Acad Emerg Med. 2023 Aug 29. doi: 10.1111/acem.14798. Online ahead of print.
ABSTRACT
BACKGROUND: Historical cardiac troponin (cTn) elevation is commonly interpreted as lessening the significance of current cTn elevations at presentation for acute heart failure (AHF). Evidence for this practice is lacking. Our objective was to determine the incremental prognostic significance of historical cTn elevation compared to cTn elevation and ischemic heart disease (IHD) history at presentation for AHF.
METHODS: 341 AHF patients were prospectively enrolled at 5 sites. The composite primary outcome was death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and/or acute myocardial infarction (AMI)/PCI/CABG at 90 days. Secondary outcomes were 30-day AMI/PCI/CABG and in-hospital AMI. Logistic regression compared outcomes versus initial emergency department (ED) cTn, the most recent electronic medical record cTn, eGFR, age, LVEF, and IHD history (positive, negative by prior coronary workup, or unknown / no prior workup).
RESULTS: Elevated cTn occurred in 163 (49%) patients, 80 (23%) experienced the primary outcome, and 29 had AMI (9%). cTn elevation at ED presentation, adjusted for historical cTn and other covariates, was associated with the primary outcome (aOR 2.39; 95%CI:1.30-4.38), 30-day AMI/PCI/CABG, and in-hospital AMI. Historical cTn elevation was associated with greater odds of the primary outcome when IHD history was unknown at ED presentation (aOR 5.27, 95%CI:1.24-21.40), and did not alter odds of the outcome with known positive (0.74; 0.33-1.70) or negative IHD history (0.79; 0.26-2.40). Nevertheless, patients with elevated ED cTn were more likely to be discharged if historical cTn was also elevated (78% vs. 32%, p=0.025).
CONCLUSION: Historical cTn elevation in AHF patients is a harbinger of worse outcomes for patients who have not had a prior IHD work-up, and should prompt evaluation for underlying ischemia rather than reassurance for discharge. With known IHD history, historical cTn elevation was neither reassuring nor detrimental, failing to add incremental prognostic value to current cTn elevation alone.
PMID:37641846 | DOI:10.1111/acem.14798