Outcomes and care of patients with acute heart failure syndromes and cardiac troponin elevation
Braga JR, Tu JV, Austin PC, Chong A, You JJ, Farkouh ME, Ross HJ, Lee DS. Circ Heart Fail. 2013; 6(2):193-202. Epub 2013 Feb 6.
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.
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