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. 2020 Jul 28;76(4):357-370.
doi: 10.1016/j.jacc.2020.05.057.

Atherosclerotic Cardiovascular Disease Risk Stratification Based on Measurements of Troponin and Coronary Artery Calcium

Yader Sandoval  1 , Suzette J Bielinski  2 , Lori B Daniels  3 , Michael J Blaha  4 , Erin D Michos  4 , Andrew P DeFilippis  5 , Moyses Szklo  6 , Christopher deFilippi  7 , Nicholas B Larson  8 , Paul A Decker  8 , Allan S Jaffe  9
Affiliations

Atherosclerotic Cardiovascular Disease Risk Stratification Based on Measurements of Troponin and Coronary Artery Calcium

Yader Sandoval et al. J Am Coll Cardiol. .

Abstract

Background: Low values of high-sensitivity cardiac troponin (hs-cTn) and coronary artery calcium (CAC) scores of zero are associated with a low risk for atherosclerotic cardiovascular disease (ASCVD).

Objectives: The purpose of this study was to evaluate baseline hs-cTnT and CAC in relation to ASCVD.

Methods: Baseline hs-cTnT (limit of detection [LoD] 3 ng/l) and CAC measurements were analyzed across participants age 45 to 84 years without clinical cardiovascular disease from the prospective MESA (Multi-Ethnic Study of Atherosclerosis) in relationship to incident ASCVD.

Results: Among 6,749 participants, 1,002 ASCVD events occurred during a median follow-up of 15 years. Participants with detectable CAC (20.1 vs. 5.0 events per 1,000 person-years; adjusted hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 2.0 to 2.76; p < 0.001) and detectable hs-cTnT (15.4 vs. 5.2 per 1,000 person-years; adjusted HR: 1.47; 95% CI: 1.21 to 1.77; p < 0.001) had higher rates of ASCVD than those with undetectable results. Individuals with undetectable hs-cTnT (32%) had similar risk for ASCVD as did those with a CAC of zero (50%) (5.2 vs. 5.0 per 1,000 person-years). Together, hs-cTnT and CAC (discordance 38%) resulted in the following ASCVD event rates: hs-cTnT < LoD/CAC = 0: 2.8 per 1,000 person-years (reference), hs-cTnT ≥ LoD/CAC = 0: 6.8 per 1,000 person-years (HR: 1.59; 95% CI: 1.17 to 2.16; p = 0.003), hs-cTnT < LoD/CAC > 0: 11.1 per 1,000 person-years (HR: 2.74; 95% CI: 1.96 to 3.83; p < 0.00001), and hs-cTnT ≥ LoD/CAC > 0: 22.6 per 1,000 person-years (HR: 3.50; 95% CI: 2.60 to 4.70; p < 0.00001).

Conclusions: An undetectable hs-cTnT identifies patients with a similar, low risk for ASCVD as those with a CAC score of zero. The increased risk among those with discordant results supports their conjoined use for risk prediction.

Keywords: atherosclerotic cardiovascular disease; coronary artery calcium; high-sensitivity cardiac troponin; primary prevention; risk stratification.

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Figures

Figure 1.
Figure 1.. Cumulative incidence of ASCVD for undetectable/detectable CAC.
Panels A-C show the cumulative incidence of ASCVD for a CAC score of zero (CAC=0) (black line) and for detectable CAC (CAC>0) (red line) for the overall cohort (panel A), men (panel B), and women (panel C).
Figure 2.
Figure 2.. Cumulative incidence of ASCVD for undetectable/detectable hs-cTnT.
Panels A-C show the cumulative incidence of ASCVD for undetectable hs-cTnT (=LoD) (red line) for the overall cohort (A), men (B), and women (C).
Figure 3.
Figure 3.. Relationship between CAC and hs-cTnT and the risk for ASCVD.
Panel A shows the relationship between CAC and the hazard ratio for ASCVD. Panel B shows the relationship between hs-cTnT concentrations and the hazard ratio for ASCVD.
Figure 4.
Figure 4.. Cumulative incidence of ASCVD for undetectable/detectable CAC/hs-cTnT.
Cumulative incidence of ASCVD for CAC=0/hs-cTnT=LoD (red line), CAC>0/hs-cTnT0/hs-cTnT=>LoD (blue line).
Figure 5.
Figure 5.. Cumulative incidence of ASCVD for undetectable/detectable hs-cTnT among patients with a CAC score of zero.
Cumulative incidence of ASCVD according to undetectable (=LoD) hs-cTnT for all patients with a CAC score of zero (A), men (B), and women (C).
Central Illustration.
Central Illustration.. Independent and conjoint use of CAC and hs-cTnT for ASCVD risk prediction.
Section A: both a CAC score of zero and undetectable hs-cTnT result in similar ASCVD risk prediction. Section B: Conjoint use of CAC and hs-cTnT improves risk-stratification, particularly in those with discordant results (38%).
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Comment in

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