High-sensitivity troponin can improve risk stratification in cardiovascular diseases

Czech version

Authors: Ján Murín
Authors‘ workplace: I. interná klinika LF UK a UNB, Nemocnica Staré Mesto, Bratislava
Published in: Diab Obez 2022; 22(44): 85-89
Category:

Overview

In 2018 AHA and ACC Societies published cholesterol management guidelines. They identified two distinct groups of patients with atherosclerotic cardiovascular disease (CVD) with different treatment recommendations. A prospective cohort biomarker substudy (PEGASUS TIMI 54 study) was performed (8 635 patients, subgroup with very high-risk for CVD and another with lower risk for CVD due to mentioned guidelines, but patients were stratified also on the basis of hs-troponin I serum levels using cut points 2 ng/l as limit for detection and 6 ng/l for risk threshold). All patients had myocardial infarction 1 to 3 years before enrollment, were at least 50 years of age and had at least 1 high-risk feature. Primary end-point (EP) was a composite of CV death, myocardial infarction or stroke (study from 2010 October – 2014 December, but analyzed in 2019 June – 2020 January). The median age was 65 years, 76.6% were men. Patients with clinical criteria for very-high risk of CVD had primary EP (3 year event rate) 8.8% compared with 5% in patients with lover-risk of CVD (HR 2.01, S). When patients in the very-high risk CVD were further stratified by hs-TnI levels – 9% of these patients had undetected hs-TnI and their 3 year event rate was only 2.7% (less than the overall rate in the lower risk CVD subgroup). Analogously in the lower-risk subgroup of CVD, 22.6% of patients had hs-TnI > 6 ng/l and their event rate was 9.1% (as was the overall rate in very high-risk subgroup of patients for CVD). From these findings we can say that strategy incorporating hs-TnI into guideline derived CVD risk algorithm is useful.

Keywords:

risk stratification – atherosclerotic cardiovascular disease – guidelines for cholesterol management guidelines – hs-troponin I

Sources

1. de Lemos JA, Drazner MH, Omland T et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general popultion. JAMA 2010; 304(22): 2503–2512. Dostupné z DOI: <http://dx.doi.org/10.1001/jama.2010.1768>.

2. Omland T, de Lemos JA, Sabatine MS et al. [Prevention of Events With Angiotensin Converting Enzyme Inhibition (PEACE) Trial Investigators]. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med 2009; 361(26):2 538–2547. Dostupné z DOI: <http://dx.doi.org/10.1056/NEJMoa0805299>.

3. White HD, Tonkin A, Simes J et al. [LIPID Study Investigators]. Association of contemporary sensitive troponin I levels at baseline and change at 1 year with long-term coronary events following myocardial infarction or unstable angina: results from the LIPID Study (Long-term Intervention With Pravastatin in Ischemic Disease). J Am Coll Cardiol 2014; 63(4): 345–354. Dostupné z DOI:<http://dx.doi.org/10.1016/j.jacc.2013.08.1643>.

4. Everett BM, Brooks MM, Vlachos HE et al. [BARI 2D Study Group]. Troponin and cardiac events in stable ischemic heart disease and diabetes. N Engl J Med 2015; 373(7): 610–620. Dostupné z DOI: <http://dx.doi.org/10.1056/NEJMoa1415921>.

5. Cavender MA, White WB, Jarolim P et al. Serial measurement of high-sensitivity troponin I and cardiovascular outcomes in patients with type 2 diabetes mellitus in the EXAMINE Trial (Examination of Cardiovascular Outcome With Alogliptin Versus Standard of Care). Circulation 2017; 135(20): 1911–1921. Dostupné z DOI: <http://dx.doi.org/10.1161/CIRCULATIONAHA.116.024632>.

6. Bonaca MP, O’Malley RG, Jarolim P et al. Serial cardiac troponin measured using a high sensitivity assay in stable patients with ischemic heart disease. J Am Coll Cardiol 2016; 68(3): 322–323. Dostupné z DOI: <http://dx.doi.org/10.1016/j.jacc.2016.04.046>.

7. Grundy SM, Stone NJ, Bailey AL et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139(25): e1082-e1143. Dostupné z DOI: <http://dx.doi.org/10.1161/CIR.0000000000000625>.

8. Marston NA, Bonaca MP, Jarolim P et al. Clinical application of hs troponin testing in the atherosclerotic cardiovascular disease framework of the current cholesterol guidelines. JAMA Cardiol 2020; 5(11): 1255–1262. Dostupné z DOI: <http://dx.doi.org/10.1001/jamacardio.2020.2981>.

9. Bonaca MP, Bhatt DL, Cohen M et al. [PEGASUS-TIMI 54 Steering Committee and Investigators]. Long-term Use of Ticagrelor in Patients With Prior Myocardial Infarction. N Engl J Med 2015; 372(19): 1791–1800. Dostupné z DOI: <http://dx.doi.org/10.1056/NEJMoa1500857>.

10. Ford I, Shah AS, Zhang R et al. High-sensitivity cardiac troponin, statin therapy, and risk of coronary heart disease. J Am Coll Cardiol 2016; 68(25): 2719–2728. Dostupné z DOI: <http://dx.doi.org/10.1016/j.jacc.2016.10.020>.

11. Blankenberg S, Salomaa V, Makarova N et al. BiomarCaRE Investigators. Troponin I and cardiovascular risk prediction in the general population: the BiomarCaRE Consortium. Eur Heart J 2016; 37(30): 2428–2437. Dostupné z DOI: <http://dx.doi.org/10.1093/eurheartj/ehw172>.

12. Everett BM, Zeller T, Glynn RJ et al. High-sensitivity cardiac troponin I and B-type natriuretic peptide as predictors of vascular events in primary prevention: impact of statin therapy. Circulation 2015; 131(21): 1851–1860. Dostupné z DOI: <http://dx.doi.org/10.1161/CIRCULATIONAHA.114.014522>.

13. Omland T, de Lemos JA, Holmen OL et al. Impact of sex on the prognostic value of high-sensitivity cardiac troponin I in the general population: the HUNT Study. Clin Chem 2015; 61(4): 646–656. Dostupné z DOI: <http://dx.doi.org/10.1373/clinchem.2014.234369>.

14. Tani S, Yagi T, Atsumi W et al. Relation between low-density lipoprotein cholesterol/apolipoprotein B ratio and triglyceride-rich lipoproteins in patients with coronary artery disease and type 2 diabetes mellitus: a cross-sectional study. Cardiovasc Diabetol 2017; 16(1): 123. Dostupné z DOI: <http://dx.doi.org/10.1186/s12933–017–0606–7>.

15. Jacobson TA, Ito MK, Maki KC et al. National Lipid Association recommendations for patient-centered management of dyslipidemia, part 1: full report. J Clin Lipidol 2015; 9(2): 129–169. Dostupné z DOI: <http://dx.doi.org/10.1016/j.jacl.2015.02.003>.

16. Apple FS, Simpson PA, Murakami MM. Defining the serum 99th percentile in a normal reference population measured by a high-sensitivity cardiac troponin I assay. Clin Biochem 2010; 43(12): 1034–1036. Dostupné z DOI: <http://dx.doi.org/10.1016/j.clinbiochem.2010.05.014>.

17. Apple FS, Collinson PO. [IFCC Task Force on Clinical Applications of Cardiac Biomarkers]. Analytical characteristics of high-sensitivity cardiac troponin assays. Clin Chem 2012; 58(1): 54–61. Dostupné z DOI: <http://dx.doi.org/10.1373/clinchem.2011.165795>.

18. Roe MT, Li QH, Bhatt DL et al. Risk categorization using new American College of Cardiology/American Heart Association guidelines for cholesterol management and its relation to alirocumab treatment following acute coronary syndromes. Circulation 2019; 140(19): 1578–1589. Dostupné z DOI: <http://dx.doi.org/10.1161/CIRCULATIONAHA.119.042551>.

19. Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71: e13-e115. Dostupné z DOI: <http://dx.doi.org/10.1161/HYP.0000000000000065>.