Coronary artery disease
Prognostic Implications of Normal (<0.10 ng/ml) and Borderline (0.10 to 1.49 ng/ml) Troponin Elevation Levels in Critically Ill Patients Without Acute Coronary Syndrome

https://doi.org/10.1016/j.amjcard.2008.04.026Get rights and content

Borderline increase of troponin I (cTnI) is associated with higher rates of cardiovascular events compared with normal levels in the setting of acute coronary syndrome (ACS), but the significance of borderline cTnI levels in patients without chest pain may differ. The aim of this study was to determine the prognostic implications of intermediate serum cTnI levels in patients without ACS in the intensive care unit (ICU). This was a 12-month retrospective study of 240 patients without ACS in the ICU with normal (<0.1 ng/ml) or intermediate (0.1 to 1.49 ng/ml) cTnI levels. End points included in-hospital mortality, lengths of ICU and hospital stays, and rates of postdischarge readmission and mortality. Overall in-hospital mortality was 13%, with 5% in the normal cTnI group and 28% in the intermediate cTnI group. By multivariate analysis, intermediate cTnI was independently associated with in-hospital mortality (p = 0.004) and length of ICU stay (p = 0.028). The only other independent risk factor for inpatient mortality was a standardized ICU prognostic measurement (Simplified Acute Physiology Score II score). Intermediate cTnI had no prognostic implications regarding length of hospital stay, readmission rate, or postdischarge mortality at 6 months. In conclusion, an intermediate level of cTnI in patients without ACS in the ICU is an independent prognostic marker predicting in-hospital mortality and length of ICU stay. Patients with intermediate cTnI levels who survive to discharge have equivalent out-of-hospital courses for up to 6 months compared with patients with normal cTnI levels.

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Methods

The protocol was approved by the institutional review board at the Veterans Administration (VA) Medical Center, Bronx, New York. All patients with cTnI levels measured from June 1, 2005 to March 30, 2006 were identified retrospectively using the VA computerized medical records system. Serum cTnI values were sorted and identified as normal (<0.1 ng/ml), intermediate (0.1 to 1.49 ng/ml), or elevated (≥1.5 ng/ml). Occasionally multiple cTnI determinations for a given patient were available during

Results

Of the 266 patients in the ICU identified during the study period with normal or intermediate cTnI values, 26 were excluded because of ACS or chest pain presentations. The remaining 240 patients with normal (n = 150) or intermediate (n = 90) cTnI levels were included in the final analysis. Admitting diagnoses for these patients are presented in Table 1. There were significantly more perioperative patients with normal cTnI values, whereas more patients with a diagnosis of infection (sepsis or

Discussion

In patients presenting with ACS in the Thrombolysis In Myocardial Infarction 18 (TIMI-18) study,1 cTnI levels even in the intermediate range were associated with higher rates of cardiovascular events compared with normal cTnI values. Therefore, patients with ACS were specifically excluded from the present study, which was restricted to patients in the ICU without apparent clinically active cardiac issues. In these critically ill patients, our results show that even modest cTnI increases were

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