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High-sensitivity cardiac troponin and the risk stratification of patients with renal impairment presenting with suspected acute coronary syndrome

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http://circ.ahajournals.org/lookup/doi/10.1161/CIRCULATIONAHA.117.030320
Original languageEnglish
JournalCirculation
Early online date4 Oct 2017
DOIs
Publication statusPublished - 4 Oct 2017

Abstract

Background—High-sensitivity cardiac troponin testing may improve the risk-stratification and diagnosis of myocardial infarction, but concentrations can be challenging to interpret in patients with renal impairment and the effectiveness of testing in this group is uncertain. Methods—In a prospective multi-center study of consecutive patients with suspected acute coronary syndrome, we evaluated the performance of high-sensitivity cardiac troponin I in those with and without renal impairment (estimated glomerular filtration rate <60mL/min/1.73m2). The negative predictive value (NPV) and sensitivity of troponin concentrations below the risk stratification threshold (5ng/L) at presentation were reported for a primary outcome of index type 1 myocardial infarction, or type 1 myocardial infarction or cardiac death at 30 days. The positive predictive value (PPV) and specificity at the 99th centile diagnostic threshold (16ng/L in women, 34ng/L in men) was determined for index type 1 myocardial infarction. Subsequent type 1 myocardial infarction and cardiac death were reported at 1 year. Results—Of 4,726 patients identified, 904 (19%) had renal impairment. Troponin concentrations <5ng/L at presentation identified 17% of patients with renal impairment as low-risk for the primary outcome (NPV 98.4%, 95% confidence interval [CI] 96.0-99.7%; sensitivity 98.9%, 95%CI 97.5-99.9%), compared to 56% without renal impairment (P<0.001) with similar performance (NPV 99.7%, 95%CI 99.4-99.9%; sensitivity 98.4%, 95%CI 97.2-99.4%). The PPV and specificity at the 99th centile were lower in patients with renal impairment at 50.0% (95%CI 45.2-54.8%) and 70.9% (95%CI 67.5-74.2%) respectively, compared to 62.4% (95%CI 58.8-65.9%) and 92.1% (95%CI 91.2-93.0%) in those without. At 1 year, patients with troponin concentrations >99th centile and renal impairment were at greater risk of subsequent myocardial infarction or cardiac death than those with normal renal function (24% vs. 10%, adjusted hazard ratio 2.19, 95%CI 1.54-3.11). Conclusions—In suspected acute coronary syndrome, high-sensitivity cardiac troponin identified fewer patients with renal impairment as low-risk and more as high-risk, but with lower specificity for type 1 myocardial infarction. Irrespective of diagnosis, patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function, and should be considered for further investigation and treatment. Clinical Trial Registration—URL: https://clinicaltrials.gov Unique Identifier: NCT01852123

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