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CLINICAL RESEARCH: BIOMARKERS AND CORONARY DISEASE

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

Manuscript received November 30, 2005; revised manuscript received May 16, 2006, accepted May 23, 2006.

^_* Reprint requests and correspondence: Dr. Stefan James, Department of Cardiology, Academic Hospital, 751 85 Uppsala, Sweden. (Email: stefan.james{at}akademiska.se).

OBJECTIVES: This study was designed to evaluate biomarkers for selection of patients with non–ST-segment elevation acute coronary syndromes (ACS) that derive mortality benefit from revascularization.

BACKGROUND: Biomarkers are essential for identification of patients at increased risk, which may be reduced by revascularization.

METHODS: During the initial 30 days, 2,340 patients of 7,800 (30%) with non–ST-segment elevation ACS in the GUSTO (Global Utilization of Strategies To open Occluded arteries)-IV trial underwent coronary revascularization. The 1-year mortality was calculated in 30-day survivors stratified by status of revascularization and levels of biomarkers. A propensity score for receiving revascularization was constructed and included in a survival analysis that also included the time point of revascularization as a time-dependent covariate.

RESULTS: Elevation of troponin-T or N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with a high mortality. In patients with either or both of these markers elevated, a lower mortality following revascularization was observed. In contrast, patients without elevation of these markers had low 1-year mortality without any reduction in mortality following revascularization. In fact, in patients with normal levels of both troponin-T and NT-proBNP, a significant increase in 1-year mortality after revascularization was observed. Elevation of C-reactive protein, interleukin-6, creatinine clearance, and ST-segment depression was also related to a higher mortality. However, independent of these markers, mortality was lower after revascularization.

CONCLUSIONS: Markers of troponin-T and NT-proBNP not only assist in risk stratification of patients with non–ST-segment elevation ACS but also appear to identify patients who have a reduced mortality associated with early coronary revascularization.

Abbreviations and Acronyms   ACS = acute coronary syndromes   CI = confidence interval   CRP = C-reactive protein   ECG = electrocardiogram   GUSTO-IV = Global Utilization of Strategies To open Occluded arteries-IV trial   IL = interleukin   MI = myocardial infarction   NT-proBNP = N-terminal pro-B-type natriuretic peptide   PCI = percutaneous coronary intervention   RR = relative risk

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