Troponins Found Highly Prognostic in Decompensated Preserved-EF Heart Failure

Marlene Busko

January 06, 2017

DALLAS, TX — Troponin levels were commonly elevated in patients who were hospitalized for decompensated heart failure with preserved ejection fraction (HFpEF), and they predicted worse in-hospital outcomes and long-term survival in a new study[1].

Specifically, in a large cohort of HFpEF patients from the Get With The Guidelines–Heart Failure registry, those with elevated vs normal peak troponin levels had worse in-hospital, 30-day, and 1-year survival, and they were also more likely to be hospitalized for 4 days or more, discharged to a care facility, or readmitted within 30 days.

"Taken together, these findings suggest a role of early troponin assessment as an important risk-stratification tool during the initial evaluation" of patients hospitalized with decompensated HFpEF, Dr Ambarish Pandey (University of Texas Southwestern Medical Center, Dallas) and colleagues conclude, in their study published online December 28, 2016 in JAMA Cardiology.

Clinicians should "really strongly consider the routine measurement of troponin in patients hospitalized with heart failure—beyond the benefits of being able to evaluate patients for potential acute coronary syndrome [ACS] that can sometimes accompany decompensated heart failure," senior author Gregg C Fonarow (Ronald Reagan University of California, Los Angeles Medical Center) told heartwire from Medscape.

Patients with HFpEF and elevated troponin may represent a high-risk population in which it would be useful to test new heart failure therapies, he added.

"The cardiac troponin assay has already established itself as a valuable component of the assessment of acute heart-failure decompensations in the setting of systolic dysfunction," Dr Gabriel Sayer and Nir Uriel (University of Chicago, IL) note in an accompanying editorial[2]. With this new study, "we now have stronger evidence to support what is already written in the guidelines: 'Cardiac troponins are useful for establishing prognosis or disease severity in acutely decompensated heart failure.' "

Clinicians may not check a patient's troponin level if they feel that it is highly unlikely that a patient is having an ACS, Fonarow noted, but this study suggests that "even if you are sure that the patient is not having an ACS or confident that the diagnosis is HFpEF, troponin gives us additional insight . . . and allows us to risk-stratify the patient and provide prognostic information to patients and their family members."

Troponin as a Risk Biomarker in HFpEF

Up to half of patients who are hospitalized with HF have preserved ejection fraction, and the clinical significance of elevated troponins in such patients in the absence of a precipitating ACS is not well established. To investigate this, the researchers identified 96,769 patients in the Get with the Guidelines–HF registry who were hospitalized between 2009 and 2014 for decompensated HF and had a left ventricular ejection fraction (LVEF) of 50% or higher.

Just over a third of these patients (34,233 patients; 35%) from 224 sites had troponin measured during their hospitalization, and they formed the study cohort.

Most patients (26,896; 79%) had troponin-I measurements, and the remaining 7319 patients had troponin-T measurements.

A total of 22.6% of the patients had an elevated peak troponin level during their hospitalization.

Having an elevated peak troponin level was more likely in patients who had higher creatinine levels; were black or older; smoked; or had ischemic heart disease, an elevated heart rate, elevated blood pressure, increasing QRS duration, or higher B-type natriuretic peptide (BNP) levels; this was less likely in patients who had a higher body-mass index (BMI) or were female.

Patients with elevated vs normal troponin levels had a higher rate of in-hospital mortality, the primary study outcome (3.95% vs 1.84%, respectively). They were twice as likely to die in the hospital and they were more likely to have a longer hospital stay or be discharged to a care facility, after adjustment for multiple risk factors, including BNP.

Outcomes in Patients with Elevated vs Normal Troponin*

Outcome Odds ratio (95% CI) P
In-hospital mortality 2.19 (1.88–2.56) <0.001
>4-d hospital stay 1.38 (1.29–1.47) <0.001
Discharged to home 0.65 (0.61–0.71) <0.001
*After adjustment for multiple variables

Patients with elevated vs normal troponin-I levels had significantly worse 30-day and 1-year survival and were more likely to be readmitted within 30 days.

Outcomes in Patients with Elevated vs Normal Troponin-I*

Outcome Odds ratio (95% CI) P
30-d mortality 1.59 (1.42–1.80) <0.001
30-d readmission 1.12 (1.01–1.25) 0.03
1-y mortality 1.35 (1.26–1.45) <0.001
*After adjustment for multiple variables

Patients with elevated vs normal troponin-T levels also had significantly worse 30-day and 1-year survival, but they were not more likely to be readmitted within 30 days.

"If you look at our data by quartiles of troponin, you can really see a continuous relationship; it shows us that over this continuum, even modest elevations [in troponin] that are still within the upper limit of . . . normal" predict worse outcomes," Fonarow noted.

"Given the strong evidence of the critical role of troponin level in assessing cardiovascular disease, and the class I recommendation for troponin testing in patients with decompensated heart failure, it was distressing for us to read that only 35% of patients in this registry had a troponin evaluation during their admission," Sayer and Uriel write.

Patients with HFpEF are very diverse, and a "simple objective biomarker" is needed to better stratify them, especially patients admitted with decompensated HF, they add.

"This study highlights the valuable role that troponins play in risk-stratifying patients with decompensated HFpEF and supports the current guidelines," according to the editorialists. "We hope that these results will promote the increased use of troponin evaluation in the assessment of HFpEF and adherence with guideline-based recommendations."

The American Heart Association provides the Get With The Guidelines–Heart Failure program, which has been previously funded through support from Medtronic, GlaxoSmithKline, Ortho-McNeil, and the American Heart Association Pharmaceutical Roundtable. Pandey has no relevant financial relationships. Fonarow has received research grants from the Agency for Healthcare Research and Quality and the National Institutes of Health and has consulted for Amgen, Baxter, Bayer, Janssen, Novartis, and Medtronic. Disclosures for the coauthors are listed in the paper. The editorialists reported no relevant financial relationships.

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