Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes

Matthew T. Roe, Eric D. Peterson, Charles V. Pollack, L. Kristin Newby, Yun Li, Robert H. Christenson, W. Frank Peacock, Francis M. Fesmire, Deborah Diercks, J. Douglas Kirk, Sidney C. Smith, E. Magnus Ohman, W. Brian Gibler

Research output: Contribution to journalArticle

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Abstract

Study objective: Previous studies in clinical trial populations have demonstrated that patients presenting with positive troponin levels have a higher risk of mortality than patients with later positive troponin levels, but the influence of the timing of troponin elevation has not been previously characterized. We evaluate the impact of the timing of troponin elevation on clinical outcomes and adherence to the American College of Cardiology/American Heart Association acute care guidelines for patients with non-ST-segment elevation acute coronary syndromes. Methods: We examined inhospital outcomes and use of acute (<24 hours) medications and invasive cardiac procedures in 23,184 high-risk patients with non-ST-segment elevation acute coronary syndromes (positive cardiac markers or ischemic ST-segment changes) during 2001 to 2002 from 396 US hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Initiative. Baseline and peak troponin values were recorded and were designated as positive if above the cutoff value used at each institution to designate definite myocardial necrosis. Results: In the study cohort, 53.2% of patients presented with baseline positive troponin levels, 30.6% had baseline negative/later positive troponin levels, and 16.2% had negative troponin levels during the entire hospitalization. Patients with baseline positive troponin levels had a higher risk of inhospital mortality than patients with baseline negative/later positive troponin levels (6.5% versus 4.1%) and were less likely to undergo early cardiac catheterization or percutaneous coronary intervention. The use of acute aspirin (in approximately 91% of patients), heparin (85%), and β-blockers (78%) was similar in patients with baseline-positive versus later-positive troponin levels. Conclusion: These findings demonstrate that evidence-based therapies and interventions for non-ST-segment elevation acute coronary syndromes are underused in patients with elevated troponin levels, but baseline troponin elevations, which are associated with a higher risk of inhospital mortality, do not stimulate more aggressive care.

Original languageEnglish (US)
Pages (from-to)355-362
Number of pages8
JournalAnnals of Emergency Medicine
Volume45
Issue number4
DOIs
StatePublished - Apr 2005

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Troponin
Acute Coronary Syndrome
Therapeutics
Hospital Mortality
Guidelines
Unstable Angina
Percutaneous Coronary Intervention
Cardiac Catheterization
Aspirin
Heparin
Patient Care
Hospitalization
Cohort Studies
Necrosis

ASJC Scopus subject areas

  • Emergency Medicine

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Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes. / Roe, Matthew T.; Peterson, Eric D.; Pollack, Charles V.; Newby, L. Kristin; Li, Yun; Christenson, Robert H.; Peacock, W. Frank; Fesmire, Francis M.; Diercks, Deborah; Kirk, J. Douglas; Smith, Sidney C.; Ohman, E. Magnus; Gibler, W. Brian.

In: Annals of Emergency Medicine, Vol. 45, No. 4, 04.2005, p. 355-362.

Research output: Contribution to journalArticle

Roe, MT, Peterson, ED, Pollack, CV, Newby, LK, Li, Y, Christenson, RH, Peacock, WF, Fesmire, FM, Diercks, D, Kirk, JD, Smith, SC, Ohman, EM & Gibler, WB 2005, 'Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes', Annals of Emergency Medicine, vol. 45, no. 4, pp. 355-362. https://doi.org/10.1016/j.annemergmed.2004.10.016
Roe, Matthew T. ; Peterson, Eric D. ; Pollack, Charles V. ; Newby, L. Kristin ; Li, Yun ; Christenson, Robert H. ; Peacock, W. Frank ; Fesmire, Francis M. ; Diercks, Deborah ; Kirk, J. Douglas ; Smith, Sidney C. ; Ohman, E. Magnus ; Gibler, W. Brian. / Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes. In: Annals of Emergency Medicine. 2005 ; Vol. 45, No. 4. pp. 355-362.
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abstract = "Study objective: Previous studies in clinical trial populations have demonstrated that patients presenting with positive troponin levels have a higher risk of mortality than patients with later positive troponin levels, but the influence of the timing of troponin elevation has not been previously characterized. We evaluate the impact of the timing of troponin elevation on clinical outcomes and adherence to the American College of Cardiology/American Heart Association acute care guidelines for patients with non-ST-segment elevation acute coronary syndromes. Methods: We examined inhospital outcomes and use of acute (<24 hours) medications and invasive cardiac procedures in 23,184 high-risk patients with non-ST-segment elevation acute coronary syndromes (positive cardiac markers or ischemic ST-segment changes) during 2001 to 2002 from 396 US hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Initiative. Baseline and peak troponin values were recorded and were designated as positive if above the cutoff value used at each institution to designate definite myocardial necrosis. Results: In the study cohort, 53.2{\%} of patients presented with baseline positive troponin levels, 30.6{\%} had baseline negative/later positive troponin levels, and 16.2{\%} had negative troponin levels during the entire hospitalization. Patients with baseline positive troponin levels had a higher risk of inhospital mortality than patients with baseline negative/later positive troponin levels (6.5{\%} versus 4.1{\%}) and were less likely to undergo early cardiac catheterization or percutaneous coronary intervention. The use of acute aspirin (in approximately 91{\%} of patients), heparin (85{\%}), and β-blockers (78{\%}) was similar in patients with baseline-positive versus later-positive troponin levels. Conclusion: These findings demonstrate that evidence-based therapies and interventions for non-ST-segment elevation acute coronary syndromes are underused in patients with elevated troponin levels, but baseline troponin elevations, which are associated with a higher risk of inhospital mortality, do not stimulate more aggressive care.",
author = "Roe, {Matthew T.} and Peterson, {Eric D.} and Pollack, {Charles V.} and Newby, {L. Kristin} and Yun Li and Christenson, {Robert H.} and Peacock, {W. Frank} and Fesmire, {Francis M.} and Deborah Diercks and Kirk, {J. Douglas} and Smith, {Sidney C.} and Ohman, {E. Magnus} and Gibler, {W. Brian}",
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T1 - Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes

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AU - Peterson, Eric D.

AU - Pollack, Charles V.

AU - Newby, L. Kristin

AU - Li, Yun

AU - Christenson, Robert H.

AU - Peacock, W. Frank

AU - Fesmire, Francis M.

AU - Diercks, Deborah

AU - Kirk, J. Douglas

AU - Smith, Sidney C.

AU - Ohman, E. Magnus

AU - Gibler, W. Brian

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