What are the benefits of using cardiac markers in therapeutic management of acute coronary syndrome (ACS)?

Updated: Jul 30, 2021
  • Author: Kamal (Komo) Gursahani, MD, MBA; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Clinical trials have demonstrated the benefits of using cardiac markers as an indicator for specific therapeutic interventions in acute coronary syndrome (ACS). However, this use remains investigational; currently, no validated therapeutic algorithms are based on an isolated positive marker result in the absence of other clinical or electrographic (ECG) findings.

Subgroup analysis of trials with low–molecular-weight heparin (LMWH) showed a decreased cardiac event rate in patients with a positive result for troponin T (TnT) and who were treated with an LMWH. [57, 58]

Similarly, in the Platelet Receptor inhibition for Ischaemic Syndrome Management (PRISM) trial, patients with an elevated troponin I (TnI) who were treated with the glycoprotein (GP) IIb/IIIa inhibitor tirofiban (Aggrastat) demonstrated a significant decrease in cardiac events compared with patients without an elevated TnI level. [59] No significant difference in outcomes was seen in patients without TnI elevations who were treated with tirofiban when compared with placebo.

In the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, patients who were treated with the GP IIb/IIIa inhibitor eptifibatide (Integrilin) within 6 hours of symptom onset obtained the greatest benefit, and subgroup analysis showed that patients with an elevated troponin level also had better responses to therapy than did those whose troponin result was negative. [60]

Finally, in the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction (TACTICS-TIMI) 18 trial, patients with elevations in TnI or TnT had a significant reduction in death, MI, or rehospitalization for ACS within 6 months after being treated with early invasive therapy consisting of aspirin, heparin, tirofiban, and catheterization/revascularization within 4-48 hours. [61, 62] Subset analysis noted that an elevation of CK-MB did not benefit the early invasive group when compared with the conservative management group. However, early invasive therapy did benefit the subgroup of patients with elevated troponin levels but normal CK-MB levels. [63]

These studies suggest that a positive troponin result alone is an independent predictor of high risk for adverse cardiac events, and that therapy with LMWHs and/or GP IIb/IIIa inhibitors appears to confer the most benefit on patients with elevated cardiac troponins levels.


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