Troponin status predicts 30-day in-hospital mortality

Abstract

Aim: To evaluate the prognostic value of high-sensitivity cardiac troponin (hscTnT) levels in unselected emergency medical admissions.

Methods: We report on all hscTnT tests in emergency medical admissions, performed over an eight year period from 2011-2018. The prognostic significance of hscTnT was related to 30-day in-hospital mortality with multivariable logistic regression, adjusted for Acute Illness Severity Score, Comorbidity Score, Sepsis, and Deprivation Status.

Results: There were 52,214 admissions from 28,982 patients during the study period. HscTnT level was a univariate - odds ratios (OR) 1.67 [95% confidence intervals (CI): 1.60-1.73] and an independent risk predictor in the multivariable logistic regression model - OR = 1.23 (95%CI: 1.16-1.29). 30-day in-hospital mortality increased as a linear function of hscTnT; not performed = 3.6%, ≥ 25 ng/L = 5.3%, > 100 ng/L = 7.4%, > 1000 ng/L = 8.8%. Increasing Comorbidity Score exacerbated risk; 30-day in-hospital mortality at a Score of 6, 10 and 16 points for those with no hscTnT performed or hscTnT < 25 ng/L were 1.8%, 6.5% and 31.3% respectively; for hscTnT ≥ 25 ng/L these increased to 2.2%, 8.8% and 41.3%.

Conclusion: HscTnT is prognostic in acutely ill medical patients; incorporation into hospital mortality predictive algorithms appears warranted.

Keywords

Troponin levels / emergency medical admissions / hospital mortality

References

[1] Langlands A,Elliott A,Graham A.RCPE UK Consensus Statement on Acute Medicine, November 2008..Br J Hosp Med (Lond)2009;70:S6-7

[2] Hall MJ, Levant S, DeFrances CJ. Trends in Inpatient Hospital Deaths: National Hospital Discharge Survey, 2000-2010 2013. Available from: https://pdfs.semanticscholar.org/1ba6/6dde91e1ef7e8f7eb80da6423cf572bc24ce.pdf. [Last accessed on 7 Aug 2020]

[3] Conway R,O’Riordan D.Comparative influence of acute illness severity and comorbidity on mortality..Eur J Intern Med2020;72:42-6

[4] Walsh JB,Murphy C,Boyle E.Demographic profile of the elderly population in Dublin accident and emergency hospital catchment areas..Ir Med J2004;97:84-6

[5] Antman EM.Decision making with cardiac troponin tests..N Engl J Med2002;346:2079-82

[6] Alpert JS,Antman E.Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction..J Am Coll Cardiol2000;36:959-69

[7] Ammann P,Minder EI,Bertel O.Elevation of troponin I in sepsis and septic shock..Intensive Care Med2001;27:965-9

[8] Baillard C,Fosse JP,Le Toumelin P.Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease..Intensive Care Med2003;29:584-9

[9] Frankel WL,Ziegler TW.Cardiac troponin T is elevated in asymptomatic patients with chronic renal failure..Am J Clin Pathol1996;106:118-23

[10] Giannitsis E,Kurowski V,Wiegand U.Independent prognostic value of cardiac troponin T in patients with confirmed pulmonary embolism..Circulation2000;102:211-7

[11] Healey JS,Smith SJ,Ooi DS.Prognostic use of cardiac troponin T and troponin I in patients with heart failure..Can J Cardiol2003;19:383-6

[12] James P,Whitlock RM,Henley J.Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study..BMJ2000;320:1502-4 PMCID:PMC27391

[13] Kathiresan S,Newell JB,MacGillivray TE.Cardiac troponin T elevation after coronary artery bypass grafting is associated with increased one-year mortality..Am J Cardiol2004;94:879-81

[14] Koutouzis M,Sfyroeras G,Nikolidakis S.Cardiac troponin I in patients with acute lower limb ischemia..Am J Cardiol2007;100:728-30

[15] Moller N,Gravholt CH,Poulsen SH.Myocardial injury with biomarker elevation in diabetic ketoacidosis..J Diabetes Complications2005;19:361-3

[16] Nunes JP,Farinha RM.Cardiac troponin I in aortic valve disease..Int J Cardiol2003;89:281-5

[17] Nunes JP,Maciel MJ.Troponin I in atrial fibrillation with no coronary atherosclerosis..Acta Cardiol2004;59:345-6

[18] Smith SC,Mason JW.Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates..Circulation1997;95:163-8

[19] Tung P,Banki N,Ko N.Predictors of neurocardiogenic injury after subarachnoid hemorrhage..Stroke2004;35:548-51

[20] Waxman DA.Troponin I is an independent predictor of all-cause mortality in hospitalized patients with congestive heart failure..Am Heart J2007;154:e27author reply e9

[21] Alcalai R,Culhaoglu A,Pollak A.Acute coronary syndrome vs nonspecific troponin elevation: clinical predictors and survival analysis..Arch Intern Med2007;167:276-81

[22] Rooney T,Bennett K,Silke B.Impact of an acute medical admission unit on hospital mortality: a 5-year prospective study..QJM2008;101:457-65

[23] Conway R,Silke B.Long-term outcome of an AMAU--a decade’s experience..Q J Med2014;107:43-9

[24] Coary R,O’Riordan D,Cournane S.Does admission via an acute medical unit influence hospital mortality? 12 years’ experience in a large Dublin hospital..Acute Med2014;13:152-8

[25] Conway R,O’Riordan D.Outcomes in acute medicine - Evidence from extended observations on readmissions, hospital length of stay and mortality outcomes..Eur J Intern Med2019;66:69-74

[26] Conway R,Cournane S,Silke B.Fifteen-year outcomes of an acute medical admission unit..Ir J Med Sci2018;187:1097-105

[27] O’Loughlin R,Barry J,Teljeur C.Using HIPE data as a research and planning tool: limitations and opportunities..Ir J Med Sci2005;174:40-5discussion 52-7

[28] O’Callaghan A,McGuigan C,Haider N.A critical evaluation of HIPE data..Ir Med J2012;105:21-3

[29] Silke B,Rooney T,O’Riordan D.An improved medical admissions risk system using multivariable fractional polynomial logistic regression modelling..Q J Med2010;103:23-32

[30] Courtney D,Kavanagh J,Silke B.High-sensitivity troponin as an outcome predictor in acute medical admissions..Postgrad Med J2014;1-7

[31] Chotirmall SH,Lyons J,Kelleher M.Blood cultures in emergency medical admissions: a key patient cohort..Eur J Emerg Med2016;23:38-43

[32] Chotirmall SH,Lyons J,O’Riordan D.Disabling disease codes predict worse outcomes for acute medical admissions..Intern Med J2014;44:546-53

[33] Kopelman PG.Application of database systems in diabetes care..Med Inform (Lond)1996;21:259-71

[34] Courtney D,Kavanagh J,Silke B.High-sensitivity troponin as an outcome predictor in acute medical admissions..Postgrad Med J2014;90:311-6

[35] Chin JL,Adnan WA,O’Riordan D.Using the MDRD value as an outcome predictor in emergency medical admissions..Nephrol Dial Transplant2011;26:3155-9

[36] Kelly A, Teljeur C. SAHRU National Deprivation Index Trinity College, Dublin 2007. Available from: http://www.sahru.tcd.ie/services/deprivation/DeprivationFiles/WebReport07.pdf. [Last accessed on 7 Aug 2020]

[37] Shimrat M.Algorithm 112: Position of point relative to polygon..Commun ACM1962;5:434

[38] Conway R,O’Riordan D.Emergency readmissions are substantially determined by acute illness severity and chronic debilitating illness: a single centre cohort study..Eur J Intern Med2015;26:12-7

[39] Conway R,Coveney S,Silke B.Deprivation as an outcome determinant in emergency medical admissions..QJM2013;106:245-51

[40] Conway R,O’Riordan D.Comparative influence of acute illness severity and comorbidity on mortality..Eur J Intern Med2020;72:42-6

[41] Conway R,O’Riordan D,Coveney S.Deprivation index and dependency ratio are key determinants of emergency medical admission rates..Eur J Intern Med2015;26:709-13

[42] Khan NA,Tonelli M,Levin A.Prognostic value of troponin T and I among asymptomatic patients with end-stage renal disease: a meta-analysis..Circulation2005;112:3088-96

[43] Nunes JP,Farinha RM,Magalhães D.Cardiac troponin I in aortic valve disease..Int J Cardiol2003;89:281-5

[44] Goriki Y,Nishihira K,Natsuaki M.A novel predictive model for in-hospital mortality based on a combination of multiple blood variables in patients with ST-segment-elevation myocardial infarction..J Clin Med2020;9:852 PMCID:PMC7141500

[45] Siciliano RF,Sommer Bittencourt M,Marcondes-Braga F.Biomarkers for prediction of mortality in left-sided infective endocarditis..Int J Infect Dis2020;96:25-30

[46] Peacock WF,Fonarow GC,Wynne J.Cardiac troponin and outcome in acute heart failure..N Engl J Med2008;358:2117-26

[47] Aimo A,Vergaro G,Latini R.Prognostic value of high-sensitivity troponin T in chronic heart failure: an individual patient data meta-analysis..Circulation2018;137:286-97

[48] Relos R,Beilman G.Moderately elevated serum troponin concentrations are associated with increased morbidity and mortality rates in surgical intensive care unit patients..Critical Care Medicine2003;31:2598-603

[49] Bajwa E,Januzzi J,Thompson B.Biomarker evidence of myocardial cell injury is associated with mortality in acute respiratory distress syndrome..Crit Care Med2007;35:2484-90

[50] Csecsei P,Ezer E,Szapary L.Relationship between cardiac troponin and thrombo-inflammatory molecules in prediction of outcome after acute ischemic stroke..J Stroke Cerebrovasc Dis2018;27:951-6

[51] He Y,Wang J,Ding H.Prognostic value of elevated cardiac troponin I in patients with intracerebral hemorrhage..Clin Cardiol2020;43:338-45 PMCID:PMC7144484

[52] Vasile V,Perez J,Song L.Long-term prognostic significance of elevated cardiac troponin levels in critically ill patients with acute gastrointestinal bleeding..Crit Care Med2009;37:140-7

[53] Humble CAS,Jammer I,Chew MS.Prognostic performance of preoperative cardiac troponin and perioperative changes in cardiac troponin for the prediction of major adverse cardiac events and mortality in noncardiac surgery: a systematic review and meta-analysis..PLoS One2019;14:e0215094 PMCID:PMC6476502

[54] Otsuka K,Shimada K,Inanami H.Ankle-brachial index, arterial stiffness, and biomarkers in the prediction of mortality and outcomes in patients with end-stage kidney disease..Clin Cardiol2019;42:656-62 PMCID:PMC6605000

[55] Firth C,Chakkera H,Shamoun F.Cardiac troponin t and right ventricular systolic pressure predict cardiovascular and mortality risk in kidney transplant candidates..Am J Nephrol2019;50:434-43

[56] Conway R,Silke B.Targets and the emergency medical system--intended and unintended consequences..Eur J Emerg Med2015;22:235-40