 < Heart rate, min -1 74± ± ±18.7 < Killip III-IV class (%) < ACS (%) STEMI < Lab data Creatinin (mg/dl) 1.2± ± ±1.2 < Hemoglobin (g/dl) 13.9± ± ± Normal ECG (%) < GRACE (points) 121.7± ± ±37.3 < 0.001
10 Results Poor correlation between GRACE score and log (troponin I) R 2 = Kolmogorov-Smirnov P < 0.001
11 Results Treatment (%) TNI T1 TNI T2 TNI T3 P value Admission medication Aspirin Clopidogrel Enoxaparin < Beta-blocker < Statin < Treatment (%) TNI T1 TNI T2 TNI T3 P value STEMI Primary PCI NSTEMI/UA Invasive strategy < No significant lesions < 0.001
12 Results Discharge (%) TNI T1 TNI T2 TNI T3 P value Coronary anatomy LM LAD Cx RCA One-vessel Two-vessel Three-vessel Complete revasc LVEF (%) 54.4± ± ±11.2 < 0.001
13 Results Univariate analysis Endpoint impact of troponin I and GRACE score Troponin I GRACE risk score 20,00% 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% * * * * 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% * * * * In-hospital mortality Combined IH and 30-day mortality In-hospital mortality Combined IH and 30-day mortality TNI T1 TNI T2 TNI T3 <= >=140 * p< 0.05
14 Results Univariate analysis In hospital impact of troponin I and GRACE score ,00% 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% Troponin I TNI T1 TNI T2 TNI T3 Log-Rank p< day
15 Results In-hospital mortality Multivariable analisys odds-ratio (CI 95%) GRACE GRACE + TNI P - value GRACE (each unit) ( ) ( ) < Log(troponin I) (each ug/ml) ( ) < ROC (AUC) ( ) ( ) Hosmer-Lemeshow (P) Sensitivity (%) % Specificity (%) %
16 Results In-hospital mortality ROC curve GRACE + TNI GRACE
17 Results In-hospital mortality 20,00% 18,00% 16,00% 14,00% 12,00% 10,00% 8,00% 6,00% 4,00% 2,00% 0,00% 8,81+ 2,01-8,80 Troponin I. ug/ml <= 109,00 110,00-139,00 140,00+ <= 2,00 GRACE score
18 Results Combined in-hospital and 30-day mortality Multivariable analisys odds-ratio (CI 95%) GRACE GRACE + TNI P value GRACE (each unit) ( ) ( ) < Log(troponin I) (each ug/ml) ( ) < ROC (AUC) ( ) ( ) Hosmer-Lemeshow (P) Sensitivity (%) % Specificity (%) %
19 Results Combined in-hospital and 30-day mortality ROC curve GRACE + TNI GRACE
20 Troponin (ug/ml) Results Combined in-hospital and 30-day mortality 21,0% 16,0% 11,0% 6,0% 1,0% 8,81+ 2,01-8,80 <= 109,00 110,00-139,00 140,00+ <= 2,00 GRACE score
21 Limitations Small sample size, single-center GRACE score was developed to predict in-hospital mortality and not 30-day mortality As troponin is readily avaliable, it does not require a special test Any additions of variables to a risk score increases its complexity and may discourage physicians from using it
22 Conclusions The currently avaliable risk scores still have some limitations in the correct stratification of ACS patients The addition of troponin to GRACE risk score can be useful, as it improves its performance for in-hospital and 30-day allcause mortality These results should lead to a continuous optimization in the currently avaliable decision-making tools in ACS
23 Quantitative troponin elevation provide incremental prognostic value beyond comprehensive risk stratification in patients with acute coronary syndromes. Rui Baptista, Elisabete Jorge, Hélia Martins, Fátima Saraiva, Paulo Mendes, Rogério Teixeira, Carolina Lourenço, Natália António, Francisco Gonçalves, Pedro Monteiro, Mário Freitas, Luís A. Providência Cardiology Department Coimbra Hospital and Medical School Portugal
24 NSTEMI In-hospital death P value Exp (b) Inf Sup ROC GRACE < LogTroponina
25 NSTEMI & UA 6-month mortality Sig. Exp(B) Lower Upper GRACE LogTroponin Invasive strategy
26 Gender ROC (AUC) Male GRACE 0.82 ( ) GRACE + TNI 0.86 ( ) Female GRACE 0.69 ( ) GRACE + TNI 0.76 ( )
27
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