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Troponin-T and N-Terminal Pro-B-Type Natriuretic Peptide Predict Mortality Benefit From Coronary Revascularization in Acute Coronary Syndromes

A GUSTO-IV Substudy

Stefan K. James, MD, PhD^_*,_*, Johan Lindbäck, MSc^_*, Johanna Tilly, MSc^_*, Agneta Siegbahn, MD, PhD, Per Venge, MD, PhD, Paul Armstrong, MD, Robert Califf, MD, Maarten L. Simoons, MD, PhD^||, Lars Wallentin, MD, PhD^_* and Bertil Lindahl, MD, PhD^_*

^_* Uppsala Clinical Research Center, Uppsala, Sweden
Department of Clinical Chemistry, Uppsala, Sweden
University of Alberta, Edmonton, Canada
Duke CRI, Durham, North Carolina
^|| Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands

View larger version (15K): [in a new window]   Figure 1 Mortality in subgroups of patients stratified by type of interventional treatment: percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). (A) Outside of Eastern Europe; (B) Eastern Europe.

View larger version (14K): [in a new window]   Figure 2 Cumulative mortality estimated by the Kaplan-Meier method of 30-day survivors stratified by revascularization (revasc.) status at 30 days and levels of biochemical markers. (A) Troponin-T (TnT) above or below the detection limit of 0.01 µg/l at admission; (B) N-terminal pro-B-type natriuretic peptide (Nt-proBNP) above or below the median of 237 ng/l at admission; (C) creatinine clearance (Crea. cl) above or below the first quartile limit of 51 ml/min at admission; (D) interleukin-6 (Il-6) above or below the third quartile limit of 10 ng/l at admission.

View larger version (22K): [in a new window]   Figure 3 One-year mortality for 30-day survivors stratified by revascularization status and combinations of troponin-T (0.01 µg/l and >0.01ug/l) and NT-proBNP (237 ng/l and >237 ng/l). Black bars represent patients who underwent revascularization and gray bars, patients who did not undergo revascularization the initial 30 days. Abbreviations as in Figure 2.

View larger version (10K): [in a new window]   Figure 4 Risk ratios regarding 1-year mortality following revascularization of patients stratified by biomarker status in a parametric survival model, including a propensity score of receiving revascularization and other confounding variables of increased mortality. The p values indicate the significance of difference between the relative risks for positive versus negative markers. A relative risk ratio and 95% confidence intervals <1.0 indicate a lower mortality with revascularization. Patients from Eastern Europe were excluded. CRP = C-reactive protein; other abbreviations as in Figure 2.

View larger version (11K): [in a new window]   Figure 5 Risk ratios regarding 1-year mortality following revascularization of patients stratified by combinations of biomarkers in a multivariable parametric survival model adjusted for a propensity score of receiving revascularization and other significant variables of increased mortality as well as the time-point of revascularization as a time-dependent variable. The p values indicate the test for difference between the marker groups regarding the reduction of mortality following revascularization. A relative risk ratio and 95% confidence intervals <1.0 indicate a lower mortality with revascularization. Abbreviations as in Figure 2.