High-Sensitivity Cardiac Troponin T and Cardiovascular Risk After Ischemic Stroke or Transient Ischemic Attack

Abstract

Background: High-sensitivity cardiac troponin T (hs-cTnT) is associated with cardiovascular disease (CVD) risk in general and various high-risk populations.

Objectives: The purpose of this study was to precisely characterize the association of hs-cTnT with CVD risk in patients following acute ischemic stroke or transient ischemic attack.

Methods: We conducted post hoc analyses of data from the STROKE-CARD trial (NCT02156778), a pragmatic randomized controlled trial of a disease management program in patients with acute ischemic stroke or transient ischemic attack (ABCD² score ≥3). We measured hs-cTnT on admission (Roche Elecsys, detection limit 5 ng/L) and quantified HRs for a composite CVD outcome (ie, stroke, myocardial infarction, CVD death) adjusted for age, sex, prior coronary heart disease, prior heart failure, diabetes, smoking, systolic blood pressure, and low- and high-density-lipoprotein cholesterol.

Results: Among 1,687 patients (mean age, 69.3 ± 13.7 years; 40.7% female), hs-cTnT was detectable in 80.7%. Median hs-cTnT was 10 ng/L (IQR: 6-18 ng/L). Over a median follow-up of 12.1 months, 110 patients had a CVD event. The association of hs-cTnT level with CVD risk was of log-linear shape, with a multivariable-adjusted HR of 1.40 (95% CI: 1.15-1.70; P < 0.001) per 1-SD higher log-transformed hs-cTnT value. The strength of association was similar when further adjusted for other potential confounders and across clinically relevant subgroups. Corresponding outcome-specific HRs were 1.33 (95% CI: 1.06-1.68; P = 0.016) for stroke, 1.28 (95% CI: 0.69-2.37; P = 0.430) for myocardial infarction, 1.98 (95% CI: 1.43-2.73; P < 0.001) for CVD death, and 1.93 (95% CI: 1.54-2.41; P < 0.001) for all-cause death.

Conclusions: High hs-cTnT is associated with increased CVD risk in ischemic stroke and transient ischemic attack patients.

Keywords: cardiovascular risk; ischemic stroke; secondary prevention; transient ischemic attack; troponin T.

Graphical abstract

Figure 1

Cross-sectional Associations Between hs-cTnT and Continuous CVD Risk Factors The geometric mean hs-cTnT level was adjusted to age 70 years. Partial correlation coefficients (r) were calculated for males and females combined and were adjusted for age and sex. DBP = diastolic blood pressure; eGFR = estimated glomerular filtration rate; HDL-C = high-density-lipoprotein cholesterol; hs-CRP = high-sensitivity C-reactive protein; hs-cTnT = high-sensitivity cardiac troponin T; LDL-C = low-density-lipoprotein cholesterol; NT-proBNP = N-terminal pro-B-type natriuretic peptide; SBP = systolic blood pressure.

Figure 2

Cumulative Hazard for the Combined CVD Endpoint by Undetectable and Quartiles of Detectable hs-cTnT Values Minimum and maximum values (ng/L) of detectable hs-cTnT were 5.0 to 8.2 in quartile 1, 8.3 to 12.4 in quartile 2, 12.5 to 20.9 in quartile 3, and ≥21.0 in quartile 4. hs-cTnT = high-sensitivity cardiac troponin T.

Figure 3

Shapes of Association of Hs-cTnT With the Risk of the Combined CVD Endpoint Across the Groups of Undetectable and Quartiles of Detectable hs-cTnT Values Sizes of boxes are proportional to the inverse of the variance of the HRs. The group with undetectable hs-cTnT values was used as the reference group. Floating absolute risks were used to calculate 95% CIs for all groups including the reference, thereby allowing head-to-head comparisons between effect sizes of any 2 of the groups. ^aAdjusted for age, sex, prior coronary heart disease, prior heart failure, diabetes, smoking, systolic blood pressure, low- and high-density-lipoprotein cholesterol. CVD = cardiovascular disease; hs-cTnT = high-sensitivity cardiac troponin T.

Figure 4

Association of hs-cTnT Levels With the Risk of the Combined CVD Endpoint According to Different Levels of Adjustment (N = 1,687, 110 CVD Events) ^aFurther adjusted models employed adjustment for each of the presented variables in turn, on top of the multivariable model including age, sex, prior coronary heart disease, prior heart failure, diabetes, smoking, systolic blood pressure, and low- and high-density-lipoprotein cholesterol. ^bThis analysis involves 1,547 patients and 99 CVD events; for head-to-head comparison, the multivariable-adjusted HR in the same subset of patients was 1.36 (95% CI: 1.10-1.68; P = 0.004). CVD = cardiovascular disease; eGFR = estimated glomerular filtration rate; HDL = high-density lipoprotein; hs-CRP = high-sensitivity C-reactive protein; hs-cTnT = high-sensitivity cardiac troponin T; LDL = low-density lipoprotein; NIHSS = National Institutes of Health Stroke Scale; NT-proBNP = N-terminal pro-B-type natriuretic peptide.

Figure 5

Multivariable-AdjustedAssociation of hs-cTnT With Individual Cardiovascular and Mortality Outcomes ^aAdjusted for age, sex, prior coronary heart disease, prior heart failure, diabetes, smoking, systolic blood pressure, and low- and high-density-lipoprotein cholesterol. ^bExcluded 61 participants with prior angina pectoris at baseline. ^cComprises 4 cases of intracerebral hemorrhage and 3 cases of subarachnoid hemorrhage. ^dExcluded 155 participants with prior heart failure at baseline. ^eComprises deaths due to pneumonia (n = 8), sepsis (n = 7), frailty (n = 6), renal disease (n = 3), chronic obstructive pulmonary disease (n = 1), severe nose bleeding with massive reduction in hemoglobin (n = 1), traumatic brain injury (n = 1), peritonitis (n = 1), and suicide (n = 1). CVD = cardiovascular disease; hs-cTnT = high-sensitivity cardiac troponin T.

Central Illustration

High-sensitivity Cardiac Troponin T and Cardiovascular Risk After Ischemic Stroke or Transient Ischemic Attack hs-cTnT = high-sensitivity cardiac troponin T; TIA = transient ischemic attack.