Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-23T20:01:13.540Z Has data issue: false hasContentIssue false
  • English
  • Français

Outcomes of non–acute coronary syndrome patients discharged from the emergency department with troponin positivity

Published online by Cambridge University Press:  04 March 2015

Nathan W. Brunner ,
Frank X. Scheuermeyer ,
Eric Grafstein  and
Krishnan Ramanathan
Nathan W. Brunner
Affiliation:
Department of Medicine, St. Paul’s Hospital and the University of British Columbia, Vancouver, BC
Frank X. Scheuermeyer
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital and the University of British Columbia, Vancouver, BC
Eric Grafstein
Affiliation:
Department of Emergency Medicine, St. Paul’s Hospital and the University of British Columbia, Vancouver, BC
Krishnan Ramanathan*
Affiliation:
Department of Medicine, St. Paul’s Hospital and the University of British Columbia, Vancouver, BC
*
1081 Burrard Street, B 475, Vancouver, BC V6Z 1Y6; mailto: [email protected].

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs)without inpatient admission is notwell known.

Methods:

Patients without a diagnosis of acute coronary syndrome discharged fromtwo EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-not-resuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year.

Results:

Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1–5.0, p < 0.001) and both of its components (p < 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3–3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2–3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6–2.9, p 5 0.5) after adjustment.

Conclusions:

A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.

Keywords

dischargemortalityoutcomestroponin
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 16 , Issue 1 , January 2014 , pp. 41 - 52
Copyright
Copyright © Canadian Association of Emergency Physicians 2014

References

REFERENCES

1.Setiadi, BM, Lei, H, Chang, J.Troponin not just a simple cardiac marker: prognostic significance of cardiac troponin. Chin Med J 2009;122:351–8.CrossRefGoogle Scholar
2.Ottani, F, Galvani, M, Nicolini, FA, et al. Elevated cardiac troponin levels predict the risk of adverse outcome in patients with acute coronary syndromes. Am Heart J 2000;140:917–27, doi:10.1067/mhj.2000.111107.Google Scholar
3.Setsuta, K, Seino, Y, Kitahara, Y, et al. Elevated levels of both cardiomyocyte membrane and myofibril damage markers predict adverse outcomes in patients with chronic heart failure. Circ J 2008;72:569–74, doi:10.1253/circj.72.569.CrossRefGoogle ScholarPubMed
4.Demir, M, Kanadasi, M, Akpinar, O, et al. Cardiac troponin T as a prognostic marker in patients with heart failure: a 3-year outcome study. Angiology 2007;58:603–9, doi:10.1177/0003319707307344.Google Scholar
5.Chow, GV, Hirsch, GA, Spragg, DD, et al. Prognostic significance of cardiac troponin I levels in hospitalized patients presenting with supraventricular tachycardia. Medicine 2010;89:141–8, doi:10.1097/MD.0b013e3181dddb3b.CrossRefGoogle ScholarPubMed
6.Becattini, C, Vedovati, MC, Agnellli, G.Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 2010;116:427–33, doi:10.1161/CIRCULATIONAHA.106.680421.Google Scholar
7.Stein, PD, Matta, F, Janjua, M, et al. Outcome in stable patients with acute pulmonary embolism who had right ventricular enlargement and/or elevated levels of troponin I. Am J Cardiol 2010;106:558–63, doi:10.1016/j.amjcard.2010.03.071.Google Scholar
8.Martins, CS, Rodrigues, MJO, Miranda, VP, et al. Prognostic value of cardiac troponin I in patients with COPD acute exacerbation. Neth J Med 2009;67:341–9.Google Scholar
9.Choy, JB, Armstrong, PW, Ulan, RA, et al. Do cardiac troponins provide prognostic insight in hemodialysis patients? Can J Cardiol 2003;19:907–11.Google ScholarPubMed
10.McGill, D, Talaulikar, G, Potter, JM, et al. Over time, highsensitivity TnT replaces NT-proBNP as the most powerfulpredictor of death in patients with dialysis-dependent chronic renal failure. Clin Chim Acta 2010;411:936–9, doi:10.1016/j.cca.2010.03.004.Google Scholar
11.Kalla, C, Raveh, D, Algur, N, et al. Incidence and significance of a positive troponin test in bacteremic patients without acute coronary syndrome Am J Med 2008;121:909–15, doi:10.1016/j.amjmed.2008.05.037.CrossRefGoogle ScholarPubMed
12.Garrett, MC, Komotar, RJ, Starke, RM, et al. Elevated troponin levels are predictive of mortality in surgical intracerebral hemorrhage patients. Neurocrit Care 2010;12:199–203, doi:10.1007/s12028-009-9245-5.Google Scholar
13.Naidech, AM, Kreiter, KT, Janjua, N, et al. Cardiac troponin elevation, cardiac morbidity and outcome after subarachnoid hemorrhage. Circulation 2005;112:2851–6, doi:10.1161/CIRCULATIONAHA.105.533620.CrossRefGoogle ScholarPubMed
14.Milani, RV, Fitzgerald, R, Milani, JN, et al. The impact of micro troponin leak on long-term outcomes following elective percutaneous coronary intervention. Catheter Cardiovasc Interv 2009;74:819–22, doi:10.1002/ccd.22160.Google Scholar
15.Croal, BL, Hillis, GS, Gibson, PH, et al. Relationship between postoperative cardiac troponin I levels and outcome of cardiac surgery. Circulation 2006;114:1468–75, doi:10.1161/CIRCULATIONAHA.105.602370.CrossRefGoogle ScholarPubMed
16.Oshima, K, Kunimoto, F, Takahashi, T, et al. Postoperative cardiac troponin I (cTnI) level and its prognostic value for patients undergoing mitral valve surgery. Int Heart J 2010; 51:166–9, doi:10.1536/ihj.51.166.Google Scholar
17.Pham, MX, Whooley, MA, Evans, GT Jr, et al. Prognostic value of low-level cardiac troponin-I elevations in patients without definite acute coronary syndromes. Am Heart J 2004;148:776–82, doi:10.1016/j.ahj.2004.03.058.Google Scholar
18.Carlson, ER, Percy, RF, Angiolillo, DJ, et al. Prognostic significance of troponin T elevation in patients without chest pain. Am J Cardiol 2008;102:668–71, doi:10.1016/j.amjcard.2008.04.046.Google Scholar
19.Srivathsan, K, Showalter, J, Wilkens, J, et al. Cardiovascular outcome in hospitalized patients with minimal troponin I elevation and normal creatine phosphokinase. Int J Cardiol 2004;97:221–4, doi:10.1016/j.ijcard.2003.08.018.CrossRefGoogle ScholarPubMed
20.Alaiti, MA, Maroo, A, Edel, TB.Troponin levels after cardiac electrophysiology procedures: review of the literature. Pacing Clin Electrophysiol 2009;32:800–10, doi:10.1111/j.1540-8159.2009.02370.x.CrossRefGoogle ScholarPubMed
21.Loeb, HS, Liu, JC.Frequency, risk factors, and effect on long-term survival of increased troponin I following uncomplicated elective percutaneous coronary intervention. Clin Cardiol 2010;33:E40–4, doi:10.1002/clc.20425.Google Scholar
22.Thygesen, K, Alpert, JS, White, HD, et al. Universal definition of myocardial infarction. Circulation 2007;116:2634–53, doi:10.1161/CIRCULATIONAHA.107.187397.Google Scholar
23.Beveridge, R.CAEP issues. The Canadian Triage and Acuity Scale: a new and critical element in health care reform. Canadian Association of Emergency Physicians. J Emerg Med 1998;16:507–11, doi:10.1016/S0736-4679(98)00031-6.Google Scholar
24.Gilbert, EH, Lowenstein, SR, Koziol-McLain, J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med 1996;27:305–8, doi:10.1016/S0196-0644(96)70264-0.CrossRefGoogle Scholar
25.Agarwal, R, Light, RP.Determinants and prognostic significance of electrocardiographic left ventricular hypertrophy criteria in chronic kidney disease. Clin J Am Soc Nephrol 2011;6:528–36, doi:10.2215/CJN.07770910.Google Scholar
26.Chronic KidneyDisease Prognosis Consortium, Matsushita, K, van der Velde, M, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet 2010;375:2073–81, doi:10.1016/S0140-6736(10)60674-5.Google Scholar
27.Hsieh, BP, Pham, MX, Froelicher, VF.Prognostic value of electrocardiographic criteria for left ventricular hypertrophy. Am Heart J 2005;150:161–7, doi:10.1016/j.ahj.2004.08.041.CrossRefGoogle ScholarPubMed
28.Roderick, PJ, Atkins, RJ, Smeeth, L, et al. CKD and mortality risk in older people: a community-based population study in the United Kingdom. Am J Kidney Dis 2009;53:950–60, doi:10.1053/j.ajkd.2008.12.036.Google Scholar
29.Dong, SL, Bullard, MJ, Meurer, DP, et al. Predictive validity of a computerized emergency triage tool. Acad Emerg Med 2007;14:16–21, doi:10.1111/j.1553-2712.2007.tb00362.x.CrossRefGoogle ScholarPubMed
30.Phillips, RS, Wenger, NS, Teno, J, et al. Choices of seriously ill patients about cardiopulmonary resuscitation: correlates and outcomes. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Am J Med 1996;100:128–37, doi:10.1016/S0002-9343(97)89450-8.Google Scholar
31.Lim, W, Cook, DJ, Griffith, LE, et al. Elevated cardiac troponin levels in critically ill patients: prevalence, incidence, and outcomes. Am J Crit Care 2006;15:280–8; quiz 289.Google Scholar
32.Mills, NL, Churchhouse, AM, Lee, KK, et al. Implementation of a sensitive troponin I assay and risk of recurrent myocardial infarction and death in patients with suspected acute coronary syndrome. JAMA 2011;305:1210–6, doi:10.1001/jama.2011.338.Google Scholar
33.Keller, T, Zeller, T, Peetz, D, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med 2009;361:868–77, doi:10.1056/NEJMoa0903515.CrossRefGoogle ScholarPubMed
34.de Lemos, JA, Drazner, MH, Omland, T, et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA 2010;304:2503–12, doi:10.1001/jama.2010.1768.Google Scholar
35.Thygesen, K, Mair, J, Katus, H, et al. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J 2010;31:2197–204, doi:10.1093/eurheartj/ehq251.Google Scholar
36.Fundaro, C, Guzzetti, S.Prognostic value of stable troponin T elevation in patients discharged from emergency department. J Cardiovasc Med (Hagerstown) 2010;11:276–80, doi:10.2459/JCM.0b013e328336ecc5.CrossRefGoogle ScholarPubMed
37.Venge, P, Lagerqvist, B, Diderholm, E, et al. Clinical performance of three cardiac troponin assays in patients with unstable coronary artery disease (a FRISC II substudy). Am J Cardiol 2002;89:1035–41, doi:10.1016/S0002-9149(02)02271-3.Google Scholar
38.Heeschen, C, Deu, A, Langenbrink, L, et al. Analytical and diagnostic performance of troponin assays in patientssuspicious for acute coronary syndromes. Clin Biochem 2000;33:359–68, doi:10.1016/S0009-9120(00)00144-2.CrossRefGoogle ScholarPubMed
39.Apple, FS, Smith, SW, Pearce, LA, et al. Use of the Centaur TnI Ultra assay for detection of myocardial infarction and adverse events in patients presenting with symptomssuggestive of acute coronary syndrome. Clin Chem 2008;54:723–8, doi:10.1373/clinchem.2007.097162.Google Scholar
40.Panteghini, M, Pagani, Y, Yeo, KT, et al. Evaluation of imprecision for cardiac troponin assays at low-range concentrations. Clin Chem 2004;50:327–32, doi:10.1373/clinchem.2003.026815.Google Scholar