CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION
Prognostic implications of elevated troponin in patients with suspected acute coronary syndrome but no critical epicardial coronary disease
A TACTICS-TIMI-18 substudy
Hisham Dokainish, MD*,
Manu Pillai, MD*,
Sabina A. Murphy, MPH ,
Peter M. DiBattiste, MD ,
Marc J. Schweiger, MD ,
Amir Lotfi, MD,
David A. Morrow, MD, MPH,
Christopher P. Cannon, MD,
Eugene Braunwald, MD,
Nasser Lakkis, MD*,* TACTICS-TIMI-18 Investigators
* Section of Cardiology, Baylor College of Medicine, Houston, Texas
Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts
Merck and Co., West Point, Pennsylvania
Manuscript received June 10, 2004;
revised manuscript received September 15, 2004,
accepted September 19, 2004.
* Reprint requests and correspondence: Dr. Nasser Lakkis, Ben Taub General Hospital, Baylor College of Medicine, Houston, Texas 77030 (Email: nlakkis{at}bcm.tmc.edu).
OBJECTIVES: The purpose of this study is to determine whether there is clinical significance to elevated troponin I in patients with suspected acute coronary syndromes (ACS) with non-critical angiographic coronary stenosis.
BACKGROUND: Elevation of troponin in patients admitted with ACS symptoms with non-critical coronary artery disease (CAD) may result from coronary atherothrombosis not evident using standard angiography or from other ischemic and non-ischemic causes that may confer increased risk for future events.
METHODS: Patients with ACS enrolled in the Treat Angina With Aggrastat and Determine Cost of Therapy With Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction (TACTICS-TIMI)-18 were included. Of 2,220 patients enrolled in the trial, 895 were eligible. Patients were divided into four groups according to troponin status on admission and presence of significant angiographic stenosis. Baseline brain natriuretic peptide (BNP) and C-reactive protein (CRP) were obtained on all patients.
RESULTS: The median troponin I levels were 0.71 ng/ml in patients with CAD compared with 0.02 ng/ml in patients without CAD (p < 0.0001). Troponin-positive patients with or without angiographic CAD had higher CRP and BNP levels compared with troponin-negative patients (p < 0.01 for both). The rates of death or reinfarction at six months were 0% in troponin-negative patients with no CAD, 3.1% in troponin-positive patients with no CAD, 5.8% in troponin-negative patients with CAD, and 8.6% in troponin-positive patients with CAD (p = 0.012).
CONCLUSIONS: Elevated troponin in ACS is associated with a higher risk for death or reinfarction, even among patients who do not have significant angiographic CAD. The mechanisms conferring this adverse prognosis merit further study.
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Abbreviations and Acronyms
| | ACS = acute coronary syndromes | | BNP = B-type natriuretic peptide | | CAD = coronary artery disease | | CRP = C-reactive protein | | cTnI = cardiac troponin I | | TACTICS-TIMI = Treat Angina With Aggrastat and Determine Cost of Therapy With Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction |
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