Outcomes and Care of Patients With Acute Heart Failure Syndromes and Cardiac Troponin Elevation

BACKGROUND: Cardiac troponins (cTn) may be elevated among patients with acute heart failure syndromes (AHFS). However, the optimal approach to management of AHFS with elevated cTn is unknown. METHODS AND RESULTS: We compared the care and outcomes of 13 656 patients with AHFS seeking care in the emergency department stratified by presence (cTn+, n=1845, 13.5%) or absence (cTn-) of elevated troponin. Clinically abstracted data on patients who were admitted or discharged from the emergency department in Ontario, Canada (April 1999 to March 2001 and April 2004 to March 2007) were examined. In an exploratory 2:1 propensity-matched analysis, we examined whether early coronary revascularization (within 14 days of emergency department visit) was associated with survival, stratified by cTn status. For cTn+ AHFS, rates of coronary angiography (21.8 vs 11.4 patients/100 person-years; P<0.001) and coronary revascularization (8.8 vs 3.2 patients/100 person-years; P<0.001) were higher than cTn-. Instantaneous 30-day adjusted hazard ratios for cTn+ versus cTn- patients were 9.17 (95% confidence interval [CI], 8.31-10.12; P<0.001) for death, 5.14 (95% CI, 4.66-5.67; P<0.001) for cardiovascular readmission, and 13.08 (95% CI, 10.95-15.62; P<0.001) for ischemic heart disease hospitalization. In propensity-matched analysis of 143 individuals with cTn+ AHFS, early coronary revascularization was associated with reduced mortality (adjusted hazard ratio, 0.29; 95% CI, 0.09-0.92; P=0.036) compared with those who were not revascularized. Mortality was not significantly reduced among 210 cTn- patients undergoing early coronary revascularization (adjusted hazard ratio, 0.61; 95% CI, 0.36-1.03; P=0.065). CONCLUSIONS: Elevated cTn was associated with increased risk of death and cardiovascular hospitalizations. Highly selected cTn+ patients who underwent early coronary revascularization for obstructive coronary artery disease experienced improved survival.