Prognostic performance of high-sensitivity cardiac troponin T kinetic changes adjusted for elevated admission values and the GRACE score in an unselected emergency department population

• Hs-cTnT values >14 ng/L are associated with a higher risk of adverse outcome.
• Kinetic changes do not improve prognostic performance of admission values.
• Coronary angiography is performed earlier in patients with rising changes.

PurposeThe aim of this study was to test the prognostic performance of rising and falling kinetic changes of high-sensitivity cardiac troponin T (hs-cTnT) and the GRACE score.MethodsRising and falling hs-cTnT changes in an unselected emergency department population were compared.Results635 patients with a hs-cTnT > 99th percentile admission value were enrolled. Of these, 572 patients qualified for evaluation with rising patterns (n = 254, 44.4%), falling patterns (n = 224, 39.2%), or falling patterns following an initial rise (n = 94, 16.4%). During 407 days of follow-up, we observed 74 deaths, 17 recurrent AMI, and 79 subjects with a composite of death/AMI. Admission values > 14 ng/L were associated with a higher rate of adverse outcomes (OR, 95%CI:death:12.6, 1.8–92.1, p = 0.01, death/AMI:6.7, 1.6–27.9, p = 0.01). Neither rising nor falling changes increased the AUC of baseline values (AUC: rising 0.562 vs. 0.561, p = ns, falling: 0.533 vs. 0.575, p = ns). A GRACE score ≥ 140 points indicated a higher risk of death (OR, 95%CI: 3.14, 1.84–5.36), AMI (OR, 95%CI: 1.56, 0.59–4.17), or death/AMI (OR, 95%CI: 2.49, 1.51–4.11). Hs-cTnT changes did not improve the prognostic performance of a GRACE score ≥ 140 points (AUC, 95%CI: death: 0.635, 0.570–0.701 vs. 0.560, 0.470–0.649 p = ns, AMI: 0.555, 0.418–0.693 vs. 0.603, 0.424–0.782, p = ns, death/AMI: 0.610, 0.545–0.676 vs. 0.538, 0.454–0.622, p = ns). Coronary angiography was performed earlier in patients with rising than with falling kinetics (median, IQR [hours]:13.7, 5.5–28.0 vs. 20.8, 6.3–59.0, p = 0.01).ConclusionNeither rising nor falling hs-cTnT changes improve the prognostic performance of elevated hs-cTnT admission values or the GRACE score. However, rising values are more likely associated with the decision for earlier invasive strategy.