In the Journals

Elevated high-sensitivity cardiac troponin predicts incident HF

Allan S. Jaffe

High-sensitivity cardiac troponin levels were strongly associated with the risk for incident HF, according to a meta-analysis published in JACC: Heart Failure.

Jonathan D. W. Evans, MBChB, BHF Cambridge CRE Clinical Research Training Fellow in the department of public health and primary care at University of Cambridge, and colleagues analyzed data from 67,063 participants (mean age, 57 years; 47% women) without HF at baseline from 16 prospective studies that measured high-sensitivity cardiac troponin and recorded incident HF events for at least 1 year. Studies that involved patients in the early phase after an acute MI, those with established multisystem or myocardial disease, or those underdoing cardiotoxic chemotherapy were excluded.

During follow-up, 4,165 incident HF events occurred. The studies included in the meta-analysis were of high quality, according to the Newcastle-Ottawa score (8.2 of 9).

Compared with those who had high-sensitivity cardiac troponin concentration in the bottom third, those in the top third had elevated risk for incident HF (HR = 2.09; 95% CI, 1.76-2.48). Significant heterogeneity was evident (80%; 95% CI, 68-87).

The results were consistent in men (HR = 2.29; 95% CI, 1.64-3.21) and women (HR = 2.18; 95% CI, 1.68-2.81), and for high-sensitivity cardiac troponin T (HR = 2.11; 95% CI, 1.69-2.63) and high-sensitivity cardiac troponin I (HR = 2.09; 95% CI, 1.53-2.85). After adjusting for B-type natriuretic peptide, the HR was 2.08 (95% CI, 1.64-2.65).

Adding high-sensitivity cardiac troponin to conventional risk factors improved the C index between 1% and 3%, Evans and colleagues wrote.

“Preliminary data showing discrimination improvements in HF risk with [high-sensitivity cardiac troponin] assessment suggest that it may be a promising biomarker for measurement as part of primary prevention of HF,” Evans and colleagues wrote.

“As advocates for biomarker use in patients with HF and from our previous studies, we appreciate the interesting proof of concept presented by Evans et al, and with which we concur in regard to establishing estimates of those at risk for HF going forward,” Allan S. Jaffe, MD, FACC, FAHA, FESC, professor of medicine, professor of laboratory medicine and pathology, and chair of the division of clinical core laboratory services at Mayo Clinic and a member of the Cardiology Today Editorial Board, and Wayne L. Miller, MD, PhD, professor in the department of cardiovascular medicine at Mayo Clinic and Foundation, wrote in a related editorial. “However, we also have tried to use this opportunity to suggest that the field needs to spend additional time and effort refining the specific techniques that might more fully optimize the ability to use summary and meta-analyses that include biomarkers.” – by Darlene Dobkowski

Disclosures: The authors and Miller report no relevant financial disclosures. Jaffe reports he has consulted for most of the major diagnostic companies either presently or in the past.

Allan S. Jaffe

High-sensitivity cardiac troponin levels were strongly associated with the risk for incident HF, according to a meta-analysis published in JACC: Heart Failure.

Jonathan D. W. Evans, MBChB, BHF Cambridge CRE Clinical Research Training Fellow in the department of public health and primary care at University of Cambridge, and colleagues analyzed data from 67,063 participants (mean age, 57 years; 47% women) without HF at baseline from 16 prospective studies that measured high-sensitivity cardiac troponin and recorded incident HF events for at least 1 year. Studies that involved patients in the early phase after an acute MI, those with established multisystem or myocardial disease, or those underdoing cardiotoxic chemotherapy were excluded.

During follow-up, 4,165 incident HF events occurred. The studies included in the meta-analysis were of high quality, according to the Newcastle-Ottawa score (8.2 of 9).

Compared with those who had high-sensitivity cardiac troponin concentration in the bottom third, those in the top third had elevated risk for incident HF (HR = 2.09; 95% CI, 1.76-2.48). Significant heterogeneity was evident (80%; 95% CI, 68-87).

The results were consistent in men (HR = 2.29; 95% CI, 1.64-3.21) and women (HR = 2.18; 95% CI, 1.68-2.81), and for high-sensitivity cardiac troponin T (HR = 2.11; 95% CI, 1.69-2.63) and high-sensitivity cardiac troponin I (HR = 2.09; 95% CI, 1.53-2.85). After adjusting for B-type natriuretic peptide, the HR was 2.08 (95% CI, 1.64-2.65).

Adding high-sensitivity cardiac troponin to conventional risk factors improved the C index between 1% and 3%, Evans and colleagues wrote.

“Preliminary data showing discrimination improvements in HF risk with [high-sensitivity cardiac troponin] assessment suggest that it may be a promising biomarker for measurement as part of primary prevention of HF,” Evans and colleagues wrote.

“As advocates for biomarker use in patients with HF and from our previous studies, we appreciate the interesting proof of concept presented by Evans et al, and with which we concur in regard to establishing estimates of those at risk for HF going forward,” Allan S. Jaffe, MD, FACC, FAHA, FESC, professor of medicine, professor of laboratory medicine and pathology, and chair of the division of clinical core laboratory services at Mayo Clinic and a member of the Cardiology Today Editorial Board, and Wayne L. Miller, MD, PhD, professor in the department of cardiovascular medicine at Mayo Clinic and Foundation, wrote in a related editorial. “However, we also have tried to use this opportunity to suggest that the field needs to spend additional time and effort refining the specific techniques that might more fully optimize the ability to use summary and meta-analyses that include biomarkers.” – by Darlene Dobkowski

Disclosures: The authors and Miller report no relevant financial disclosures. Jaffe reports he has consulted for most of the major diagnostic companies either presently or in the past.

    Perspective
    L. Kristin Newby, MD

    L. Kristin Newby

    This meta-analysis pooled all the available prospective studies of the relationship between high-sensitivity troponin level and occurrence of new HF events. It showed about a twofold increased risk in new HF events, even after considering B-type natriuretic peptide. By pooling all studies, the estimate of the relationship is tighter and confidence in the association is greater than from any individual study.

    The results suggest that it could be possible to use high-sensitivity troponin as a screening tool to identify patients at risk for incident HF in whom early intervention might avert the clinical occurrence. However, how and when/how frequently to employ the testing and how to intervene based on the result of testing to improve clinical outcomes remain to be determined. 

    It would be helpful to see prospective studies in which high-sensitivity troponin testing is implemented in a protocolized fashion and interventions then tested based on the results of testing. For example, in patients at risk for HF but without clinical evidence of it, would high-sensitivity troponin testing be conducted at each clinic visit, and if elevated above their baseline or a set threshold (that would have to be determined), would patients be randomly assigned to a medication and/or lifestyle intervention? This would answer the question of whether treatment decisions based on high-sensitivity troponin level could improve clinical outcomes and demonstrate the utility of testing.

    • L. Kristin Newby, MD, MHS, FACC, FAHA
    • Cardiology Today Editorial Board Member
      Duke Clinical Research Institute
      Duke University School of Medicine

    Disclosures: Newby reports she has received consulting honoraria from Ortho-Clinical Diagnostics, Philips Healthcare and Roche Diagnostics and funding from the NIH as a co-primary investigator for research into development of a novel point-of-care testing platform for biomarkers, including BNP.