High-Sensitivity Cardiac Troponin T in Patients with Severe Chronic Kidney Disease and Suspected Acute Coronary Syndrome.

Brunilda Alushi,Karl Stangl,Adnan Kastrati,Ulf Landmesser,Massimiliano Fusaro,Alexander Lauten,Fabian Jost-Brinkmann,Salvatore Cassese,Holger Thiele

doi:10.3390/jcm10184216

Abstract

(1) Background: Patients with severe chronic kidney disease (CKD G4–G5) often have chronically elevated high-sensitivity cardiac troponin T (hs-cTnT) values above the 99th percentile of the upper reference limit. In these patients, optimal cutoff levels for diagnosing non-ST-elevation acute coronary syndrome (NSTE-ACS) requiring revascularization remain undefined. (2) Methods: Of 11,912 patients undergoing coronary angiography from 2012 to 2017 for suspected NSTE-ACS, 325 (3%) had severe CKD. Of these, 290 with available serial hs-cTnT measurements were included, and 300 matched patients with normal renal function were selected as a control cohort. (3) Results: In the CKD cohort, 222 patients (76%) had NSTE-ACS with indication for coronary revascularization. Diagnostic performance was high at presentation and similar to that of the control population (AUC, 95% CI: 0.81, 0.75–0.87 versus 0.85, 0.80–0.89, p = 0.68), and the ROC-derived cutoff value was 4 times higher compared to the conventional 99th percentile. Combining the ROC-derived cutoff levels for hs-cTnT at presentation and absolute 3 h changes, sensitivity increased to 98%, and PPV and NPV improved up to 93% and 86%, respectively. (4) Conclusions: In patients with severe CKD and suspected ACS, the diagnostic accuracy of hs-cTnT for the diagnosis of NSTE-ACS requiring revascularization is improved by using higher assay-specific cutoff levels combined with early absolute changes.

Highlights

Acute myocardial infarction (AMI) is a leading cause of death and disability worldwide
One third of the patients presenting with persistent ST-segment elevation myocardial infarction (STEMI) and more than 40% of patients with non-ST-elevation acute myocardial infarction (NSTEMI) have chronic kidney disease (CKD) [4]
Two independent cardiologists (BA and AL) a-posteriori adjudicated the final diagnosis of NSTE-ACS and the indication for revascularization after reviewing all available medical records, including patient history, physical examination, results of laboratory testing, electrocardiograms, echocardiographs, cardiac exercise tests, and coronary angiograms obtained from the time of the index event to one year of followup

Summary

Introduction

Acute myocardial infarction (AMI) is a leading cause of death and disability worldwide. The early diagnosis and therapy of NSTE-ACS in this population can be challenging, mostly due to frequent atypical clinical presentation, preexisting electrocardiogram abnormalities, and the vulnerability of these patients to adverse events related to antiplatelet treatment and invasive procedures as coronary interventions [5,6]. These patients, especially those undergoing dialysis for kidney failure (CKD G5D), are less likely to receive guideline-indicated care despite several studies indicating a higher risk of poor outcomes after AMI [3,4,7]. Coronary angiography is performed too infrequently in the context of NSTEMI-ACS in patients with CKD [3,8,9,10,11]

Methods

Results

Conclusion