Elevated troponin in cardio-renal patients linked to worse outcome
MedWire News: Baseline troponin elevation is associated with significantly worse short- and long-term clinical outcomes in patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD), a study shows.
However, bivalirudin monotherapy "safely" reduces major bleeding in these patients, report Gregg Stone (Columbia University Medical Center, New York, USA) and colleagues in Circulation: Cardiovascular Interventions.
They conducted a substudy of the Acute Catheterization and Urgent Intervention Triage strategy (ACUITY) trial, in which 13,819 patients with moderate- and high-risk non ST-segment-elevation ACS were randomly assigned to receive treatment with heparin plus a glycoprotein IIb/IIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin monotherapy.
Among 2179 patients with CKD, defined as a creatinine clearance of less than 60 mL/min, baseline troponin elevation (either I or T subunits greater than upper limits of local laboratory normal) was present in 1291 (59.2%) patients.
Major bleeding and major adverse cardiac events (MACE), including death, myocardial infarction (MI), or unplanned revascularization, were examined according to baseline troponin status and treatment arm.
CKD patients with an elevated baseline troponin level had significantly higher rates of death, MI, and MACE at 30 days than CKD patients without an elevated baseline troponin level, at 4.7% versus 1.0%, 8.3% versus 5.0%, and 20.6% versus 14.8%, respectively.
CKD patients with an elevated baseline troponin level also had significantly higher rates of death, MI, and cardiac events at 1 year than those without elevated troponin at 1 year, at 10.7% versus 6.8%, 13.3% versus 7.3%, and 6.8% versus 2.7%, respectively.
Multivariate analysis revealed that baseline troponin elevation in CKD patients was an independent predictor for the composite of death or MI at 30 days and 1 year, at hazard ratios (HR) of 2.05 and 1.72, respectively (p<0.0001 for both).
In CKD patients with baseline troponin elevation, bivalirudin monotherapy significantly reduced 30-day major bleeding compared with heparin plus a GPI. However, the rates of MACE at 30 days and 1 year were not significantly different between these two treatment groups.
"Despite concerns of impaired renal clearance, baseline troponin elevation is an important predictor of adverse cardiac outcomes in ACS patients with moderate CKD undergoing an early invasive management strategy," say the authors.
They conclude that treatment of these patients with bivalirudin monotherapy reduces bleeding complications and provides long-term ischemic protection.
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By Piriya Mahendra