Prognostic Comparison of Different Sensitivity Cardiac Troponin Assays in Stable Heart Failure

Abstract

Background Cardiac troponin levels offer prognostic information for patients with heart failure. Highly sensitive assays detect levels of cTn much lower than the 99th percentile of standard cTn assays. We hypothesize that cardiac troponin (cTn) levels measured by a high sensitivity assay provide better prognostic value compared to cTn levels measured by a standard assay in patients with chronic heart failure. Methods We measured high sensitivity cTnT (hs-cTnT) and standard cTnI levels, as well as aminoterminal pro B-type natriuretic peptide (NT-proBNP) in 504 sequential stable patients with a history of heart failure who underwent elective coronary angiography, without acute coronary syndrome, and with 5-year follow-up of all-cause mortality. Results The median hs-cTnT level was 21.2 [interquartile range 12.3, 40.9] ng/L and 170 subjects died over 5-years. In a head-to-head overall comparison, hs-cTnT provided increased prognostic utility compared to cTnI (area under the curve [AUC] 66.1% and AUC 69.4%, respectively, p=0.03; 9.0% integrated discrimination improvement, p<.001; and 13.6% event-specific reclassification, p<.001), and was independent of NT-proBNP and renal function. Even within the subset of patients where cTn levels by both assays were above the limit of quantification, higher hs-cTnT is associated with a 2-fold increase in 5-year mortality risk after adjusting for traditional risk factors (tertile 1 vs. 3: Hazard ratio [95% confidence interval] 2.0 [1.3-3.2]; p=0.0002). Conclusion Cardiac troponin can be detected by the high sensitivity assay in more patients with chronic heart failure than the standard assay, and may yield independent and better prognostic accuracy for mortality prediction than standard assay.

Circulating Cardiac Troponin I Levels Measured by a Novel Highly Sensitive Assay in Acute Decompensated Heart Failure: Insights From the ASCEND-HF Trial

“…Although, circulating cTn levels below the 99% URL in patients with acute HF may be of low, long-term risk. 14 Yet, there remains a prognostic role for very low levels of circulating cTn 2 , especially when only detectable by increasingly sensitive assays, 15 and whether there is a prognostic advantage apart from lower cTn detection is not clear. Unlike myocardial infarction with a clearer link to pathology and cTn level, changes in cTn levels in HF are not well understood.…”

Prognostic importance of emerging cardiac, inflammatory, and renal biomarkers in chronic heart failure patients with reduced ejection fraction and anaemia: RED‐HF study

“…Several established risk models in HF, based on routinely collected clinical data, perform reasonably effectively . In recent years, there has been an explosion of reports of new biomarkers in HF, many of which individually predict adverse outcomes in HF . However, since both NT‐proBNP and high‐sensitivity troponins are available as standardized assays in most countries and are routinely used in the diagnostic work‐up of HF and myocardial infarction, these findings have important implications for usual clinical practice.…”

“…B‐type natriuretic peptide, produced by the myocardium primarily in response to volume overload and increase in wall stress, and its inactive metabolite N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), are established prognostic markers in patients with heart failure and reduced ejection fraction (HFrEF) . Similarly, elevated levels of cardiac troponins reflecting cardiomyocyte necrosis, consistently relate to worse clinical outcomes in both acute and chronic HFrEF patients. Both these biomarkers may provide additive prognostic information to routinely collected demographic, clinical and laboratory data in patients with chronic heart failure (HF) …”

Biomarkers in Acute Decompensated Heart Failure

“…125 Serial elevated troponins in the out patient setting have been shown to be independently associated with mortality, cardiac transplant, and HF hospitalization, especially in combination with elevated NT-proBNP. 126,127 Increased troponin-T levels are associated with increased risk of development of HF, 97,128,129 and elevated troponins are a strong, independent prognostic marker in the hospitalized population for future HF 98,107,125 and mortality, 114,125,[130][131][132][133][134] often independently of NT-proBNP levels or with additive benefit. 70,97 As a result of these data, it would be reasonable to obtain cTnT level at 1) presentation with ADHF, as it is a useful prognostic marker and a marker for evaluating the potential for a type 1 myocardial infarction, and 2) in the outpatient setting as a strong indicator of prognosis both for mortality and re-hospitalization.…”