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Multicenter Study
. 2018 Jan 30;137(5):425-435.
doi: 10.1161/CIRCULATIONAHA.117.030320. Epub 2017 Oct 4.

High-Sensitivity Cardiac Troponin and the Risk Stratification of Patients With Renal Impairment Presenting With Suspected Acute Coronary Syndrome

Eve Miller-Hodges  1   2 , Atul Anand  1 , Anoop S V Shah  1 , Andrew R Chapman  1 , Peter Gallacher  1   2 , Kuan Ken Lee  1 , Tariq Farrah  1   2 , Nynke Halbesma  3 , James P Blackmur  1 , David E Newby  1 , Nicholas L Mills  1 , Neeraj Dhaun  4   2
Affiliations
Multicenter Study

High-Sensitivity Cardiac Troponin and the Risk Stratification of Patients With Renal Impairment Presenting With Suspected Acute Coronary Syndrome

Eve Miller-Hodges et al. Circulation. .

Abstract

Background: High-sensitivity cardiac troponin testing may improve the risk stratification and diagnosis of myocardial infarction, but concentrations can be challenging to interpret in patients with renal impairment, and the effectiveness of testing in this group is uncertain.

Methods: In a prospective multicenter study of consecutive patients with suspected acute coronary syndrome, we evaluated the performance of high-sensitivity cardiac troponin I in those with and without renal impairment (estimated glomerular filtration rate <60mL/min/1.73m2). The negative predictive value and sensitivity of troponin concentrations below the risk stratification threshold (5 ng/L) at presentation were reported for a primary outcome of index type 1 myocardial infarction, or type 1 myocardial infarction or cardiac death at 30 days. The positive predictive value and specificity at the 99th centile diagnostic threshold (16 ng/L in women, 34 ng/L in men) was determined for index type 1 myocardial infarction. Subsequent type 1 myocardial infarction and cardiac death were reported at 1 year.

Results: Of 4726 patients identified, 904 (19%) had renal impairment. Troponin concentrations <5 ng/L at presentation identified 17% of patients with renal impairment as low risk for the primary outcome (negative predictive value, 98.4%; 95% confidence interval [CI], 96.0%-99.7%; sensitivity 98.9%; 95%CI, 97.5%-99.9%), in comparison with 56% without renal impairment (P<0.001) with similar performance (negative predictive value, 99.7%; 95% CI, 99.4%-99.9%; sensitivity 98.4%; 95% CI, 97.2%-99.4%). The positive predictive value and specificity at the 99th centile were lower in patients with renal impairment at 50.0% (95% CI, 45.2%-54.8%) and 70.9% (95% CI, 67.5%-74.2%), respectively, in comparison with 62.4% (95% CI, 58.8%-65.9%) and 92.1% (95% CI, 91.2%-93.0%) in those without. At 1 year, patients with troponin concentrations >99th centile and renal impairment were at greater risk of subsequent myocardial infarction or cardiac death than those with normal renal function (24% versus 10%; adjusted hazard ratio, 2.19; 95% CI, 1.54-3.11).

Conclusions: In suspected acute coronary syndrome, high-sensitivity cardiac troponin identified fewer patients with renal impairment as low risk and more as high risk, but with lower specificity for type 1 myocardial infarction. Irrespective of diagnosis, patients with renal impairment and elevated cardiac troponin concentrations had a 2-fold greater risk of a major cardiac event than those with normal renal function, and should be considered for further investigation and treatment.

Clinical trial registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01852123.

Keywords: acute coronary syndrome; myocardial infarction; renal insufficiency; risk; troponin.

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Figures

Figure 1.
Figure 1.
Cardiac troponin I concentration at presentation stratified by renal function (A) and adjudicated index diagnosis >99th centile stratified by renal function (B). GFR indicates glomerular filtration rate; and MI, myocardial infarction.
Figure 2.
Figure 2.
Cumulative incidence plot for a composite of readmission with type 1 myocardial infarction or cardiac death at 1 year stratified by troponin and renal function. Across all patients, the risk of readmission with type 1 myocardial infarction or cardiac death increased with cardiac troponin (HR, 1.15; 95% CI, 1.07–1.25 per doubling; P<0.001) and eGFR (HR, 1.28; 95% CI, 1.15–1.41 per fall of 10 mL/min/1.73m2; P<0.001) after adjustment for age, sex, established ischemic heart disease, diabetes mellitus, hypertension, and a cardiac troponin: eGFR interaction term (see Table VII in the online-only Data Supplement for detailed model). CI indicates confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; and MI, myocardial infarction.
Figure 3.
Figure 3.
Cox regression models for readmission with type 1 myocardial infarction or cardiac death at 1 year per 2-fold increase in cardiac troponin concentration below the 99th centile. CI indicates confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; and MI, myocardial infarction.
See this image and copyright information in PMC

Comment in

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