Outcomes and care of patients with acute heart failure syndromes and cardiac troponin elevation

Background — Cardiac troponins (cTn) may be elevated among patients with acute heart failure syndromes (AHFS). However, the optimal approach to management of AHFS with elevated cTn is unknown.

Methods and Results — The researchers compared the care and outcomes of 13,656 AHFS patients seeking care in the emergency department (ED) stratified by presence (cTn+, n=1845, 13.5%) or absence (cTn-) of elevated troponin. Clinically-abstracted data on patients who were admitted or discharged from the ED in Ontario, Canada (April 1999–March 2001 and April 2004–March 2007) were examined. In an exploratory 2:1 propensity-matched analysis the researchers examined whether early coronary revascularization (within 14 days of ED visit) was associated with survival, stratified by cTn status. For cTn+ AHFS, rates of coronary angiography (21.8 versus 11.4 patients/100 person-years; p<0.001) and coronary revascularization (8.8 versus 3.2 patients/100 person-years, p<0.001) were higher than cTn-. Instantaneous 30-day adjusted hazards ratios for cTn+ versus cTn- patients were 9.17 (95%CI; 8.31–10.12, p<0.001) for death, 5.14 (95%CI; 4.66–5.67, p<0.001) for cardiovascular readmission, and 13.08 (95%CI; 10.95–15.62, p<0.001) for ischemic heart disease hospitalization. In propensity-matched analysis of 143 individuals with cTn+ AHFS, early coronary revascularization was associated with reduced mortality (adjusted HR 0.29, 95%CI; 0.09–0.92; p=0.036) compared to those who were not revascularized. Mortality was not significantly reduced amongst 210 cTn- patients undergoing early coronary revascularization (adjusted HR 0.61, 95%CI; 0.36–1.03; p=0.065).

Conclusions — Elevated cTn was associated with increased risk of death and cardiovascular hospitalizations. Highly-selected cTn+ patients who underwent early coronary revascularization for obstructive coronary artery disease experienced improved survival.