Outcomes of patients presenting with acute coronary syndromes and negative Troponin-T

The aim of the study was to compare need for revascularization and clinical course between troponin-positive and troponin-negative patients with unstable angina pectoris defined as class IIIB according to Braunwald classification. Methods: The study group consisting of 104 patients was divided into troponin-positive (28 patients) and troponin-negative (76 patients) subgroups. Per study design all patients underwent coronary angiography. The subgroups were compared in regard to angiographic status and consequently the need for revascularization. Additionally, major adverse cardiac events (MACE) consisting of death, myocardial infarction, in-hospital revascularization during 30-days follow-up were assessed in subgroups. Results: In 58 (76%) patients with negative troponin test, the angiographically significant coronary artery stenosis was shown. Major adverse cardiac events were similar in both groups. Regardless of the initial TnT status, in both groups revascularizations (percutaneous or surgical) were performed with high frequency (89 versus 72%, P=NS). Conclusion: In patients with unstable angina in class IIIB according to Braunwald classification, the negative cardiac troponin test did not exclude severe coronary artery disease, which in the majority of patients required revascularization without any additional non-invasive testing for ischemia. Therefore, we postulate that patients with clinically evident unstable angina (IIIB) should be referred to early invasive assessment despite negative troponin T screening.     

Prognostic significance of troponin T elevation in patients without chest pain

Increased cardiac troponin with chest pain is important for the diagnosis, triage, and treatment of patients in the emergency department. However, the use of troponin for the diagnosis and triage of patients without chest pain is poorly established. The aim of this study was to determine 30-day and 1-year mortality and morbidity of troponin T increases in patients without chest pain. This retrospective study compared 92 hospitalized patients without (study group) and 91 patients with chest pain (control group), followed up for 1 year. Study group patients had troponin T >0.04 mug/L, normal creatine kinase or creatine kinase-MB fraction <5%, and no electrocardiographic ischemia. Excluded were high-risk patients with end-stage kidney disease, those with left ventricular ejection fraction <40%, and the critically ill. Outcome variables included 30-day and 1-year death, myocardial infarction, unstable angina, and coronary revascularization rates. Thirty-day (13.0% vs 4.4%; p = 0.032) and 1-year (33% vs 4.6%; p <0.001) mortality rates were significantly higher in the study group, whereas myocardial infarction, unstable angina, and revascularization were infrequent. In conclusion, patients with increased troponin T and no chest pain had a high mortality rate and required careful follow-up.     

Prognostic value of quantitative troponin T measurements in unstable angina/non-ST-segment elevation acute myocardial infarction treated early and predominantly with percutaneous coronary intervention

PURPOSE: To evaluate the effect of baseline cardiac troponin T measurements on in-hospital and long-term outcomes in patients with unstable angina/non-ST-segment elevation myocardial infarction who are treated with an early invasive strategy. METHODS: We conducted a prospective cohort study involving 1024 consecutive patients with unstable angina/non-ST-segment elevation myocardial infarction. Patients were stratified according to quantitative troponin T measurements on admission, and underwent coronary angiography and subsequent coronary stenting of the culprit lesion as the primary revascularization strategy within 24 hours. The primary endpoint was all-cause mortality. RESULTS: The risk of in-hospital and long-term mortality increased with absolute levels of troponin T. In-hospital mortality was 0.7% (3/449) in patients with levels <0.010 microg/L, 2.0% (4/197) in those with levels from 0.010 to 0.035 microg/L, 3.2% (6/186) in those with levels from 0.035 to 0.229 microg/L, and 4.7% (9/192) in patients with levels >0.229 microg/L. Cumulative 2-year mortality rates were 2.8%, 8.0%, 10.5%, and 14.8% from the lowest to highest troponin T groups (P <0.001). In contrast, the risk of nonfatal myocardial infarction assumed an inverted U-shaped curve and was lower in the lowest and highest troponin T groups. CONCLUSION: Troponin T remains a strong predictor of mortality, even at low levels, in patients with unstable angina/non-ST-segment elevation myocardial infarction who are treated with early revascularization. The risk associated with elevated levels is linear for death but not for myocardial infarction.     

Coronary angiographic findings and troponin T in patients with unstable angina pectoris

This study sought to identify differences in coronary anatomic pathology in patients with unstable angina and elevated versus nonelevated serum troponin T values. Previous studies have shown a worse prognosis in unstable angina patients with elevated serum troponin T values. Consecutive patients (n = 117) with Braunwald class IIIB angina were included in the study. Serum samples for troponin T were obtained at admission and every 6 to 8 hours for 18 to 24 hours. Acute myocardial infarction was excluded by routine creatine kinase measurements. All patients underwent coronary angiography before discharge. Cardiac events including cardiac death and myocardial infarction were recorded. Two thirds of the patients with unstable angina had no increase in serum troponin T (<0.1 microg/L) (n = 80). They had a lower incidence of 3-vessel disease (26% vs 46%, p <0.001), left main disease (5% vs 16%, p = 0.04), visible thrombus (4% vs 22%, p = 0.006), and less severe stenosis of the culprit artery (65% vs 84%, p <0.004) than patients with elevated serum troponin T values (> or =0.1 microg/L) (n = 37). The 1-year cardiac event rate was 0% versus 19% in patients with troponin T values <0.1 microg/L compared with patients with serum troponin T values > or =0.1 microg/L (p <0.0001). It was concluded that patients with unstable angina and no release of troponin T have less severe coronary artery disease, and have an excellent prognosis. It is suggested that these patients may be managed more conservatively and without invasive evaluation before discharge.     

Low-molecular-weight heparin as a bridge to timely revascularization in unstable coronary artery disease -- an update of the Fragmin during Instability in Coronary Artery Disease II Trial

This article summarizes the design and findings -- both at 3 months and at 1 year follow-up -- of the Fragmin during Instability in Coronary Artery Disease (FRISC) II trial. This multicentre randomized trial compared both an early invasive with an early non-invasive stategy, and prolonged treatment with dalteparin as opposed to placebo, in patients with unstable coronary artery disease. The results show that an early invasive strategy with coronary angiography and, if appropriate, revascularization procedures within 7 days after admission reduces the subsequent rate of mortality and myocardial infarction. The benefits of the invasive treatment were noticeably more marked in patients with any high-risk indicator -- for example, male gender, age above 65 years, previous severe angina, or signs of ischaemia (ST depression on ECG) or of myocardial damage (elevated levels of troponin T). Treatment with dalteparin reduced the risk of death and myocardial infarction in high-risk (i.e. troponin-positive) patients, particularly during the first month of treatment. However, continuation with dalteparin therapy after revascularization procedures conferred no benefit. It is concluded that extended treatment with dalteparin is useful as a bridge to revascularization in this high-risk subgroup of patients with unstable coronary artery disease.     

Prognostic significance of asymptomatic coronary artery disease in patients with diabetes and need for early revascularization therapy.

AIMS: Information on the clinical outcome of patients with diabetes with silent myocardial ischaemia is limited. We compared the clinical and angiographic characteristics, and the clinical outcomes of diabetic patients with asymptomatic or symptomatic coronary artery disease (CAD). METHODS: Three hundred and ten consecutive diabetic patients with CAD were divided into two groups according to the presence of angina and followed for a mean of 5 years. Fifty-six asymptomatic patients with a positive stress test and CAD on coronary angiography were compared with 254 symptomatic patients, 167 with unstable angina and 87 with chronic stable angina. RESULTS: Although the severity of coronary atherosclerosis was similar in asymptomatic and symptomatic patients, revascularization therapy was performed less frequently in the asymptomatic than the symptomatic patients (26.8 vs. 62.0%; P < 0.001). Asymptomatic patients experienced a similar number of major adverse cardiac events (MACEs; death, non-fatal myocardial infarction, and revascularization; 32 vs. 28%; P = 0.57), but had higher cardiac mortality than symptomatic patients (26 vs. 9%; P < 0.001). However, patients who underwent revascularization therapy at the time of CAD diagnosis in these two groups showed similar MACE and cardiac mortality (20.0 vs. 22.5%, 6.7 vs. 5.3%, respectively; all P > 0.05). CONCLUSIONS: This study suggests that diabetic patients with asymptomatic CAD have a higher cardiac mortality risk than those with symptomatic CAD, and that lack of revascularization therapy may be responsible for the poorer survival.     

Predictive value of C-reactive protein and troponin T in patients with unstable angina: a comparative analysis. CAPTURE Investigators. Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial

OBJECTIVES: We evaluated C-reactive protein (CRP) and troponin T (TnT) for predicting six-month cardiac risk in patients with unstable angina. BACKGROUND: Troponin T is predictive of cardiac risk in patients with unstable angina. The clinical implications of elevated CRP in such patients remains controversial. METHODS: Baseline TnT and CRP values were determined in 447 patients with unstable angina enrolled in the placebo group of the Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial (CAPTURE) trial. All patients underwent a coronary intervention and were followed for a six month period in which 13 deaths and 47 myocardial infarctions were documented (MIs). RESULTS: Troponin T was >0.1 microg/liter in 30% and CRP was >10 mg/L in 41% of the patients. For the initial 72-h period (including coronary intervention), TnT (17.4% vs. 4.2%; p < 0.001) but not CRP (10.3% vs. 8%; p = 0.41) was predictive of mortality and MI. The TnT-positive patients displayed more frequent recurrent instability before the planned intervention (44.8% vs. 16.9%; p < 0.001), but in the CRP-positive patients, no such increase was observed (25.9% vs. 24.8%; p = 0.92). In contrast, for the six month follow-up period, CRP was predictive of cardiac risk (mortality, MI) (18.9% vs. 9.5%; p = 0.003). Using multivariate analysis, both CRP and TnT emerged as independent predictors of mortality and MI at six-month follow-up. Furthermore, the incidence of coronary restenosis during six-month follow-up was not related to TnT status (3% vs. 4.5%; p = 0.49); however, it was significantly related to CRP status (7% vs. 2.3%; p = 0.03). CONCLUSIONS: Troponin T, but not CRP, was predictive of cardiac risk during the initial 72-h period, whereas CRP was an independent predictor of both cardiac risk and repeated coronary revascularization (coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty) during six month follow-up.     

Relation of minor cardiac troponin I elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris.

There is little information about the relation between mild cardiac troponin I (cTn-I) increase after coronary interventions and late outcome. We therefore focused on the long-term outcome and the clinical, morphologic, and procedural correlates of elevation of cTn-I compared with cardiac troponin T, creatine kinase (CK), CK-MB activity and mass, and myoglobin in 105 patients with successful elective percutaneous transluminal coronary angioplasty (PTCA) for stable or unstable angina. Patients with myocardial infarction and those with unstable angina who had a detectable increase in serum markers before PTCA were excluded. Markers were measured before and after the procedure and for 2 days. Patients were followed up to record recurrent angina, myocardial infarction, cardiac death, repeat PTCA, or elective coronary artery bypass graft surgery. Procedure success was achieved in all cases. Elevation in cTn-I (> or =0.1 microg/L) was observed in 23 of 105 patients (22%) (median peak: 0.25 microg/L); 18% had cardiac troponin T (cTn-T) release (> or = 0.1 microg/L, median peak 0.21); 11.4% CK-MB mass (> or =5 microg/L), and 7.6% myoglobin (> or =90 microg/L) release. Five and 2 patients had elevated CK and CK-MB activity, respectively. Fourteen of 18 patients with cTn-T elevation had a corresponding elevation in cTn-I (kappa 0.68; p = 0.001). Patients positive for cTn-I had more unstable angina (p = 0.042) and heparin before PTCA (p = 0.046), and had longest total time (p = 0.004) and single inflation (p = 0.01). By multivariate logistic regression, predictors of postprocedure cTnI elevation were maximum time of each inflation (odds ratio 9.2; p = 0.0012), type B lesions (odds ratio 6.6; p = 0.013), unstable angina (p = 0.041), and age > or =60 years (p = 0.032). Clinical follow-up was available in 103 patients (98%) (mean 19+/-10 months). Kaplan-Meier survival analysis showed that cTn-I elevation was not an important correlate of cardiac events (p = 0.34, by log-rank analysis). The incidence of recurrent angina, myocardial infarction, cardiac death, and repeat revascularization after 12 months was not different in patients positive or negative for cTn-I. We conclude that cTn-I elevation after successful PTCA is not associated with significantly worse late clinical outcome. Levels of cTn-I allow a much higher diagnostic accuracy in detecting minor myocardial injury after PTCA compared with other markers, but there is no association with periprocedural myocardial cell injury and late outcome when cTn-I and other markers are considered.     

Use of statins prior to percutaneous coronary intervention reduces myonecrosis and improves clinical outcome.

Primary and secondary prevention with statins reduce major cardiac events in patients with coronary artery disease. The impact of pretreatment with statins prior to percutaneous coronary intervention (PCI) is not well established. The objective of this study was to determine if pretreatment with statins prior to PCI reduce myonecrosis and improve clinical outcome. One hundred nineteen consecutive patients with acute coronary syndrome who underwent PCI were identified. We compared the incidence of myonecrosis defined as peak elevation of CK-MB or CK three time above upper limit of normal within 24 hr and the 6-month cardiovascular event rate (death, nonfatal myocardial infarction unrelated to PCI, target vessels revascularization, and unstable angina requiring hospitalization) among patients who received statins prior to PCI (n = 63) to those who did not (n = 56). Pretreated patients were more likely to have history of myocardial infarction or revascularization (63% vs. 43%; P = 0.015), hyperlipidemia (80% vs. 48%; P = 0.001), hypertension (83% vs. 49%; P = 0.02), and use of angiotensin-converting enzyme inhibitor (62% vs. 38%; P = 0.008). The rest of baseline characteristics were similar between the two groups, including use of glycoprotein IIb/IIIa inhibitors, number of diseased vessels, and type of lesions. Patients pretreated with statins had a significantly lower incidence of myonecrosis (2% vs. 10%; P = 0.04) at 24 hr and a significantly lower clinical event (CE) rate at 6 months (17% vs. 21%; P = 0.015). Of patients not pretreated with statins, 72% were taking statins at 6 months as compared to 98% of pretreated patients. After adjusting for all baseline characteristics, use of statins prior to PCI was associated with a marked decrease in risk of all CEs (OR = 0.2; CI = 0.06-0.63; P = 0.006). Statin therapy prior to PCI may reduces peri-PCI myonecrosis and late cardiac events. These results need to be confirmed in large prospective randomized trials.     

Prognostic implications of elevated whole blood choline levels in acute coronary syndromes

Troponins I and T represent the current biomarker standard for diagnosis of myocardial infarction. Even small increases of cardiac troponins have prognostic implications, but not all patients at risk are correctly classified, particularly at admission. We identified elevated whole-blood choline as a promising marker and performed a prospective study of 327 patients with a suspected acute coronary syndrome that focused on the analysis of troponin-negative patients. Diagnostic classification of patients and the definition of troponin cutoffs were performed according to the new European Society of Cardiology/American College of Cardiology criteria. Blood was sampled serially and choline was measured using high-performance liquid chromatography mass spectrometry in whole blood. Patients were followed for 30 days. In patients with negative troponin I test results at admission (n = 250), choline was a predictor of cardiac death and nonfatal cardiac arrest (hazard ratio 6.0, p = 0.003), life-threatening arrhythmias (hazard ratio 3.75, p = 0.004), heart failure (hazard ratio 2.87, p = 0.002), and coronary angioplasty (hazard ratio 2.57, p = 0.001). In multivariate analysis of troponin-negative patients, choline was the strongest predictor of cardiac death or arrest (odds ratio 6.05, p = 0.01). Choline was not a marker for myocardial necrosis but indicated high-risk unstable angina in patients without acute myocardial infarction (sensitivity 86.4%, specificity 86.2%). Thus, an increased concentration of choline at hospital admission is a predictor of adverse cardiac events in patients with suspected acute coronary syndromes. Whole blood choline may be useful for early risk stratification of these patients, particularly if troponin results are negative on admission.     

12-month outcomes of percutaneous and surgical revascularization in acute coronary syndromes without ST-segment elevation in patients with multivessel coronary artery disease

Early invasive strategy is one of two methods of treatment of acute coronary syndromes without ST-segment elevation (NSTEACS). We aimed at assessing 12-month outcomes and quality of life in patients with NSTEACS and multivessel coronary artery disease (CAD) who underwent percutaneous or surgical revascularization. Analyzed group comprised 412 patients (92%) who were qualified for invasive treatment based on coronary angiography performed 24 hours after admission and in whom long-term follow up data was available. The inclusion criteria were: rest angina within 24 hours prior to admission and at least one of the following: ST segment depression (> or = 0.5 mm), transient (< 20 min) ST-segment elevation, negative T-waves (> or = 1 mm)in at least 2 contiguous leads, positive serum cardiac markers. Patients with single-vessel CAD or qualified for conservative treatment were excluded from the study. We analysed the rate of adverse cardiac events (death, non-fatal myocardial infarction, unstable angina, repeated revascularization, cardiovascular hospitalization) at one year. The quality of life was assessed using Short-Form-36 (SF-36) questionnaire. The rate of death was 5.3% vs 9.3% (NS), myocardial infarction 3.4% vs 0% (p = 0.054), unstable angina 20.9% vs 2.8% (p = 0.0000), repeated revascularization 12.6% vs 0% (p = 0.0001) and cardiovascular hospitalization 36% vs 22.7% (p = 0.001) in the PCI and CABG group respectively. Physical Component Summary scores were 38.7 +/- 11.6 vs 43.08 +/- 9.5, p = 0.001 in the PCI and CABG group respectively. Mental Component Summary Scores were similar in both groups (46.34 +/- 13.05 vs 45.97 +/- 11.9, NS). Conclusions: Overall mortality rate was similar in both groups. PCI patients had more frequent rate of unstable angina, rate of hospitalization and repeat revascularization. This study has shown that there is a significant difference in health-related quality of life 12 months after PCI and CABG. This difference arises from better physical function (Physical Component) for CABG surgery patients compared with PCI patients. Despite impairment of the physical health status, the mental health status (Mental Component) remained similar in both groups.     

Prognostic value of myocardial contrast echocardiography in patients presenting to hospital with acute chest pain and negative troponin

We hypothesized that myocardial contrast echocardiography (MCE) could be used to stratify risk in patients with suspected acute coronary syndrome but a nondiagnostic electrocardiogram and negative troponin. Pretest Thrombolysis In Myocardial Infarction (TIMI) scores were determined. Exercise electrocardiographic data in those patients undergoing treadmill stress echocardiography as part of risk evaluation were analyzed independently of echocardiographic data. On a separate day, low-power MCE at rest and during vasodilator stress was performed. All patients were followed for cardiac events (cardiac death, myocardial infarction, and revascularization). Of 148 patients, 27 demonstrated abnormal myocardial contrast echocardiographic results and had higher cardiac event rates compared with those with normal myocardial contrast echocardiographic findings (59% vs 7%, p <0.0001) at follow-up (8 +/- 5 months). Hard cardiac event rates (death and nonfatal myocardial infarction) were low (3%) in patients with normal myocardial contrast echocardiographic findings. Cardiac events in patients with abnormal myocardial contrast echocardiographic findings (59%) were significantly higher than those predicted by a high-risk TIMI score (33%, p = 0.0023) and compared with those predicted by high-risk exercise electrocardiography (80% vs 57%, p = 0.0003). In conclusion, stress MCE was superior to TIMI risk score and exercise electrocardiography in the assessment of risk in patients with suspected acute coronary syndrome, nondiagnostic electrocardiogram, and negative troponin.     

Prognostic value of stress-gated Tc-99m sestamibi SPECT after acute myocardial infarction

Stress-gated technetium-99m (Tc-99 m) sestamibi single-photon emission computed tomography (SPECT) is used to risk stratify patients after acute myocardial infarction (AMI). In clinical practice, results of this test are used primarily to identify patients with myocardial ischemia for intervention. The value of this test to risk stratify patients with AMI not at high ischemic risk has not been addressed. More than 1-year follow-up was undertaken in 124 patients who underwent predischarge gated Tc-99m sestamibi SPECT studies and who did not undergo subsequent revascularization. Clinical variables and test-derived variables were evaluated to predict cardiac death, recurrent AMI, and hospitalization for unstable angina, congestive heart failure, or coronary revascularization. Independent predictors by multivariate analysis for cardiac death or recurrent AMI were a history of prior AMI (relative risk [RR] = 5.32, confidence interval [CI] 2.17 to 12.96), a low exercise capacity (RR = 6.84, CI 1.99 to 23.48), and left ventricular (LV) ejection fraction (EF) <40% (RR = 2.63, CI 1.04 to 6.38). The incidence of cardiac death or recurrent AMI was 29.8% in patients with a low exercise capacity versus 4.5% in those with good exercise capacity, and 38.1% in patients with LVEF <40% versus 9.4% in those with LVEF >40%. Independent predictors of cardiac death, AMI, or hospitalization for unstable angina, congestive heart failure, or revascularization were a history of prior AMI (RR = 2.24, CI 1.11 to 4.50) and LVEF <40% (RR = 3.13, CI 1.64 to 5.95). Among patients followed after AMI without revascularization Tc-99m sestamibi SPECT can identify a high-risk subset. The strongest independent predictors are poor exercise capacity and LVEF < 40%.     

Long-term outcome in patients treated by intracoronary stenting with ticlopidine and aspirin, and deleterious prognostic role of unstable angina pectoris

Compared with stable clinical conditions, unstable angina carries an increased risk of immediate and delayed cardiac adverse events after balloon coronary angioplasty. The influence of stent use in reducing these differences remains unknown. We analyzed the early (30 days) and late outcome of a cohort of 459 consecutive patients who underwent stent placement with ticlopidine and aspirin as antithrombotic regimen according to the presence (group 1, n = 151) or absence (group 2, n = 308) of unstable angina at rest (Braunwald classes II and III). Group 1 patients were older and more likely to be current or former smokers. In group 2, prior myocardial infarction was more frequent. Procedural, in-hospital results, and early outcome were similar in the 2 groups. However, over the long term, the incidence of myocardial infarction (11% vs 6%, p <0.04), target lesion revascularization (19% vs 13%, p <0.04), or any revascularization (30% vs 20%, p <0.01) was significantly higher in group 1. Kaplan-Meier probabilities of survival without myocardial infarction (85% vs 91%, p <0.05), survival without revascularization of the target lesion (73% vs 83%, p <0.01), survival without any revascularization (65% vs 77%, p <0.006), and survival without any events (61% vs 73%, p <0.009) were significantly worse in group 1. In addition, Cox multivariate analysis showed that unstable angina at rest was an independent predictor of target lesion revascularization, of survival without any revascularization, and without any events. Thus, unstable angina at rest remains an adverse prognostic indicator in patients treated with intracoronary stents, particularly with regard to subsequent requirement of revascularization procedures and event-free survival.     

Prognostic value of cardiac troponin I re-elevation following percutaneous coronary intervention in high-risk patients with acute coronary syndromes.

Troponin I is a predictive marker of short- and intermediate-term adverse cardiac events in patients with acute coronary syndromes (ACS). These high-risk patients may benefit from early percutaneous coronary intervention. However, whether additional myocardial injury, defined as postprocedural troponin I elevation, may be associated with adverse short- and intermediate-term outcomes has not been fully explored. Accordingly, we studied 132 consecutive patients with non-ST-elevation ACS (62% with non-Q-wave myocardial infarction) and elevated troponin I levels at admission (>0.15 ng/ml) who underwent percutaneous coronary intervention > or =48 hours after admission. Troponin I levels were routinely measured at 6 and 18 to 24 hours after intervention and patients were stratified according to the presence or absence of troponin I re-elevation, defined as postprocedural troponin I levels >1 times the admission levels. In-hospital and cumulative 6-month clinical outcomes were compared between groups. Patients with troponin I re-elevation (n = 51) were older (68 +/- 13 vs 64 +/- 12 years, p = 0.05) and had experienced prior myocardial infarction more frequently (92.5 vs 82.1, p = 0.09), but otherwise had similar baseline clinical characteristics. Patients with troponin I re-elevation had significantly higher in-hospital mortality (9.8% vs 0%, p = 0.016) and a higher 6-month cumulative death rate (24% vs 3.7%, p = 0.001). There was a trend for an increased 6-month myocardial infarction rate in patients with troponin I re-elevation (13.7% vs 3.7%, p = 0.11) and target vessel revascularization was similar between groups (16.7% vs 17.4%, p = 0.92). By multivariate analysis, troponin I re-elevation (odds ratio [OR] 6.2, p = 0.011) and diabetes mellitus (OR 5.7, p = 0.014) were the strongest independent predictors for increased 6-month cumulative mortality, whereas creatine kinase MB-fraction re-elevation had no prognostic value. We conclude that troponin I re-elevation after percutaneous coronary intervention in high-risk patients with ACS is associated with a substantial increase in mortality and reduced event-free survival at 6-month follow-up.     

Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK)

AIMS: To determine characteristics, outcomes, prognostic indicators and management of patients with acute coronary syndromes without ST elevation. METHODS AND RESULTS: A prospective registry was carried out with follow-up for 6 months after index hospital admission. A history of acute cardiac chest pain was required plus ECG changes consistent with myocardial ischaemia and/or prior evidence of coronary heart disease. Patients with ST elevation or those receiving thrombolytic therapy were excluded. A total of 1046 patients were enrolled from 56 U.K. hospitals. The mean age was 66+/-12 years and 39% were female. The rate of death or non-fatal myocardial infarction at 6 months was 12.2% and of death, new myocardial infarction, refractory angina or re-admission for unstable angina at 6 months was 30%. In a multivariate analysis, patients >70 years had a threefold risk of death or new myocardial infarction compared with those <60 years (P<0.01) and those with ST depression or bundle branch block on the ECG had a five-fold greater risk than those with normal ECG (P<0.001). Aspirin was given to 87% and heparin to 72% of patients in hospital. At 6 months 56% received no lipid-lowering therapy at all. The 6-month rate of coronary angiography was 27% and any revascularization 15%. CONCLUSIONS: In this cohort there was a one in eight chance of death or myocardial infarction, and a one in three chance of death, new myocardial infarction, refractory angina or re-admission for unstable angina, over 6 months. Age and baseline ECG were useful markers of risk. Aspirin, heparin and statins were not given to about one-sixth, one-third and one-half respectively. Rates of angiography and revascularization appear low. A review of treatment strategies of unstable angina and myocardial infarction without ST elevation is warranted in the U.K. to ensure that patients are receiving optimum treatments to reduce mortality and morbidity.     

Elevated troponin T and C-reactive protein predict impaired outcome for 4 years in patients with refractory unstable angina, and troponin T predicts benefit of treatment with abciximab in combination with PTCA.

AIMS: Treatment with the glycoprotein IIb/IIIa receptor antagonist abciximab before and during coronary intervention in refractory unstable angina improves early outcome. We collected 4-year follow-up data to assess whether this benefit is sustained. Additionally, we investigated the predictive value of baseline troponin T and CRP for long-term cardiovascular events. METHODS AND RESULTS: Of 1265 patients enrolled in the CAPTURE trial follow-up was available in 94% of the patients alive after 6 months (median 48 months). Survival was similar in both groups. Both elevated troponin T and CRP were associated with impaired outcome, independently of other established risk factors, but with a different time course. Elevated troponin was associated with increased procedure related risk, and elevated CRP with increased risk for subsequent events. Lower rates of the composite end-point of death or myocardial infarction with abciximab vs. placebo were sustained during long-term follow up: 15.7% vs 17.2% at 4 years (P=ns), particularly in patients with elevated troponin T: 16.9% with abciximab vs 28.4% with placebo: P=0.015. Elevated CRP was not associated with specific benefit of abciximab. CONCLUSION: Troponin T as a marker of thrombosis and CRP as a marker of inflammation are independent predictors of impaired outcome at 4 years follow-up. The initial benefit from abciximab with regard to death and myocardial infarction was preserved at 4 years. No specific benefit with abciximab was observed for patients with elevated CRP, suggesting that a chronic inflammatory process is not affected by abciximab. In contrast the benefit of treatment in patients with elevated troponin T implies that the acute thrombotic process in refractory unstable angina is treated effectively.     

Prognostic value of troponin T in hospitalized patients with angina or non-ST-segment elevation myocardial infarction

INTRODUCTION AND OBJECTIVES: Cardiac troponins are highly specific and sensitive for detecting minimal myocardial damage. The aim of our study was to determine the prognostic value of troponin T levels in patients hospitalized for suspected angina or myocardial infarction without ST-segment elevation. PATIENTS AND METHOD: We recorded the frequency of death, acute myocardial infarction, heart failure, or need for coronary revascularization in the three months after the onset of symptoms in 346 consecutive patients admitted for suspected acute coronary syndrome, excluding those who developed myocardial infarction with persistent ST-segment elevation. RESULT:. Serum troponin T levels were > or = 0.1 ng/ml in 133 patients (troponin T positive group) and lower in 213 patients (troponin T negative group). The relative risk (RR) and 95 percent confidence intervals (95% CI) of individual and grouped events for the troponin T positive group were 3.2 (95% CI, 1.4-7.3; p = 0.006) for death; 2.8 (95% CI, 1.43-5.51; p = 0.003) for death or myocardial infarction; and 2.8 (95% CI, 1.6-5.0; p < 0.001) for death, myocardial infarction or heart failure. Diabetes mellitus and troponin T levels > or = 0.1 ng/ml had independent prognostic value after adjusting for age, sex, and electrocardiographic changes; with RR 2.5 (95% CI, 1.01-5.9) for death, myocardial infarction or heart failure. CONCLUSIONS: The prognosis of patients hospitalized for chest pain who do not immediately develop transmural necrosis depends on serum troponin T levels at hospital admission. Troponin T levels > or = 0.1 ng/ml almost triple the risk of major events in the three months after the acute episode. The prognostic value of troponin T is independent of age, sex, presence of diabetes mellitus, and electrocardiographic changes.     

Prediction of outcome after percutaneous coronary intervention for the acute coronary syndrome

BACKGROUND: The seven-component Thrombolysis In Myocardial Infarction (TIMI) score has been used to risk stratify, and to guide the medical management of, patients with unstable angina or non-ST-elevation myocardial infarction. We assessed the usefulness of the risk score in predicting in-hospital and 30-day outcomes in such patients who were undergoing percutaneous coronary intervention. METHODS: Using the TIMI score, 2501 patients with unstable angina or non-ST-elevation myocardial infarction were divided into low-risk (zero to two risk factors; n = 974), intermediate-risk (three to four risk factors; n = 1339), and high-risk (five to seven risk factors; n = 188) groups, and outcomes were compared. RESULTS: Angiographic/clinical success and the rate of minor procedural events were similar among the three groups. A higher TIMI risk score was associated with more cardiac comorbid conditions and more complicated angiographic lesions: longer lesions (P = 0.0009), more thrombotic lesions (P = 0.03), more multivessel disease (P <0.0001), and more American College of Cardiology/American Heart Association type B2/C lesions (P = 0.05). Although the risk score did not predict interventional technical success or intraprocedural complications, a high score was associated with prolonged hospital stay, higher postprocedural peak troponin levels, and 30-day major adverse cardiac events. Stepwise logistic regression showed that in conjunction with lesion length and patient sex, a high score was an independent predictor of 30-day major adverse cardiac events (odds ratio = 2.3; 95% confidence interval: 1.1 to 4.1; C statistic = 0.62). CONCLUSION: Although a higher TIMI risk score in patients with unstable angina or non-ST-elevation myocardial infarction who were undergoing percutaneous coronary intervention correlated with adverse clinical outcome, the score alone cannot be used to guide diagnostic or therapeutic strategies.     

Prognostic value of C-reactive protein and troponin T level in patients with unstable angina pectoris

OBJECTIVES: The prognosis of unstable angina pectoris may be more accurately predicted by the combination of C-reactive protein (CRP), which is a known inflammation marker, and troponin T (TnT), which is used for risk assessment for the prognosis of acute coronary syndrome. The present study investigated the correlations between pathophysiology and prognosis of severe unstable angina pectoris and CRP and TnT levels. METHODS: The correlation between CRP at admission and the prognosis was studied in 367 patients with severe unstable angina pectoris (Braunwald type II and III) who were admitted to our hospital between January 1998 and December 2000. The in-hospital and long-term prognosis was investigated in TnT-positive patients. In-hospital cardiac events were defined as death, myocardial infarction, heart failure and angina attacks during hospitalization. Long-term cardiac events were defined as death, myocardial infarction, heart failure and recurrence of angina. RESULTS: The incidence of in-hospital cardiac events in all patients was 30.2%. The CRP levels were higher in patients with cardiac events (0.97 +/- 2.67 vs 0.53 +/- 1.29 mg/d/, p = 0.057), but there was no significant difference between the two groups. The incidence of long-term cardiac events was 26.8%. The mean CRP level was significantly higher in patients with cardiac events than in patients without cardiac events (1.17 +/- 1.86 vs 0.43 +/- 1.14 mg/dl, p = 0.098). In TnT-positive patients (TnT > 0.1 ng/ml, 23% of all patients), the incidence of in-hospital cardiac events was 47.6% (p < 0.0001), significantly higher than that in all patients. TnT-positive patients with CRP levels of 0.5 mg/dl or higher (8% of all patients) had a markedly higher incidence of in-hospital cardiac events of 56.7% (p = 0.001) and long-term cardiac events of 46.7% (p = 0.01). CONCLUSIONS: CRP levels were useful in prediction of the long-term prognosis. TnT levels were useful in prediction of in-hospital prognosis. The present study suggested the possibility that the combined use of these biological markers could predict the prognosis of patients with unstable angina at early stage and more accurately.