Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction
Ronnier J. Aviles, M.D., Arman T. Askari, M.D., Bertil Lindahl, M.D., Ph.D., Lars Wallentin, M.D., Ph.D., Gang Jia, M.S., E. Magnus Ohman, M.D., Kenneth W. Mahaffey, M.D., L. Kristin Newby, M.D., Robert M. Califf, M.D., Maarten L. Simoons, M.D., Eric J. Topol, M.D., Peter Berger, M.D., and Michael S. Lauer, M.D.
Background Among patients with suspected acute coronary syndromes,cardiac troponin T levels have prognostic value. However, thereis concern that renal dysfunction may impair the prognosticvalue, because cardiac troponin T may be cleared by the kidney.
Methods We analyzed the outcomes in 7033 patients enrolled inthe Global Use of Strategies to Open Occluded Coronary ArteriesIV trial who had complete base-line data on troponin T levelsand creatinine clearance rates. The troponin T level was consideredabnormal if it was 0.1 ng per milliliter or higher, and creatinineclearance was assessed in quartiles. The primary end point wasa composite of death or myocardial infarction within 30 days.
Results Death or myocardial infarction occurred in 581 patients.Among patients with a creatinine clearance above the 25th percentilevalue of 58.4 ml per minute, an abnormally elevated troponinT level was predictive of an increased risk of myocardial infarctionor death (7 percent vs. 5 percent; adjusted odds ratio, 1.7;95 percent confidence interval, 1.3 to 2.2; P<0.001). Amongpatients with a creatinine clearance in the lowest quartile,an elevated troponin T level was similarly predictive of increasedrisk (20 percent vs. 9 percent; adjusted odds ratio, 2.5; 95percent confidence interval, 1.8 to 3.3; P<0.001). When thecreatinine clearance rate was considered as a continuous variableand age, sex, ST-segment depression, heart failure, previousrevascularization, diabetes mellitus, and other confoundershad been accounted for, elevation of the troponin T level wasindependently predictive of risk across the entire spectrumof renal function.
Conclusions Cardiac troponin T levels predict short-term prognosisin patients with acute coronary syndromes regardless of theirlevel of creatinine clearance.
Cardiac troponins are useful in establishing a diagnosis andprognosis in patients who present with suspected acute coronarysyndromes.1,2,3,4 Renal dysfunction may interfere with the prognosticvalue of troponins because their clearance may be decreased.5,6,7,8,9,10,11,12We conducted a study to determine the prognostic value of base-linecardiac troponin T levels in relation to renal function in alarge population of patients who presented with suspected acutecoronary syndromes.
Methods
The Global Use of Strategies to Open Occluded Coronary ArteriesIV in Acute Coronary Syndromes study was a randomized, double-blind,placebo-controlled trial evaluating the effect of an infusionof abciximab, given for either 24 or 48 hours, on the compositeend point of death or myocardial infarction in patients withhigh-risk acute coronary syndromes who were not undergoing earlyrevascularization. The study was conducted between July 17,1998, and April 21, 2000. Details of the design and primaryresults of the trial have been published elsewhere.13 The investigatorshad full access to all data and conducted all analyses; thesponsors had no control over the decision to publish.
Study Population
The participants were recruited from 458 hospitals in 24 countries.13Patients were eligible if they had either or both of the followingsets of findings: one or more episodes of angina while at restthat lasted at least five minutes and new ST-segment depressionof at least 0.5 mm; or an abnormal result on a cardiac troponinT or troponin I strip test or a quantitative cardiac troponinT or troponin I level above the upper limit of normal on theassay used locally. Patients with renal disease were not excluded.The protocol was approved by each hospital's institutional reviewboard or ethics committee, and all participants gave writteninformed consent.
Study Protocol
All patients were treated with aspirin. Patients were randomlyassigned to one of three groups: abciximab for 24 hours andplacebo for 24 hours, abciximab for 48 hours, or placebo for48 hours. Abciximab (ReoPro, Centocor) was administered as abolus of 0.25 mg per kilogram of body weight, followed by aninfusion of 0.125 µg per kilogram per minute, up to amaximum of 10 mg per kilogram per minute. All patients receivedan infusion of unfractionated heparin, except those participatingin the substudy of low-molecular-weight heparin. Treatment withcardiac medications was left to the discretion of the treatingphysician. The use of glycoprotein IIb/IIIa inhibitors in patientswho later underwent percutaneous coronary intervention was alsoleft to the discretion of the treating physician. Electrocardiographywas performed at base line, 48 hours, and 30 days.
Troponin T Analysis
Base-line blood samples for measurement of troponin T were obtainedbefore randomization, centrifuged, frozen in aliquots at –20°C,and then shipped to a central core laboratory in Uppsala, Sweden,where they were stored at –70°C before being thawedand analyzed. Personnel who were unaware of the clinical dataperformed all measurements of troponin T.
Troponin T levels were determined by means of a third-generationtroponin T assay (Elecsys, Roche Diagnostics) that uses recombinanthuman cardiac troponin T as standard material.8,10 The 99thpercentile of the troponin T level in a reference populationis below the lower limit of detection of 0.01 ng per milliliter.However, on the basis of experience with the second-generationassay, the cutoff point for the prognostic evaluation was prespecifiedas 0.1 ng per milliliter. The interassay coefficient of variationat a discriminator value of 0.1 ng per milliliter was below10 percent.
Renal Function
Base-line creatinine concentrations (in milligrams per deciliter)were routinely measured and recorded for all patients. Age andweight in kilograms were also available for all patients. Thecreatinine clearance rate was calculated with the equation ofCockcroft and Gault, with adjustment for sex: [(140 –age) x (weight in kilograms)] ÷ [72 x serum creatinineconcentration in milligrams per deciliter].14
End Points
The primary end point was a composite of death and myocardialinfarction within 30 days. A secondary end point was death within30 days. The definition of myocardial infarction used in thetrial has been published previously.13 A blinded clinical eventscommittee classified all end points.
Statistical Analysis
Analyses included all patients who had complete core-laboratorydata on troponin T levels and creatinine clearance and 30-dayfollow-up data on death and myocardial infarction. All analyseswere prespecified. Base-line characteristics were analyzed ineach quartile of creatinine clearance and in groups definedaccording to the troponin T level, creatinine clearance rate,or both; these analyses were performed with the use of frequencydistributions and chi-square tests. Age was dichotomized into65 years or younger and older than 65 years, and weight wasdichotomized into 90 kg or less and more than 90 kg. An abnormaltroponin T level was defined as a value of at least 0.1 ng permilliliter, and a cutoff point of 0.03 ng per milliliter wasused in secondary analyses. The troponin T level was not treatedas a continuous variable because the distribution of the datawas highly skewed and all values of less than 0.01 ng per milliliter— the lower limit of discrimination of the assay —were recorded as 0.01 ng per milliliter. An abnormal creatinineclearance rate was defined as a value in the lowest quartile(less than 58.4 ml per minute).
Patients were grouped according to the quartile of creatinineclearance. Simple logistic regression was used to estimate theodds ratios for the quartiles of creatinine clearance and thegroups defined according to troponin T status. Multivariablelogistic-regression analyses were performed to adjust for potentialconfounders.15,16
When considering the creatinine clearance rate as a continuousvariable, we used a generalized additive model with logit-linkand spline methods to determine the univariable relation betweenrenal function and death or myocardial infarction within 30days, according to troponin T status.16 On the basis of theunivariable analysis, we developed a multivariable logistic-regressionmodel with linear and quadratic terms for creatinine clearance.Interactions between troponin T status and both linear and quadraticterms for creatinine clearance were included in the model toanalyze the relation among troponin T status, creatinine clearance,and death or myocardial infarction within 30 days. We used astepwise method to introduce significant covariates into themodel. Beta coefficients of the linear and quadratic terms forcreatinine clearance, troponin T status, their interactions,and the covariance matrix of the estimates were used to calculatethe adjusted odds ratios (and 95 percent confidence intervals)for abnormal troponin T levels in relation to the rate of creatinineclearance. Reported P values are two-sided. All statisticalanalyses were performed with SAS software, version 6.12 (SASInstitute).
Results
Study Patients
Of 7800 patients enrolled, 7033 (90.2 percent) had completeclinical, troponin T, and creatinine clearance data. Data ontroponin T levels were missing for 673 patients (8.6 percent),creatinine clearance data were missing for 82 patients (1.1percent), and data for both variables were missing for 12 patients(0.2 percent). Thirty-day follow-up was complete for all 7033patients.
Base-line characteristics according to troponin T status andcreatinine clearance status are presented in Table 1. Patientswith both abnormal troponin T levels and creatinine clearancerates in the lowest quartile were older and more likely to havediabetes and to have a history of myocardial infarction. Thequartile groups were similar in terms of treatment with abciximabor placebo.
Table 1. Base-Line Characteristics According to Groups Defined by Creatinine Clearance and Troponin T Status.
Troponin T and Creatinine Clearance
Only 11 patients had severe renal impairment, with a creatinineclearance of less than 10 ml per minute. The median creatinineclearance rate was 76 ml per minute, and the 25th and 75th percentilevalues were 58 and 99 ml per minute, respectively. The distributionof troponin T levels was highly skewed. The median troponinT level was 0.12 ng per milliliter (25th and 75th percentilevalues, 0.01 and 0.47 ng per milliliter, respectively). TroponinT was abnormally elevated to 0.1 ng per milliliter or higherin 3645 patients (52 percent), and to 0.03 ng per milliliteror higher in 4512 patients (64 percent).
Troponin T, Creatinine Clearance, and Outcomes
To evaluate whether the troponin T status was predictive ofthe outcome in patients with abnormal creatinine clearance andin those with normal creatinine clearance, we analyzed bothtroponin T status and creatinine clearance as categorical variables.The troponin T level was considered to be abnormal at the prespecifiedcutoff point of 0.1 ng per milliliter as well as at a lowercutoff point of 0.03 ng per milliliter.
The results of the univariable and multivariable analyses areshown in Table 2. Death or myocardial infarction occurred in581 patients. Of these patients, 305 had a nonfatal myocardialinfarction, 71 had a fatal myocardial infarction, and 205 diedwithout a documented myocardial infarction. Thus, 276 patientsdied. Among patients with a creatinine clearance above the 25thpercentile value of 58.4 ml per minute, an abnormally elevatedtroponin T level was predictive of an increased risk of myocardialinfarction or death (7 percent vs. 5 percent; unadjusted oddsratio, 1.6; 95 percent confidence interval, 1.2 to 2.0; P<0.001)in analyses using a cutoff point for the troponin T level of0.1 ng per milliliter. Similarly, among patients in the lowestquartile of creatinine clearance, an abnormal troponin T levelwas associated with an increased risk of myocardial infarctionor death (20 percent vs. 9 percent; unadjusted odds ratio, 2.5;95 percent confidence interval, 1.9 to 3.3; P<0.001; P forinteraction = 0.01). When we used the lower cutoff point forthe troponin T level of 0.03 ng per milliliter, an abnormaltroponin T level also conferred an increased risk among patientsin the lowest quartile of creatinine clearance (odds ratio,2.7; 95 percent confidence interval, 1.9 to 3.8; P<0.001).
Table 2. Unadjusted and Adjusted Odds Ratios for Death or Myocardial Infarction within 30 Days According to Troponin T Status and Quartile of Creatinine Clearance.
In multivariable analyses, after adjustment for potential confounders— including sex and the presence or absence of an ageof more than 65 years, ST-segment depression, and a historyof angina, myocardial infarction, heart failure, stroke, diabetesmellitus, bypass surgery, and angioplasty — an abnormallyelevated troponin T level (0.1 ng per milliliter or higher)was predictive of an increased risk of myocardial infarctionor death among patients with a creatinine clearance rate abovethe 25th percentile (adjusted odds ratio, 1.7; 95 percent confidenceinterval, 1.3 to 2.2; P<0.001). Similarly, an abnormal troponinT level among patients in the lowest quartile of creatinineclearance was associated with an increased risk (adjusted oddsratio, 2.5; 95 percent confidence interval, 1.8 to 3.3; P<0.001;P for interaction=0.06). The adjusted risk was also significantlyincreased among patients in the lowest quartile of creatinineclearance when a cutoff point of 0.03 ng of troponin T per milliliterwas used (adjusted odds ratio, 2.7; 95 percent confidence interval,1.9 to 3.8; P<0.001).
The unadjusted predicted rates of events (and their 95 percentconfidence intervals) according to the troponin T status (normalvs. abnormal) in relation to creatinine clearance consideredas a continuous variable are shown in Figure 1 (with a cutoffpoint of 0.1 ng per milliliter) and Figure 2 (with a cutoffpoint of 0.03 ng per milliliter). The curves were derived fromgeneralized additive models with the use of a logit-link function,with the curve for creatinine clearance smoothed by a splinemethod.
Figure 1. Incidence of the Primary End Point of Death or Myocardial Infarction, According to the Base-Line Troponin T Level and Creatinine Clearance Rate.
The curves were derived from generalized additive models with a logit-link function, smoothed with the use of a spline method. The rate of death or myocardial infarction was significantly higher among patients with a base-line troponin T level of 0.1 ng per milliliter or higher across the entire spectrum of creatinine clearance rates, according to an unadjusted analysis. The dashed lines indicate the 95 percent confidence intervals.
Figure 2. Incidence of the Primary End Point of Death or Myocardial Infarction, According to the Base-Line Troponin T Level and Creatinine Clearance Rate.
The curves were derived from generalized additive models with a logit-link function, smoothed with the use of a spline method. The rate of death or myocardial infarction was significantly higher among patients with a base-line troponin T level of 0.03 ng per milliliter or higher across the entire spectrum of creatinine clearance rates, according to an unadjusted analysis. The dashed lines indicate the 95 percent confidence intervals.
Figure 3 shows the adjusted odds ratios for death or myocardialinfarction among patients with abnormal troponin T levels inrelation to the creatinine clearance rate considered as a continuousvariable. Odds ratios were adjusted for all significant covariatesshown in Table 1 and were derived from the multivariable logistic-regressionmodel.
Figure 3. Adjusted Odds Ratio for Death or Myocardial Infarction among Patients with Abnormal Troponin T Levels in Relation to Creatinine Clearance Rates.
An abnormal troponin T level was defined as a level of 0.1 ng per milliliter or higher. Odds ratios were derived from the multivariable logistic-regression model and were adjusted for all significant base-line variables. An abnormal troponin T value at base line predicted the risk of death or myocardial infarction within 30 days across the entire spectrum of creatinine clearance rates. The dashed lines indicate the 95 percent confidence intervals.
An abnormal troponin T level at base line was associated withan increased risk of death within 30 days among patients inall quartiles of creatinine clearance, including the lowestquartile (adjusted odds ratio, 3.4; 95 percent confidence interval,2.3 to 5.2; P<0.001; P for interaction = 0.10).
Discussion
Even though cardiac troponin T may be cleared by the kidney,we found that, among patients presenting with suspected acutecoronary syndromes, base-line measurements of cardiac troponinT were strongly predictive of the risk of death or myocardialinfarction, even when impaired renal function was present. Becausepatients with renal insufficiency were not excluded from ourtrial, we had the opportunity to evaluate the predictive valueof elevations in cardiac troponin T in a large cohort of patientsacross a wide spectrum of renal function. Until now, the prognosticand diagnostic significance of cardiac troponins among patientswith renal dysfunction has been controversial. Whereas somestudies have found that the predictive value of elevated levelsof troponins was reduced among such patients, others have questionedthe prognostic or diagnostic significance of these levels.5,9,11,12,13,17,18,19,20,21Our study supports the value of the test in patients with renalimpairment who present with symptoms suggestive of acute coronarysyndromes.
Some limitations of our study are noteworthy. We used the equationof Cockcroft and Gault, which uses the serum creatinine concentration,age, weight, and sex to estimate the glomerular filtration rate.14Although this equation is used widely in clinical practice,it is only an approximation of the glomerular filtration rate.22Nonetheless, the equation not only is practical, but also remainsthe method of choice for estimating the glomerular filtrationrate at the bedside. Given this fact, our analysis is clinicallyrelevant to actual practice situations.
Our trial differed in some respects from other trials involvingpatients with acute coronary syndromes.13 The observed rateof myocardial infarction or death was lower than expected (8percent vs. 11 percent); a liberal criterion for ST-segmentdepression (0.5 mm) was used; and the subjects included a highproportion of women (38 percent). It is therefore possible thatthe trial may have enrolled patients with chest pain syndromeswho did not have active unstable coronary disease.
There are two potentially important implications of our findings.First, given that renal dysfunction is common in patients withcoronary disease, the ability of cardiac troponin levels topredict the outcome irrespective of the creatinine clearancerate expands their clinical usefulness.23,24,25 Second, a numberof treatment strategies, such as low-molecular-weight heparins,glycoprotein IIb/IIIa inhibitors, and aggressive treatment withcardiac catheterization, are emerging as particularly beneficialfor patients who present with elevated levels of cardiac troponins.26,27,28,29Given that levels of cardiac troponins are used to stratifyrisk and guide therapeutic decisions in patients suspected ofhaving acute coronary syndromes, it is important to define theusefulness of this marker in a growing population of patientswith acute coronary syndromes and renal impairment.
Supported by Centocor and Eli Lilly.
Source Information
From the Department of Cardiology, the Cleveland Clinic Foundation, Cleveland (R.J.A., A.T.A., G.J., E.J.T., M.S.L.); the Department of Cardiology, University of Uppsala, Uppsala, Sweden (B.L., L.W.); the University of North Carolina, Chapel Hill (E.M.O.); the Duke Clinical Research Institute, Durham, N.C. (K.W.M., L.K.N., R.M.C.); and the Department of Cardiology, University Hospital Rotterdam, Rotterdam, the Netherlands (M.L.S.). Peter Berger, M.D., Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn., was also an author.
Address reprint requests to Dr. Lauer at the Department of Cardiology, Desk F25, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44951, or at lauerm{at}ccf.org.
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