Advertisement
Heart, Lung and Circulation

Clinically Acquired High Sensitivity Cardiac Troponin T is a Poor Predictor of Reduced Left Ventricular Ejection Fraction After ST Elevation Myocardial Infarction: A National Cohort Study–ANZACS-QI 65

Published:August 27, 2022DOI:https://doi.org/10.1016/j.hlc.2022.07.014

      Objective

      Cardiac troponins (cTn) have been used historically to estimate infarct size in ST elevation myocardial infarction (STEMI). Within a resource constrained health care environment, cTn could therefore be used for prioritisation of patients for cardiac imaging, in particular echocardiography. We aimed to determine how useful routinely collected cTn would be in predicting significant left ventricular (LV) impairment.

      Methods

      All patients in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry with their first episode of STEMI between January 2013 and November 2018, who had high sensitivity troponin T measured, were included. We excluded patients with no left ventricular ejection fraction (LVEF) assessment, known LV dysfunction, or prior myocardial infarction.

      Results

      In total, 3,698 patients were included in the analysis. A higher mean hsTnT (admission and peak) was seen in patients with more severely impaired LV function but there was significant overlap in the range of hsTnT between the different LVEF categories. Cardiac troponins demonstrated poor discriminative ability to either predict or exclude significant LV impairment (LVEF <40%). At an optimal cutpoint of 3,405 ng/L, peak hsTnT had a sensitivity of 56.5% (95% confidence interval [CI] 42–62%), a specificity of 65.3% (95% CI 62–79%) and an area under the receiver operating curve of 0.62 (95% CI 0.60–0.64).

      Conclusion

      This is the largest study comparing clinically measured troponin levels and LV function in patients presenting with STEMI. A definite, but weak, association was seen between peak troponin and the degree of LV dysfunction, with significant overlap in troponin levels between levels of myocardial dysfunction. Routinely acquired troponin is not suitable for clinical use as a method of prioritising patients for cardiac imaging.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Xu R.Y.
        • Zhu X.F.
        • Yang Y.
        • Ye P.
        High-sensitive cardiac troponin T.
        J Geriatr Cardiol. 2013; 10: 102-109
        • Rao A.C.R.
        • Collinson P.O.
        • Canepa-Anson R.
        • Joseph S.P.
        Troponin T measurement after myocardial infarction can identify left ventricular ejection of less than 40%.
        Heart. 1998; 80: 223-225
        • Coelho-Lima J.
        • Georgiopoulos G.
        • Ahmed J.
        • Adil S.E.R.
        • Gaskin D.
        • Bakogiannis C.
        • et al.
        Distinct prognostic value of pre- and post-reperfusion hs-cTnT for STEMI patient risk stratification.
        Heart. 2021; 107: 1881-1888
        • Hallén J.
        Troponin for the estimation of infarct size: what have we learned?.
        Cardiology. 2012; 121: 204-212
        • Brush J.E.
        • Kaul S.
        • Krumholz H.M.
        Troponin testing for clinicians.
        J Am Coll Cardiol. 2016; 68: 2365-2375
        • Apple F.S.
        • Sharkey S.W.
        • Falahati A.
        • Murakami M.
        • Mitha N.
        • Christensen D.
        Assessment of left ventricular function using serum cardiac troponin I measurements following myocardial infarction.
        Clin Chim Acta. 1998; 272: 59-67
        • Skeik N.
        • Patel D.C.
        A review of troponins in ischemic heart disease and other conditions.
        Int J Angiol. 2007; 16: 53-58
        • Apple F.S.
        • Collinson P.O.
        Analytical characteristics of high-sensitivity cardiac troponin assays.
        Clin Chem. 2012; 58: 54-61
        • Hamer A.
        • Kerr A.J.
        • Wong B.
        • Renner C.
        • Wong C.-K.
        • Ellis C.
        • et al.
        ST-elevation myocardial infarction: New Zealand Management Guidelines, 2013.pdf.
        N Z Med J. 2013; 126: 127-164
        • Ellis C.
        • Gamble G.
        • Hamer A.
        • Williams M.J.A.
        • Matsis P.
        • Elliott J.
        • et al.
        Patients admitted with an acute coronary syndrome in New Zealand in 2007: results of a second comprehensive nationwide audit and a comparison with the first audit from 2002.
        N Z Med J. 2010; 123: 195-200
        • Bridgman P.
        • District C.
        • Board H.
        • Ashrafi A.
        • Mann S.
        • Whalley G.
        Survey of clinical echocardiography in New Zealand (SCANZ).
        N Z Med J. 2008; 121
        • McLeod P.
        • Coffey S.
        • Adamson P.
        Do we need risk stratification after ST elevation myocardial infarction?.
        Heart. 2021; 107: 1852-1853
        • Kerr A.
        • Williams M.J.A.
        • Harding S.
        • White H.
        • Doughty R.
        • Nunn C.
        • et al.
        The all New Zealand acute coronary syndrome quality improvement programme: implementation, methodology and cohorts (ANZACS-QI 9).
        N Z Med J. 2016; 129: 23-36
        • Granger C.B.
        • Goldberg R.J.
        • Dabbous O.
        • Pieper K.S.
        • Eagle K.A.
        • Cannon C.P.
        • et al.
        Predictors of hospital mortality in the Global Registry of Acute Coronary Events.
        Arch Intern Med. 2003; 163: 2345-2353
        • Thygesen K.
        • Alpert J.S.
        • White H.D.
        Universal definition of myocardial infarction.
        Circulation. 2007; 116: 2634-2653
        • O’Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • Casey Jr., D.E.
        • Chung M.K.
        • de Lemos J.A.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
        Circulation. 2013; 127: 362-425
        • R-Core-Team
        R: A Language and Environment for Statistical Computing.
        • Thiele C.
        cutpointr: Determine and Evaluate Optimal Cutpoints in Binary Classification Tasks.
        • Steen H.
        • Giannitsis E.
        • Futterer S.
        • Merten C.
        • Juenger C.
        • Katus H.A.
        Cardiac troponin T at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function.
        J Am Coll Cardiol. 2006; 48: 2192-2194
        • Katus H.A.
        • Remppis A.
        • Scheffold T.
        • Diederich K.W.
        • Kuebler W.
        Intracellular compartmentation of cardiac troponin T and its release kinetics in patients with reperfused and non-reperfused myocardial infarction.
        Am J Cardiol. 1991; 67: 1360-1367
        • Omura T.
        • Teragaki M.
        • Tani T.
        • Yamagishi H.
        • Yanagi S.
        • Nishikimi T.
        • et al.
        Estimation of infarct size using serum troponin T concentration in patients with acute myocardial infarction.
        Jpn Circ J. 1993; 57: 1062-1070
        • Wagner I.
        • Mair J.
        • Fridrich L.
        • Artner-Dworzak E.
        • Lechleitner P.
        • Morass B.
        • et al.
        Cardiac troponin T release in acute myocardial infarction is associated with scintigraphic estimates of myocardial scar.
        Coron Artery Dis. 1993; 4: 537-544
        • Mair J.
        • Wagner I.
        • Morass B.
        • Fridrich L.
        • Lechleitner P.
        • Dienstl F.
        • et al.
        Cardiac troponin I release correlates with myocardial infarction size.
        Clin Chem Lab Med. 1995; 33: 869-872
        • Licka M.
        • Zimmermann R.
        • Zehelein J.
        • Dengler T.J.
        • Katus H.A.
        • Kübler W.
        Troponin T concentrations 72 hours after myocardial infarction as a serological estimate of infarct size.
        Heart. 2002; 87: 520-524
        • Panteghini M.
        • Cuccia C.
        • Bonetti G.
        • Giubbini R.
        • Pagani F.
        • Bonini E.
        Single-point cardiac troponin T at coronary care unit discharge after myocardial infarction correlates with infarct size and ejection fraction.
        Clin Chem. 2002; 48: 1432-1436
        • Tzivoni D.
        • Koukoui D.
        • Guetta V.
        • Novack L.
        • Cowing G.
        Comparison of troponin T to creatine kinase and to radionuclide cardiac imaging infarct size in patients with ST-elevation myocardial infarction undergoing primary angioplasty.
        Am J Cardiol. 2008; 101: 753-757
        • Chia S.
        • Senatore F.
        • Raffel O.C.
        • Lee H.
        • Wackers F.J.T.
        • Jang I.K.
        Utility of cardiac biomarkers in predicting infarct size, left ventricular function, and clinical outcome after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.
        JACC Cardiovasc Interv. 2008; 1: 415-423
        • Hassan A.K.M.
        • Bergheanu S.C.
        • Hasan-Ali H.
        • Liem S.S.
        • van der Laarse A.
        • Wolterbeek R.
        • et al.
        Usefulness of peak troponin-T to predict infarct size and long-term outcome in patients with first acute myocardial infarction after primary percutaneous coronary intervention.
        Am J Cardiol. 2009; 103: 779-784
        • Byrne R.A.
        • Ndrepepa G.
        • Braun S.
        • Tiroch K.
        • Mehilli J.
        • Schulz S.
        • et al.
        Peak cardiac troponin-T level, scintigraphic myocardial infarct size and one-year prognosis in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction.
        Am J Cardiol. 2010; 106: 1212-1217
        • Ingkanisorn W.P.
        • Rhoads K.L.
        • Aletras A.H.
        • Kellman P.
        • Arai A.E.
        Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction.
        J Am Coll Cardiol. 2004; 43: 2253-2259
        • Younger J.F.
        • Plein S.
        • Barth J.
        • Ridgway J.P.
        • Ball S.G.
        • Greenwood J.P.
        Troponin-I concentration 72 h after myocardial infarction correlates with infarct size and presence of microvascular obstruction.
        Heart. 2007; 93: 1547-1551
        • Giannitsis E.
        • Steen H.
        • Kurz K.
        • Ivandic B.
        • Simon A.C.
        • Futterer S.
        • et al.
        Cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin T.
        J Am Coll Cardiol. 2008; 51: 307-314
        • Bøhmer E.
        • Hoffmann P.
        • Abdelnoor M.
        • Seljeflot I.
        • Halvorsen S.
        Troponin T concentration 3 days after acute ST-elevation myocardial infarction predicts infarct size and cardiac function at 3 months.
        Cardiology. 2009; 113: 207-212
        • Hallén J.
        • Jensen J.K.
        • Fagerland M.W.
        • Jaffe A.S.
        • Atar D.
        Cardiac troponin I for the prediction of functional recovery and left ventricular remodelling following primary percutaneous coronary intervention for ST-elevation myocardial infarction.
        Heart. 2010; 96: 1892-1897
        • Hallén J.
        • Buser P.
        • Schwitter J.
        • Petzelbauer P.
        • Geudelin B.
        • Fagerland M.W.
        • et al.
        Relation of cardiac troponin I measurements at 24 and 48 hours to magnetic resonance-determined infarct size in patients with ST-elevation myocardial infarction.
        Am J Cardiol. 2009; 104: 1472-1477
        • Klug G.
        • Mayr A.
        • Mair J.
        • Schocke M.
        • Nocker M.
        • Trieb T.
        • et al.
        Role of biomarkers in assessment of early infarct size after successful p-PCI for STEMI.
        Clin Res Cardiol. 2011; 100: 501-510
        • Mayr A.
        • Mair J.
        • Klug G.
        • Schocke M.
        • Pedarnig K.
        • Trieb T.
        • et al.
        Cardiac troponin T and creatine kinase predict mid-term infarct size and left ventricular function after acute myocardial infarction: a cardiac MR study.
        J Magn Reson Imaging. 2011; 33: 847-854
        • Vasile V.C.
        • Babuin L.
        • Giannitsis E.
        • Katus H.A.
        • Jaffe A.S.
        Relationship of MRI-determined infarct size and cTnI measurements in patients with ST-elevation myocardial infarction.
        Clin Chem. 2008; 54: 617-619
        • Reinstadler S.J.
        • Feistritzer H.J.
        • Klug G.
        • Mair J.
        • Tu A.M.D.
        • Kofler M.
        • et al.
        High-sensitivity troponin T for prediction of left ventricular function and infarct size one year following ST-elevation myocardial infarction.
        Int J Cardiol. 2016; 202: 188-193
        • Miller R.
        • Stokes T.
        • Nixon G.
        Point-of-care troponin use in New Zealand rural hospitals: A national survey.
        N Z Med J. 2019; 132: 25-37
        • Panteghini M.
        • Bonetti G.
        • Pagain F.
        • Stefani F.
        • Giubbinin R.
        • Cuccia C.
        Measurement of troponin I 48h after admission as a tool to rule out impaire left ventricular function in patients with a first myocardial infarction.
        Clin Chem Lab Med. 2005; 43: 848-854
        • Ohlmann P.
        • Monassier J.P.
        • Michotey M.O.
        • Berenger N.
        • Jacquemin L.
        • Laval G.
        • et al.
        Troponin I concentrations following primary percutaneous coronary intervention predict large infarct size and left ventricular dysfunction in patients with ST-segment elevation acute myocardial infarction.
        Atherosclerosis. 2003; 168: 181-189
        • Rao A.C.R.
        • Collinson P.O.
        • Rose A.J.
        • John C.
        • Canepa-Anson R.
        • Joseph S.P.
        Prospective evaluation of the role of routine cardiac troponin T measurement to identify left ventricular ejection fraction < 40% after first myocardial infarction.
        Heart. 2003; 89: 559-560
        • Nguyen T.L.
        • Phan J.A.K.
        • Hee L.
        • Moses D.A.
        • Otton J.
        • Terreblanche O.D.
        • et al.
        High-sensitivity troponin T predicts infarct scar characteristics and adverse left ventricular function by cardiac magnetic resonance imaging early after reperfused acute myocardial infarction.
        Am Heart J. 2015; 170 (–25.e2): 715
        • Reindl M.
        • Reinstadler S.J.
        • Feistritzer H.J.
        • Klug G.
        • Tiller C.
        • Mair J.
        • et al.
        Relation of inflammatory markers with myocardial and microvascular injury in patients with reperfused ST-elevation myocardial infarction.
        Eur Heart J Acute Cardiovasc Care. 2017; 6: 640-649
        • Mohammad M.A.
        • Koul S.
        • Smith J.G.
        • Noc M.
        • Lang I.
        • Holzer M.
        • et al.
        Predictive value of high-sensitivity troponin T for systolic dysfunction and infarct size (six months) after ST-elevation myocardial infarction.
        Am J Cardiol. 2018; 122: 735-743
        • Costello B.T.
        • Stub D.
        • Hare J.
        • Ellims A.H.
        • Wang X.
        • Smith K.
        • et al.
        Comparison of magnetic resonance analysis of myocardial scarring with biomarker release following ST elevation myocardial infarction.
        Heart Lung Circ. 2019; 28: 397-405
        • Tiller C.
        • Reindl M.
        • Holzknecht M.
        • Klapfer M.
        • Beck A.
        • Henninger B.
        • et al.
        Biomarker assessment for early infarct size estimation in ST-elevation myocardial infarction.
        Eur J Intern Med. 2019; 64 (March): 57-62
        • Mohammad M.A.
        • Koul S.
        • Lønborg J.T.
        • Nepper-Christensen L.
        • Høfsten D.E.
        • Ahtarovski K.A.
        • et al.
        Usefulness of high sensitivity troponin T to predict long-term left ventricular dysfunction after ST-elevation myocardial infarction.
        Am J Cardiol. 2020; 134: 8-13