Causes of Troponin Elevation and Associated Mortality in Young Patients - 11/01/18

Doi : 10.1016/j.amjmed.2017.10.026

Candace Wu, MPH ^a, Avinainder Singh, MBBS ^a, Bradley Collins, BS ^a, Amber Fatima, MBBS ^a, Arman Qamar, MD ^b, Ankur Gupta, MD, PhD ^a, Jon Hainer, BS ^a, Josh Klein, BS ^a, Petr Jarolim, MD, PhD ^c, Marcelo Di Carli, MD ^a, Khurram Nasir, MD, MPH ^d, Deepak L. Bhatt, MD, MPH ^b, Ron Blankstein, MD ^a,^*
^a Cardiovascular Imaging Program, Departments of Medicine and Radiology, Harvard Medical School, Boston, Mass
^b Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Mass
^c Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
^d Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Fla

^*Requests for reprints should be addressed to Ron Blankstein, MD, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115.Brigham and Women's Hospital75 Francis St.BostonMA02115

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 11 January 2018

Abstract

Background

While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals.

Methods

We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file.

Results

Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001).

Conclusion

There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction.

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Keywords : Cardiac contusion, Cardiac troponin, Cardiomyopathy, End-stage renal disease, Myocardial infarction, Myocarditis, Myositis, Pulmonary embolism, Rhabdomyolysis, Seizure, Stroke, Subarachnoid hemorrhage

Plan

Adjudication of Acute Myocardial Infarction

Adjudication of Nonmyocardial Infarction Causes of Troponin Elevation

Troponin Assays

Statistical Analysis

Results

Baseline Characteristics and Causes of Troponin Elevation

Causes of Troponin Elevation by Age

Causes of Troponin Elevation by Sex and Race

Causes of Troponin Elevation and All-Cause Mortality

Discussion

Limitations

Conclusion

	Funding: None.
	Conflicts of Interest: CW, AS, BC, AF, JH, JK, MD, and KN have no financial disclosures.
	DLB discloses the following relationships—Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical (now Abbott); Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, PLx Pharma, Takeda.
	AQ is supported by the National Heart, Lung, and Blood Institute T32 postdoctoral training grant T32HL007604.
	AG is supported by grant 5T32HL094301-07 from the National Institutes of Health.
	PJ discloses the following Grant/Research Support: Research support from Abbott Laboratories, AstraZeneca LP, Beckman Coulter, Daiichi Sankyo, Inc., GlaxoSmithKline, Janssen Scientific Affairs, LLC, Merck & Co., Inc., Roche Diagnostics Corporation, Takeda Global Research and Development Center, and Waters Technologies Corporation.
	RB receives research support from Amgen Inc, Gilead Inc and serves on the advisory board for Amgen Inc, EKOS Inc, Astellas Inc.
	Authorship: All authors had access to the data and a role in writing the manuscript.